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

    1. 1. 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
    2. 2. The Intro <ul><li>60% of all nursing home residents receive a psychoactive drug. </li></ul><ul><li>Substituting drugs for care happens at all levels of care. </li></ul><ul><li>Causes include path dependence, heretofore weak advocacy, and a failure of critical thinking </li></ul><ul><li>Change is a-coming </li></ul>
    3. 3. Thank you <ul><li>For what you do </li></ul><ul><li>No individual fault </li></ul><ul><li>There is another way and it is worth the effort </li></ul>
    4. 4. What Are We Talking About, Willis? <ul><li>Four Classes of Psychoactive Drugs: </li></ul><ul><ul><li>Anti-Depressants (e.g. Zoloft, Remeron, Effexor) </li></ul></ul><ul><ul><li>Hypnotics (e.g. Halcion, Restoril) </li></ul></ul><ul><ul><li>Anti-Anxieties (e.g. Ativan, Valium) </li></ul></ul><ul><ul><li>Anti-Psychotics (e.g. Zyprexa, Risperdal, Seroquel, Haldol) </li></ul></ul>
    5. 5. Why are Anti-psychotics Used? <ul><li>People with dementia: </li></ul><ul><ul><li>resist care; </li></ul></ul><ul><ul><li>call out; </li></ul></ul><ul><ul><li>wander </li></ul></ul><ul><li>To ease suffering or prevent violence </li></ul><ul><li>We don’t know what else to do </li></ul>
    6. 6. Psych Drugs for Dementia is Off-Label Use <ul><li>Most psych drug use in long-term </li></ul><ul><li>care is to “manage behavior,” </li></ul><ul><li>not to treat a specific condition - </li></ul><ul><li>i.e. to chemically restrain. </li></ul><ul><li>Off-label: medication not approved by the FDA to treat the condition at issue. (83% of snf anti-psychotic use) </li></ul>
    7. 7. Antipsychotics - Risks Galore, Including DEATH <ul><li>Side Effects: too many to name - strokes, falls, dizziness,weakness, headache, tardive diskinesia </li></ul><ul><li>Some side effects are the symptoms the drugs are supposed to treat: agitation, restlessness, confusion, delirium, cognitive decline, seizures. </li></ul><ul><li>Double risk of death for elderly with dementia (FDA Black Box warning) </li></ul>
    8. 8. More Harm than Good? <ul><li>Outperformed by placebos </li></ul><ul><li>Growing belief that psych drugs are not “treatment” (disrupt normal brain functioning, long-time users experience worse outcomes, number of “mentally ill” is growing) </li></ul>
    9. 9. The Resident Perspective <ul><li>“ 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.” </li></ul><ul><li>My epiphany </li></ul>
    10. 10. Despite Horribles, Awash in Drugs
    11. 11. Why? <ul><li>Lack of physician presence (payment structure favors prescribing over observing) </li></ul><ul><li>Autonomic drug requests for “behaviors” </li></ul><ul><li>Overworked staff </li></ul><ul><li>No Law Enforcement </li></ul><ul><li>Vulnerable Consumers and Families </li></ul>
    12. 12. Did Somebody Say Money?
    13. 13. Big Pharma <ul><li>“ 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 </li></ul>
    14. 14. The Scorpion’s Tale
    15. 15. Kern Valley
    16. 16. Drugging Process: Schizophrenia vs. Dementia <ul><li>Schizophrenia </li></ul><ul><li>72-hour hold </li></ul><ul><li>14 day certification </li></ul><ul><li>Commitment Hearing </li></ul><ul><li>Involuntary Drugging Hearing </li></ul><ul><li>Dementia </li></ul><ul><li>[insert sound of chirping crickets] </li></ul>
    17. 17. The Law is Good <ul><li>Informed Consent </li></ul><ul><li>No Unnecessary Drugs </li></ul><ul><li>Chemical Restraints Prohibited </li></ul><ul><li>Gradual Dose Reduction </li></ul>
    18. 18. Informed Consent <ul><li>Informed: risks, benefits, and alternatives (failure is negligence) </li></ul><ul><li>Consent: all treatment requires agreement from the patients or surrogate (failure is battery) </li></ul><ul><li>Regardless of “capacity,” all residents have right to refuse. </li></ul><ul><li>Two instances where i.c. can be presumed: emergencies and Hlth. & Safe. 1418.8 </li></ul>
    19. 19. Informed Consent (cont’d) <ul><li>Obtaining informed consent is a doctor’s duty. </li></ul><ul><li>Nursing homes have a separate duty of ensuring that informed consent has been obtained. </li></ul><ul><li>Information regarding psych drugs is explicitly directed by 22 Cal. Code Regs 72528. </li></ul>
    20. 20. “ Pre-Existing” Drugs <ul><li>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.” </li></ul>
    21. 21. Informed Consent (cont’d) <ul><li>Informed Consent is often a sham </li></ul><ul><ul><li>May be totally overlooked </li></ul></ul><ul><ul><li>May be fraud </li></ul></ul>
    22. 22. Informed Consent?
    23. 23. Battery?
    24. 24. IC in Practice <ul><li>A: [nursing home staff] get the consent over the phone . . . I can’t do that in nursing home patients. It’s impossible. </li></ul><ul><li>Q: Why is that? </li></ul><ul><li>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. </li></ul>
    25. 25. IC in Practice <ul><li>Q: On those circumstances where you caught the family and you’ve had the conversation, do you disclose the black box warning? </li></ul><ul><li>A: I’ve never had that situation arise. </li></ul>
    26. 26. No Unnecessary Drugs <ul><li>Unnecessary if: </li></ul><ul><ul><li>1) In excessive dose (including duplicate therapy); </li></ul></ul><ul><ul><li>2) For excessive duration; </li></ul></ul><ul><ul><li>3) Without adequate monitoring; </li></ul></ul><ul><ul><li>4) Without adequate indications for its use; </li></ul></ul><ul><ul><li>5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued </li></ul></ul><ul><li> (F-Tag 329, 42 CFR 483.25(l)) </li></ul>
    27. 27. No Unnecessary Drugs <ul><li>Inadequate Indications for Use: </li></ul><ul><li> (F-Tag 329, 42 CFR 483.25(l)) </li></ul><ul><li>wandering; poor self-care; restlessness; impaired memory; mild anxiety; insomnia; unsociability; inattention; fidgeting; uncooperativeness; behavior that is not dangerous to others </li></ul>
    28. 28. No Chemical Restraints <ul><li>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)) </li></ul><ul><li>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) </li></ul>
    29. 29. Gradual Dose Reduction <ul><li>Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated. (42 CFR 483.25(l)) </li></ul>
    30. 30. Law is Good, Enforcement WEAK <ul><li>In the last 20 years: </li></ul><ul><li>I.C.: 11 citations </li></ul><ul><li>Unnecessary Drugs: 25 citations </li></ul><ul><li>Chemical Restraints: 30 citations </li></ul><ul><li>GDR: 3 citations </li></ul>
    31. 31. Why is Enforcement so Weak? <ul><li>Perspective & Priorities </li></ul><ul><li>informed consent is a “paperwork concern” </li></ul><ul><ul><li>But Black Box warnings have correlated with 9% reduction in atypical antipsychotics nationwide </li></ul></ul>
    32. 32. Absent Ombudsman <ul><li>CA Ombudsman Complaint Category 62 (psych drug assessment, use, evaluation): </li></ul><ul><li>2007-08: 33 </li></ul><ul><li>2008-09: 24 </li></ul><ul><li>2009-10: 20 </li></ul><ul><li>Suggests a lack of visibility, access, and maybe curiosity </li></ul>
    33. 33. Alternatives - Drugging Must Be Last Resort <ul><li>Diagnosis: rule out dehydration, infection, pain, sleep deprivation, etc. </li></ul><ul><li>Care, attention, and observation </li></ul><ul><ul><li>consistent assignment is a key </li></ul></ul><ul><ul><li>Experiential Audit is one approach </li></ul></ul><ul><li>Patience </li></ul><ul><li>Non-drug therapy (e.g. psychologist, exercise) </li></ul>
    34. 34. The Pros Are With Us <ul><li>Amer. Psychiatric Ass’n: cognition, emotion, stimulation, behavior-oriented approaches first </li></ul><ul><li>AMDA: behaviors should be anticipated and accommodated instead of being seen as a symptom to be treated. </li></ul><ul><li>Jonathan Evans: Patient / environment interaction </li></ul>
    35. 35. Alternatives - Resources
    36. 36. Déjà Vu All Over Again <ul><li>“ 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.” </li></ul>
    37. 37. The CANHR Campaign <ul><li> </li></ul>
    38. 38. DATA!
    39. 39. We Know We Can Succeed <ul><li>Campaign to reduce use of physical restraints dropped use from 21% in 1991 to 2.6% in 2010 </li></ul><ul><li>Key - re-order thinking and stigmatize use </li></ul><ul><ul><li>Loud Advocates </li></ul></ul><ul><ul><li>Progressive Providers </li></ul></ul><ul><ul><li>Robust Enforcement </li></ul></ul>
    40. 40. The Movement is in Motion <ul><li>Massachusetts - state regulators and industry together </li></ul><ul><ul><li>Identify best practices </li></ul></ul><ul><ul><li>Teach alternative behavioral management </li></ul></ul><ul><li>VT Gold Star Project </li></ul><ul><li>Ecumen Awakenings Initiative </li></ul><ul><li>Beatitudes </li></ul>
    41. 41. What Can You Do? <ul><li>Doctors: </li></ul><ul><li>Drug last instead of first </li></ul><ul><li>Obtain informed consent </li></ul><ul><li>Administrators: </li></ul><ul><li>Lead </li></ul><ul><li>Train </li></ul><ul><li>Watch drugging numbers </li></ul>
    42. 42. What Can You Do? <ul><li>Nursing: </li></ul><ul><li>Learn and teach </li></ul><ul><li>Find the balance </li></ul><ul><li>Care Providers: </li></ul><ul><li>Observe and communicate </li></ul><ul><li>Question </li></ul>
    43. 43. What Can You Do? <ul><li>Enforcement: </li></ul><ul><li>Perspective </li></ul><ul><li>Raise expectations </li></ul><ul><li>Family / Advocates: </li></ul><ul><li>Breakout Session </li></ul>
    44. 44. Summary Points <ul><li>Anti-psychotic risks often exceed benefits </li></ul><ul><li>The law requires a least medicating approach </li></ul><ul><li>Least medicating is a well-proven better way </li></ul><ul><li>We will back you up 100% </li></ul>
    45. 45. The Takeaway <ul><li>Given their </li></ul>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
    46. 46. Thank you <ul><li>We are all here because we care. </li></ul>