Nursing Homes Create Phony Diagnoses to Sedate Patients with Dangerous Drugs, Doubling Risk of Death

The New York Times (NYT), in a recent front-page Sunday article, "Phony Diagnoses Hide High Rates of Drugging at Nursing Homes," explores and exposes the use of chemical restraints, including antipsychotic medications, to control behavior of  long-term care residents. This blog has previously discussed the use of pointless  and dangerous drugs dispensed to terminally ill dementia patients in nursing homes.  See, "Most Terminal Dementia Patients in Nursing Homes Given Pointless and Potentially Dangerous Drugs."

Antipsychotic drugs have faced criticism for decades as “chemical straitjackets. They are medically unnecessary and dangerous for older people with dementia, nearly doubling their chance of death from heart problems, infections, falls and other ailments. Understaffed nursing homes have, nonetheless, often used the sedatives so they don’t have to hire more staff to handle residents.  

The battle against this pernicious practice is not new.  In 1987, President Ronald Reagan signed a law banning the use of drugs that serve the interest of the nursing home or its staff, not the patient.

But the practice persisted. In the early 2000s, studies found that antipsychotic drugs like Seroquel, Zyprexa and Abilify made older people drowsy and more likely to fall. The drugs were also linked to heart problems in people with dementia. More than a dozen clinical trials concluded that the drugs nearly doubled the risk of death for older dementia patients.

In 2005, the Food and Drug Administration (FDA) required manufacturers to put a label on the drugs warning that they increased the risk of death for patients with dementia.  While FDA advisories generated public awareness, it is well known that prescribers’ compliance with black-box warnings is low. Seven years later, in 2012, with antipsychotics still widely used, nursing homes were required to report to Medicare how many residents were getting the drugs. That data is posted online and becomes part of a facility’s “quality of resident care” score, one of three major categories that contribute to a home’s star rating.

The only catch: antipsychotic prescriptions for residents with any of three uncommon conditions, schizophrenia, Tourette’s syndrome and Huntington’s disease, are not included in a facility’s public tally. The theory was that since the drugs were approved to treat patients with those conditions, nursing homes shouldn’t be penalized.

The loophole was opened. The NYT has discovered that residents are simply  given "new" diagnoses of, for example, schizophrenia, attempting to justify the sedation associated with major antipsychotic medications, such as Haldol, despite the fact that such medications are contraindicated for dementia patients. According to the NYT, since 2012, the share of residents classified as having schizophrenia has risen to 11 percent from less than 7 percent.  The diagnoses rose even as nursing homes reported a decline in behaviors associated with the disorder. The number of residents experiencing delusions, for example, fell to 4 percent from 6 percent.

Today, one in nine residents has received a schizophrenia diagnosis. In the general population, the disorder, which has strong genetic roots, afflicts roughly one in 150 people.  Moreover, Schizophrenia, which often causes delusions, hallucinations and dampened emotions, is almost always diagnosed before the age of 40.

“People don’t just wake up with schizophrenia when they are elderly,”  Dr. Michael Wasserman, a geriatrician and former nursing home executive who has become a critic of the industry told the NYT. “It’s used to skirt the rules.”

Some portion of the rise in schizophrenia diagnoses probably stems from the fact that nursing homes, like prisons, have become a refuge of last resort for people with the disorder, after large psychiatric hospitals closed decades ago.

But unfounded diagnoses are also undoubtedly driving the increase. In May, a report by a federal oversight agency said nearly one-third of long-term nursing home residents with schizophrenia diagnoses in 2018 had no Medicare record of being treated for the condition.  Even for those for which there was some record of treatment, the treatment records, do not provide important details about the drug use (e.g., which antipsychotic drugs were prescribed; at what quantities and strengths; and for what durations).  The lack of treatment records suggest the drugs are not being prescribed to treat a legitimate condition, but are being used for other purpose.

The revelation should come as no surprise: many facilities have found ways to hide serious problems, like inadequate staffing and haphazard care, from government audits and inspectors.  The problem with misreporting staffing was so outrageous that, in 2019, CMS actually demanded payroll reports to verify nursing home reporting of staff numbers, immediately after which implementing such verification, more than one-third of nursing homes saw their ratings decline. See, this blog's article: "Medicare Ratings Fall for Short-Staffed Nursing Homes- One-Third of Nursing Homes See Ratings Drop."  There were a minority of nursing homes that didn't even have a staff nurse, resulting in home closures. 

The NYT, demonstrating the power of investigative journalism, reports:

According to Medicare’s web page that tracks the effort to reduce the use of antipsychotics, fewer than 15 percent of nursing home residents are on such medications. But that figure excludes patients with schizophrenia diagnoses.

To determine the full number of residents being drugged nationally and at specific homes, The Times obtained unfiltered data that was posted on another, little-known Medicare web page, as well as facility-by-facility data that a patient advocacy group got from Medicare via an open records request and shared with The Times.

The figures showed that at least 21 percent of nursing home residents...are on antipsychotics [link included in original].

That means a full one in five nursing home residents are receiving potentially unnecessary and dangerous medications!  The reasons why this practice continues are obvious: caring for dementia patients is time- and labor-intensive. Workers need to be trained to handle challenging behaviors like wandering and aggression. But many nursing homes are chronically understaffed and do not pay enough to retain a sufficient number of employees, especially the nursing assistants who provide the bulk of residents’ daily care. 

Studies have found that the worse a home’s staffing situation, the greater its use of antipsychotic drugs. That suggests that some homes are using the powerful drugs to subdue and sedate patients to avoid having to hire extra staff, or alternately to relieve already over-worked staff from the burden of caregiving.  According to the NYT analysis of Medicare data, homes with staffing shortages are also the most likely to misrepresent the number of residents on antipsychotics.

Staffing shortages are extreme, and threatening, made worse by a pandemic that has battered the industry. Nursing home employment is down more than 200,000 since early last year and is at its lowest level since 1994.

As staffing dropped, the use of antipsychotics rose.

Recent vaccine mandates further threaten industry staffing. In fact, following an announcement from President Biden that all nursing home staff will be required to be fully vaccinated against COVID-19 in a forthcoming regulation, the nursing home industry warned about the potential impact on the profession’s already challenging workforce situation. Industry leaders are deeply concerned that it may cause a "mass exodus" from the nursing home profession, leaving frail seniors without the caregivers and access to care they need.

In Ohio, only 54.3% of nursing home staff have been vaccinated, according to federal data.  Pete Van Runkle, head of the Ohio Health Care Association, which represents the state's for-profit long-term care facilities, fears additional staffing shortages. A facility in Ohio on average has 19 open positions it can't fill, according to a recent Ohio Health Care Association survey. The mandate could make things worse, Van Runkle has said.

"I'm scared to death of what that's going to look like," he said.

Van Runkle noted there was one large long-term care company that voluntarily mandated vaccines, only to walk it back later after workers threatened to leave.

Staff exodus will only increase the already strong incentives to misuse and abuse drugs as chemical restraints.  According to the NYT, the country’s leading experts on elder care are already "taken aback" by the frequency of false diagnoses and the overuse of antipsychotics.  Barbara Coulter Edwards, a senior Medicaid official in the Obama administration, told the NYT she discovered that her own father was given an incorrect diagnosis of psychosis in the nursing home where he lived even though he had dementia.

“I just was shocked,” Ms. Edwards said. “And the first thing that flashed through my head was this covers a lot of ills for this nursing home if they want to give him drugs.”

In 2019 and again in 2021, Medicare said it planned to conduct targeted inspections to examine the issue of false schizophrenia diagnoses, but those plans were repeatedly put on hold because of the pandemic.

In an analysis of government inspection reports, The NYT found about 5,600 instances of inspectors citing nursing homes for misusing antipsychotic medications. Nursing home officials told inspectors that they were dispensing the powerful drugs to frail patients for reasons that ranged from “health maintenance” to efforts to deal with residents who were “whining” or “asking for help.”  

"Asking for help."  Let that sink in.