OP-ED

Outrage is Easy. Solutions are Hard.

The inspector general of HHS reported this week that nearly half of the anti-psychotic drugs fed to the demented elderly in nursing homes are inappropriately prescribed. That’s about one in fourteen nursing home residents.

Forget about cost, which is over a quarter billion dollars a year. “Government, taxpayers, nursing home residents as well as their families and caregivers should be outraged and seek solutions,” wrote Daniel R. Levinson, the HHS I.G. wrote in his letter to Senators Charles Grassley (R-Ia.) and Herb Kohl (D-Wis.), who asked for the report.

Why is this happening? First, the medication patterns of the frail elderly are not monitored by the Centers for Medicare and Medicaid Services, which is afraid of a backlash from Capitol Hill where doctors and nursing home operators fiercely lobby to protect the hallowed doctor-patient relationship. The drug industry has also, in some cases, paid kickbacks to the pharmacy operators in nursing homes.

But at the root of the issue are the doctors who are faced with caring for these patients. Even though clinical trials have shown the drugs are likely to result in earlier deaths for some of these elderly patients, doctors prescribe them to reduce agitation, as Daniel Carlat, a practicing psychiatrist and purveyor of non-industry-funded continuing medical education, told the New York Times. “Doctors want to maximize quality of life by treating the patient’s agitation even if that means the patient will die a bit sooner,” he said.

As someone who watched his father’s decline with dementia over a ten year period (usually from a distance), I can attest that shortening one’s lifespan is not the crucial issue, especially in the last few years when the personality in the shell of the human being that has survived the loss of cognition has largely disappeared. The first question is whether the anti-psychotics are effective in reducing the outbursts associated with severe dementia, and whether those benefits outweigh the side effects (catatonia?). The second question is whether families have been adequately informed about the risks and benefits of this approach. That the drug companies deploy their marketing arms to stoke sales in this situation is outrageous. But even eliminating their right to do so wouldn’t solve the underlying problem.

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Craig "Quack" Vickstrom, M.D.Devon Devine Recent comment authors
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Craig "Quack" Vickstrom, M.D.
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Craig "Quack" Vickstrom, M.D.

The amount of regulation and second-guessing in nursing homes is really getting ridiculous. My solution has been to let the regulators admit patients to nursing homes. They presume to know more about geriatrics than those who trained me, so they can admit and manage patients in the nursing home. I have plenty of work to do with inpatient, clinic, urgent care, ER and surgery/post-op care.

Devon Devine
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Should we expect to see Pharmacy Benefit Management companies roll anti-psychotic medication into their Drug Therapy Management programs? Will sending off reams of faxes to doctors and letters to patients help?