Thursday, February 17, 2011

Clearing the Fog in Nursing Homes -

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“What’s people’s biggest fear? Being a ‘zombie’ in a nursing home,” said Laurel Baxter, the Awakenings project manager.

Any visitor can see what she means. Even in quality nursing homes, some residents sit impassively in wheelchairs or nod off in front of televisions, apparently unable to interact with others or to summon much interest in their lives. Nursing home reformers and regulators have long believed that this disengagement results in part from the overuse of psychotropic medication to quell the troublesome behaviors that can accompany dementia — yelling, wandering, aggression, resisting care. For nearly 25 years, federal law has required that psychotropic drugs (which critics call “chemical restraints”) be used only when necessary to ensure the safety of a resident or those around her.

The drugs can cause serious side effects. Since 2008, the Food and Drug Administration has required a so-called black box warnings on their packaging, cautioning that they pose an increased mortality risk for elderly patients. Nevertheless, a national survey reported that in 2004 about a quarter of nursing home residents were receiving antipsychotic drugs. (Among the antipsychotic drugs most commonly used in nursing homes are Risperdal, Seroquel and Zyprexa.)

Though they may be prescribed less frequently following the F.D.A.’s warnings, these drugs are still overused in long-term care, said Dr. Mark Lachs, chief of geriatrics at Weill Cornell Medical College. And once the pills are prescribed, residents keep taking them. “They get perpetualized, like insulin,” he told me, even though the behaviors they’re meant to soothe may wane anyway as dementia progresses.

“If a place is understaffed, if it takes particularly unruly patients, you can see how it happens,” Dr. Lachs added. “Behavioral interventions are far more time-consuming than giving a pill.”

Nevertheless, Ecumen’s Awakenings project emphasizes nondrug responses. “Medications have a place, but that shouldn’t be the first thing you try,” said Eva Lanigan, director of nursing at the Two Harbors facility.

So the home trained its entire staff (housekeepers, cooks, dining room servers, everyone) in a variety of tools to calm and reassure its 55 residents: exercise, activities, music, massage, aromatherapy. It taught people the kind of conversation known as “redirecting” — listening to elders and responding to them without insisting on facts that those with dementia can’t absorb or won’t recall.

“The hands-on, caring part is the most important,” Ms. Lanigan said. “Sometimes, people just want a hug. You sit and hold their hand.”

At the same time, consulting with a geriatric psychiatrist and a pharmacist, the home began gradually reducing the doses of antipsychotics and antidepressants for patients whose families agreed. Among them: the woman with the mysterious cries.

As Dr. Lachs pointed out, behavioral interventions are labor-intensive. Two Harbors hired an additional nurse to oversee those efforts, and Ms. Lanigan was available to answer staff questions around the clock. Ecumen estimates that introducing the program to a 60-bed nursing home cost an additional $75,000 a year for two full-time employees.

The results startled even the believers, however. Every resident on antipsychotics (about 10) was able to stop taking them, and 30 to 50 percent of those taking antidepressants also did well without them. When drugs still seemed necessary, “we tried to reduce them to the lowest dose possible,” Ms. Lanigan said.
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