Imagine, if you will, this scenario: You’re an underpaid, overworked aide in a nursing home suddenly faced with a violent outburst by an elderly resident suffering from Alzheimer’s. You try to calm him down without success, which inhibits your ability to determine whether he’s in pain or simply reacting to some currently unidentifiable force. So where do you turn? Sedation.
Also known as “chemical restraints,” this pharmaceutical response to unruly residents typically involves one of three generic antipsychotic drugs — Seroquel, Risperdal, and Zyprexa — that are designed to treat people diagnosed with mental health issues including schizophrenia, bipolar disorder, and depression. But they are increasingly prescribed as an off-label drug for Alzheimer’s patients in long-term care facilities who display psychotic behavior, despite black-box warnings from the Food and Drug Administration that these drugs can increase their risk of falling, stroke, and premature death.
The practice, however, has become so commonplace in an industry wracked by inadequate staffing that federal regulators in recent years have been forced to increase their oversight of drug usage and penalize long-term care facilities that display an overreliance on this approach by reducing their ratings on the government’s Nursing Home Care Compare website.
As Christopher Rowland reports in The Washington Post, the current administration is pondering whether to relax those penalties after a feverish lobbying campaign by manufacturers of the drugs. These companies argue that discouraging the use of antipsychotics would deprive some nursing home residents of the meds that allow them to remain in the facility.
The government’s penalties have “placed relentless downward pressure on facilities to continue to reduce antipsychotic use,” Sue Peschin, chief executive of the Alliance for Aging Research, tells the Post. “And some patients are going to go without the specific medication that they need.”
Despite these lamentations, a new study suggests that “relentless” pressure has been more perceived than productive. It hasn’t done much to discourage nursing homes from using antipsychotics. In fact, you might say the industry has displayed not-so-subtle signs of addiction.
A team of researchers from Rutgers and Columbia universities reviewed data from a national prescription-claims database to track antipsychotics prescriptions between 2015 and 2024. What they found was disturbing: The percentage of nursing home residents 65 or older who were given these drugs increased by more than 50 percent during that period to include more than one in five of these seniors.
Perhaps more disturbing, prescriptions ordered by psychiatrists declined by a third while those from primary care physicians increased by half, the team reported. Writing in JAMA Psychiatry, study coauthor Stephen Crystal, PhD, director of Rutgers’s Center for Health Services Research, believes that trend reveals increasing skepticism of the drugs’ benefits among experts — and some naiveté among general practitioners.
“Qualitative research suggests some primary care physicians view the use of antipsychotics for dementia symptoms as safer and more effective than experimental research indicates,” he notes.
The trend also suggests that seniors residing in long-term care facilities may be getting short shrift on the treatment front. In a clinical setting, psychiatrists would more thoroughly evaluate patients exhibiting unruly behavior as a result of cognitive dysfunction, checking for medication interactions, mental health issues, and other potential causes. Nonpharmacological remedies, under these circumstances, would be considered more seriously than in a nursing home, where inadequate staffing and other issues can push caregivers to employ more short-term solutions.
“This can look like managing symptoms,” Crystal says. “Which is common because it’s so much easier to write a prescription than do the work of addressing the underlying condition, particularly at nursing home and assisted living facilities that are dangerously short-staffed.”
And to avoid government penalties, some nursing homes have underreported the usage of antipsychotics or falsely claimed schizophrenia diagnoses among residents to whom the drugs were administered. Rowland cites a 2021 Department of Health and Human Services report showing that a third of those individuals had never been diagnosed with the disease.
“There are definitely people who need antipsychotics. Their behavior can’t be managed in other ways, and it poses threats to safety and well-being,” Michael Steinman, MD, a geriatrician at the University of California, San Francisco, tells the Post. “But it’s substantially less than the number of people getting them currently.”
That certainly seems to be the case. But I suspect that the underpaid, overworked nursing home aide wrestling with an unruly dementia sufferer would beg to differ.
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