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Dementia care w o drugs - south sf 10-27-11

Dementia care w o drugs - south sf 10-27-11






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  • Many side fx attributable to prolonged heavy sedation, immobilization - loss of muscle and bone strength
  • Big Pharma is now biggest defrauder
  • 22 over medicated, 3 died; criminal charges; bad nurse started 9/06 - mention i.c. form
  • Excessive dose / duration
  • Swine flu - marshaled all resources
  • Find the source of the agitation.
  • 1995 Little Hoover Commission: no i.c., chemical restraint abuse, abuse of prn meds
  • Several Calif. facilities already have low rates and better policies and procedures.

Dementia care w o drugs - south sf 10-27-11 Dementia care w o drugs - south sf 10-27-11 Presentation Transcript

  • Stop Drugging Our Elders! Ending the Epidemic Misuse of Psychotropic Drugs in California Nursing Homes Anthony Chicotel Staff Attorney California Advocates for Nursing Home Reform
  • The Intro
    • 60% of all nursing home residents receive a psychoactive drug.
    • Substituting drugs for care happens at all levels of care.
    • Causes include path dependence, heretofore weak advocacy, and a failure of critical thinking
    • Change is a-coming
  • Thank you
    • For what you do
    • No individual fault
    • There is another way and it is worth the effort
  • What Are We Talking About, Willis?
    • Four Classes of Psychoactive Drugs:
      • Anti-Depressants (e.g. Zoloft, Remeron, Effexor)
      • Hypnotics (e.g. Halcion, Restoril)
      • Anti-Anxieties (e.g. Ativan, Valium)
      • Anti-Psychotics (e.g. Zyprexa, Risperdal, Seroquel, Haldol)
  • Why are Anti-psychotics Used?
    • People with dementia:
      • resist care;
      • call out;
      • wander
    • To ease suffering or prevent violence
    • We don’t know what else to do
  • Psych Drugs for Dementia is Off-Label Use
    • Most psych drug use in long-term
    • care is to “manage behavior,”
    • not to treat a specific condition -
    • i.e. to chemically restrain.
    • Off-label: medication not approved by the FDA to treat the condition at issue. (83% of snf anti-psychotic use)
  • Antipsychotics - Risks Galore, Including DEATH
    • Side Effects: too many to name - strokes, falls, dizziness,weakness, headache, tardive diskinesia
    • Some side effects are the symptoms the drugs are supposed to treat: agitation, restlessness, confusion, delirium, cognitive decline, seizures.
    • Double risk of death for elderly with dementia (FDA Black Box warning)
  • More Harm than Good?
    • Outperformed by placebos
    • Growing belief that psych drugs are not “treatment” (disrupt normal brain functioning, long-time users experience worse outcomes, number of “mentally ill” is growing)
  • The Resident Perspective
    • “ Everything was foggy. I couldn’t think clearly and couldn’t say what I wanted. I don’t remember feeling any emotions other than confusion.”
    • My epiphany
  • Despite Horribles, Awash in Drugs
  • Why?
    • Lack of physician presence (payment structure favors prescribing over observing)
    • Autonomic drug requests for “behaviors”
    • Overworked staff
    • No Law Enforcement
    • Vulnerable Consumers and Families
  • Did Somebody Say Money?
  • Big Pharma
    • “ Despite [lethality], there’s ample evidence that some drug companies aggressively marketed their products towards such populations [elderly with dementia], putting profits before safety.” HHS Inspector General Daniel Levinson
  • The Scorpion’s Tale
  • Kern Valley
  • Drugging Process: Schizophrenia vs. Dementia
    • Schizophrenia
    • 72-hour hold
    • 14 day certification
    • Commitment Hearing
    • Involuntary Drugging Hearing
    • Dementia
    • [insert sound of chirping crickets]
  • The Law is Good
    • Informed Consent
    • No Unnecessary Drugs
    • Chemical Restraints Prohibited
    • Gradual Dose Reduction
  • Informed Consent
    • Informed: risks, benefits, and alternatives (failure is negligence)
    • Consent: all treatment requires agreement from the patients or surrogate (failure is battery)
    • Regardless of “capacity,” all residents have right to refuse.
    • Two instances where i.c. can be presumed: emergencies and Hlth. & Safe. 1418.8
  • Informed Consent (cont’d)
    • Obtaining informed consent is a doctor’s duty.
    • Nursing homes have a separate duty of ensuring that informed consent has been obtained.
    • Information regarding psych drugs is explicitly directed by 22 Cal. Code Regs 72528.
  • “ Pre-Existing” Drugs
    • DPH AFL 11-08: “surveyors must confirm that health records contain documentation that the patient gave informed consent for the treatments listed in the regulation for all residents, including those admitted with preexisting orders.”
  • Informed Consent (cont’d)
    • Informed Consent is often a sham
      • May be totally overlooked
      • May be fraud
  • Informed Consent?
  • Battery?
  • IC in Practice
    • A: [nursing home staff] get the consent over the phone . . . I can’t do that in nursing home patients. It’s impossible.
    • Q: Why is that?
    • A: Because you can never catch the family at the right time. If you can, you’ll do that, you’ll do the consent at that time.
  • IC in Practice
    • Q: On those circumstances where you caught the family and you’ve had the conversation, do you disclose the black box warning?
    • A: I’ve never had that situation arise.
  • No Unnecessary Drugs
    • Unnecessary if:
      • 1) In excessive dose (including duplicate therapy);
      • 2) For excessive duration;
      • 3) Without adequate monitoring;
      • 4) Without adequate indications for its use;
      • 5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued
    • http://www.cms.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf (F-Tag 329, 42 CFR 483.25(l))
  • No Unnecessary Drugs
    • Inadequate Indications for Use:
    • http://www.cms.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf (F-Tag 329, 42 CFR 483.25(l))
    • wandering; poor self-care; restlessness; impaired memory; mild anxiety; insomnia; unsociability; inattention; fidgeting; uncooperativeness; behavior that is not dangerous to others
  • No Chemical Restraints
    • Federal: any drug imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms (42 C.F.R. Sec. 483.13(a))
    • State: a drug used to control behavior and used in a manner not required to treat the patient's medical symptoms (22 Cal. Code Regs 72018)
  • Gradual Dose Reduction
    • Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated. (42 CFR 483.25(l))
  • Law is Good, Enforcement WEAK
    • In the last 20 years:
    • I.C.: 11 citations
    • Unnecessary Drugs: 25 citations
    • Chemical Restraints: 30 citations
    • GDR: 3 citations
  • Why is Enforcement so Weak?
    • Perspective & Priorities
    • informed consent is a “paperwork concern”
      • But Black Box warnings have correlated with 9% reduction in atypical antipsychotics nationwide
  • Absent Ombudsman
    • CA Ombudsman Complaint Category 62 (psych drug assessment, use, evaluation):
    • 2007-08: 33
    • 2008-09: 24
    • 2009-10: 20
    • Suggests a lack of visibility, access, and maybe curiosity
  • Alternatives - Drugging Must Be Last Resort
    • Diagnosis: rule out dehydration, infection, pain, sleep deprivation, etc.
    • Care, attention, and observation
      • consistent assignment is a key
      • Experiential Audit is one approach
    • Patience
    • Non-drug therapy (e.g. psychologist, exercise)
  • The Pros Are With Us
    • Amer. Psychiatric Ass’n: cognition, emotion, stimulation, behavior-oriented approaches first
    • AMDA: behaviors should be anticipated and accommodated instead of being seen as a symptom to be treated.
    • Jonathan Evans: Patient / environment interaction
  • Alternatives - Resources
  • Déjà Vu All Over Again
    • “ E xcessive use of tranquilizers can quickly reduce an ambulatory patient to a zombie, confining the patient to a chair or bed, causing the patient’s muscles to atrophy from inaction and causing general health to deteriorate quickly . . . it appears many doctors give blanket instructions to nursing home staffs for the use of tranquilizer drugs on patients who do not need them.”
  • The CANHR Campaign
    • www.canhr.org/stop-drugging
  • DATA!
  • We Know We Can Succeed
    • Campaign to reduce use of physical restraints dropped use from 21% in 1991 to 2.6% in 2010
    • Key - re-order thinking and stigmatize use
      • Loud Advocates
      • Progressive Providers
      • Robust Enforcement
  • The Movement is in Motion
    • Massachusetts - state regulators and industry together
      • Identify best practices
      • Teach alternative behavioral management
    • VT Gold Star Project
    • Ecumen Awakenings Initiative
    • Beatitudes
  • What Can You Do?
    • Doctors:
    • Drug last instead of first
    • Obtain informed consent
    • Administrators:
    • Lead
    • Train
    • Watch drugging numbers
  • What Can You Do?
    • Nursing:
    • Learn and teach
    • Find the balance
    • Care Providers:
    • Observe and communicate
    • Question
  • What Can You Do?
    • Enforcement:
    • Perspective
    • Raise expectations
    • Family / Advocates:
    • Breakout Session
  • Summary Points
    • Anti-psychotic risks often exceed benefits
    • The law requires a least medicating approach
    • Least medicating is a well-proven better way
    • We will back you up 100%
  • The Takeaway
    • Given their
    normal brain physiological dangers, functioning, and association with inappropriate chemical restraint, antipsychotic drugs as a treatment for the behavioral symptoms associated with dementia should only be used as a last resort, after all non-pharmacological interventions have been attempted and failed. effects on
  • Thank you
    • We are all here because we care.