Thousands of patients with dementia in nursing facilities are being overmedicated with psychotropic drugs, according to a report by Human Rights Watch (HRW). The nonprofit found that the drugs are often given to residents who don't have the diagnoses for which the drugs were approved, and without informed consent from patients or family members.

Laurel Cline visits her mother, Lenora, who suffers from Alzheimer's disease, twice a day at her nursing home. Cline had to persuade the facility to discontinue her mother's antipsychotic medications. "Every little thing, they want to put you on psych meds," she says. Photo by Ed Kashi / VII.

According to the report, "They Want Docile," the drugs are used primarily for their "sedative effect" to control behavior, despite laws against such "chemical restraints."

Tony Chicotel, staff attorney for California Advocates for Nursing Home Reform, said in an HRW video: "We need good enforcement for those laws and regulations to mean something; right now, they mean very little."

The report's author, Hannah Flamm, a New York University School of Law fellow at HRW, said in comments to AJN that it is "nearly impossible for a nursing home to deliver adequate care, compliant with the law[horizontal ellipsis] without sufficient and well-trained staff." She added that "thousands of U.S. nursing facilities fail to meet this standard." In a press release accompanying the report, Flamm said staff often justify giving antipsychotic drugs "because they interpret urgent expressions of pain or distress as disruptive behavior that needs to be suppressed." The HRW report referenced studies showing that use of antipsychotic drugs almost doubles the risk of death in older patients with dementia.

Nurses can identify possible reasons for dementia-related behaviors that the patient's long-term care facility may not be aware of, according to Leslie Chang Evertson, lead dementia care manager for the University of California, Los Angeles, Alzheimer's and Dementia Care Program. "Non-pharmacological behavior modifications should be used as much as possible before adding antipsychotic medications," Evertson told AJN.

The HRW report is based on visits by researchers to 109 nursing facilities in six states during 2016 and 2017; interviews with residents, families, staff, long-term care and disability experts, officials, and advocates; and a review of studies, regulations, and government reports.

Susan Renz, director of the adult-gerontology primary care NP program at the University of Pennsylvania in Philadelphia, explained that the prescribing of antipsychotic drugs in nursing homes had not been well scrutinized. "The report quantifies the magnitude of the problem, why it developed, and what harm it has caused," she told AJN.

Elderly patients outside of nursing homes may also be overmedicated. A study of benzodiazepine use between 2010 and 2016 in people ages 65 and older in three countries found that although use declined significantly in the United States and Canada, and to a lesser extent in Australia, it remains "inappropriately high," especially in those ages 85 and older.

The American Health Care Association, which represents long-term and post-acute care providers, acknowledged in a statement that more can be done, but in general downplayed the findings of the HRW report: "The report does little to highlight the effort launched by our profession in 2012 that has resulted in a dramatic decline in the use of these medications, with more than half of our members achieving at least a 30% reduction."-Serena Stockwell

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