Is The Nursing Home Over-Medicating My Family Member?

Elderly nursing home residents are frequently over-medicated increasing their risk of injuries and death.

Across the country elderly patients are being dangerously overmedicated for no good reason. There is a serious problem with the elderly being overmedicated with antipsychotic and similar medications in nursing homes, rehabilitation centers, and assisted living facilities.

Overmedication and chemical restraints are common signs of elder abuse and neglect.

The Problem of Overmedication

Antipsychotics drugs are approved mainly to treat serious mental illnesses like schizophrenia and bipolar disorder. But many nursing homes prescribe these drugs to elderly patients simply to calm anxiety or agitation that is associated with Alzheimer’s disease and dementia.

A report published by National Public Radio (NPR) found that almost 300,000 nursing home residents are currently receiving anti-psychotic medications. The study also found that reason these medications are being prescribed is to sedate patient with Alzheimer’s and dementia.

Doctors who specialize in treating elderly patients (called gerontologists) say that anti-psychotic drugs are unnecessary in the vast majority of dementia and Alzheimer’s patients.

Family members are often never provided with a complete explanation about why these medications are being prescribed to their loved one.  The evidence proves that nursing home residents are ordered to take antipsychotic drugs for the convenience of the staff by sedating elderly residents.

This is especially true in nursing homes that do not have enough staff to properly care for each resident because of understaffing.

The Use of Medications As Chemical Restraints

Federal law prohibits the use of antipsychotics for “discipline” or “convenience” of staff, which is considered a “chemical restraint.”  A chemical restraint can only be used as a last resort to prevent an agitated patient from harming himself or others.  Ohio law also prevents the use of chemical restraints except in extreme circumstances.  Ohio’s Nursing Home Bill of Rights states that nursing home residents have the following rights:

“The right to be free from … chemical restraints … except to the minimum extent necessary to protect the resident from injury to self, others, or to property and except as authorized in writing by the attending physician for a specified and limited period of time and documented in the resident’s medical record.”

These drugs can have an intoxicating and even stupefying effect on elderly patients.  According to a study published in the Journal of the American Medical Association, the use of antipsychotic medications greatly increases the risk of falling and suffering injuries, including fractures and death.

Seroquel is an anti-psychotic that is often given to seniors who are over-medicated.

These drugs also include black box warnings stating that they can increase the risk for heart failure, infections, and death.  Antipsychotic drugs should be used only as last a resort.

While antipsychotic medications are the most common types of medications that are used as chemical restraints, there are other medications that can be used to restrain nursing home residents.  These are primarily benzodiazepines and dissociative anesthetics.

Benzodiazepines are a class of drugs that can be used to help alleviate insomnia, panic attacks, anxiety, muscle tension, and seizures.  Although there are others, the most common benzodiazepines used as chemical restraints are:

• alprazolam (Xanax);
• clonazepam (Klonopin)
• diazepam (Valium);
• lorazepam (Ativan); and
• midazolam (Versed).

Studies show that benzodiazepines are effective for sedating the elderly but are dangerous and unusually unnecessary.

Other drugs that nursing homes use to chemically restrain elderly residents include dissociative anesthetics. Dissociative anesthetics are a type of hallucinogen.

These drugs distort the patient’s perceptions of sound and sight. They also tend to dissociate, or detach, individuals from their self and environment.

Dissociative anesthetics work by blocking or reducing brain signals between the conscious mind and other parts of the brain. Due to the intensity of dissociative drugs, they are less commonly used than drugs such as antipsychotics and benzodiazepines.  There are numerous types of dissociative anesthetics, including ketamine.

Over-medication of elderly patients is an epidemic in nursing homes.

Use any of these drugs unnecessarily will expose a patient to several other risks and harmful effects including:

• Increased dependence and functional decline;
• Memory loss and confusion;
• Increased agitation;
• Withdrawal and depression;
• Orthostatic hypotension (blood pressure falling upon standing resulting in an increased risk of falling);
• Loss of mobility and strength;
• Increased risk of accidents and falls;
• Low blood pressure;
• Muscle disorders; and
• Adverse drug effects, including heart problems and death.

Many patients or their guardians may not know that antipsychotics or similar drugs are not needed for their condition. Worse yet, they are rarely told about the serious risks associated with taking these drugs.

In fact, many family members and guardians may not know that their loved one is taking these medications at all.

Alternatives to Chemical Restraints

Good nursing homes should be able to provide alternatives to chemical restraints to calm the anxiety and agitation that sometimes accompanies dementia and Alzheimer’s and to limit impulsivity and confusion.

Aggression and Anger

Dementia and Alzheimer’s aggression, agitation, and anger can be influenced—positively or negatively—by the behavior of nursing home staff. There are several ways that staff can avoid the use of use of chemical restraints.

• If staff behavior is a trigger for agitation and anger, staff should modify behavior by moving slowly, speaking softly, and directing the patient to engage in less stimulating, stressful behavior;
• Nursing home staff should minimize stimulation in the environment (noise, lights, visitors);
• Staff should maximize consistency and routine;
• Items should be removed from the room that can cause injury;
• If family is comforting to the resident, they should be added to the schedule on a consistent basis.

Impulsivity

Impulsive behaviors can lead to injury and be irritating to staff members.  However, there are alternatives that should be considered by a nursing home before chemical restraints are used.  These include:

• Cueing the patient to stop, think, and act;
• Verbally reviewing steps before beginning an activity;
• Identifying and intervening with impulsive behavior;
• Rehearsing how to appropriately behave in a given circumstance;
• Frequently checking on the patient;
• Providing constant observation of the patient, including potentially asking a family member to spend time with the patient; and
• Placing the resident in a common area where they can easily be observed by staff.

Confusion

A resident’s confusion can be a major source of frustration to nursing home staff.  Before restraints or medications are used, it is important for the nursing home caregivers to look for causes of the confusion, including physiologic, pharmacologic, environmental, or emotional factors.

For example, a confused patient may routinely try to get out of bed to use the toilet.  Nursing home staff can look to find out whether the resident has a urinary tract infection or is on any medication, such as a diuretic like Lasix, that may cause the resident to need to go to the restroom more often.

Nursing home staff can anticipate any problems by putting a toileting plan in place—for example, every 1-2 hours a staff member enters the room and asks the resident if she needs to use the restroom.

Other measures can be taken to help understand the reason for confusion and improve the resident’s cognition without the need for restraints.  These alternatives commonly include:

• Consistent Care – Providing a predictable routine, a memory book, a calendar, and frequent reorientation;
• Placing the patient near the nurse’s station so there is more frequent monitoring and less chance for injury;
• Looking for any medications that may cause confusion—including sedatives and hypnotics—and reducing those medications when possible;
• Providing a toileting schedule;
• Providing frequent opportunities for exercise, walking, and movement;
• Lowering bedrails or providing half bed rails if the patient can walk;
• Providing bed and wheelchair alarms;
• Discontinuing any tubes or lines that the resident can be caught in; and
• Providing environmental exit alarms in case the resident begins to wander or elope.

The next time you visit your loved one who is in a nursing home be sure to check out the list of the drugs given to him or her to make sure the he or she is not being overmedicated.

Overmedication and chemical restraints are common sign of elder abuse and neglect.

Michael A. Hill is an accomplished trial lawyer focusing on representing individuals in wrongful death cases and who have suffered life changing injuries. His practice is concentrated on nursing home and assisted living negligence and medical malpractice cases involving heart attack and stroke.

Michael practices in state and federal courts around the country and has argued cases in front of numerous appellate courts, including the Ohio Supreme Court.  Michael has recorded several seven figure verdicts and settlements.  Michael is a regular speaker for lawyers concerning litigation and trial practice.  Michael is a member of The National Trial Lawyers Top 40 under 40, Top 10 Nursing Homes Lawyers, Top 25 Medical Malpractice Lawyers, Super Lawyers: Rising Star, and Multi-Million Dollar Advocates Forum.

Michael is from Flint, Michigan and received his undergraduate degree from Oberlin College in Oberlin, Ohio, where he was introduced to his wife, Hilary.  Michael received his law degree from Case Western Reserve University School of Law where he graduated Magna Cum Laude.  Michael and Hilary live in Lakewood, Ohio. Michael is a partner and founder of Eadie Hill Trial Lawyers.