Anti-Psychotic Drug Use in Nursing Homes

A current, controversial area of medical, legal, and ethical concern in America is the distribution of anti-psychotic drugs to nursing home patients as a method of chemical restraint. According to the Code of Federal Regulations for Public Health, a nursing home “resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident’s medical symptoms.” State laws reinforce the federal regulations and delve into further detail about defining and administering anti-psychotic drugs. An example from Indiana’s regulations includes requiring an “order for chemical restraints [to] specify the dosage and the interval of and reasons for the use of chemical restraint.”

Most of the state laws are still unclear as to what the use of chemical restraints should be. The definition of chemical restraints, according to California’s Code of Regulations , explains that a “chemical restraint is anything that is used for discipline or convenience and not required to treat medical symptoms. . . . If a medication is used solely or primarily to treat a medical condition, it is not a chemical restraint.” While operating under the federal regulations, California’s definition implies that the use of chemical restraints is unlawful. The state’s regulations go on further to outline that “[r]estraints shall not be used for disciplinary purposes, for staff convenience or to reduce the need for care of residents during periods of understaffing.” These discrepancies within states’ own regulations is an excellent example of the unclear boundaries of which physicians and nursing facilities may take advantage.

In the “State Regulations Pertaining to Resident Behavior & Facility Practices,” most of the states agree that residents have the right to be free from restraints that are “not required to treat” a resident’s medical symptoms. Most states reinforce the prohibition of using these drugs for the purpose of “discipline or convenience,” already required by federal regulations. However, there are more holistic treatments available to appease these patients’ symptoms; thus, if not for discipline or convenience—what are these drugs for?

The Food and Drug Administration has determined that the risks of anti-psychotic drugs include “complications such as movement disorders, falls, hip fractures, cerebrovascular adverse events . . . and increased risk of death.” The FDA attributes roughly 15,000 deaths each year in nursing homes to “unnecessary anti-psychotic use” and has not approved any drugs for the purpose of chemical restraint. For all the risks of potential long-lasting effects, these anti-psychotic drugs provide only temporary behavioral solutions. Since the definition and legality of chemical restraints is vague, nursing homes often use them in order to control outbursts and behaviors that have undetermined causes, a more cost-effective solution for the facility in comparison to more individualized, holistic approaches.

Nursing homes often use chemical restraints to supplant increased staff, trained in managing dementia patients. The anti-psychotic drugs serve as a quick fix to suppress outbursts that the staff does not have the means to handle. Yet, the lack of a foundational understanding of these patients translates into an inability to properly administer these drugs and gage their effectiveness. In a study, the Centers for Medicare & Medicaid Services ran 42 investigations, involving patients already receiving anti-psychotic medications and of those 69% “resulted in deficiencies related to inappropriate antipsychotic use.” Within 85% of those investigations, the consultant pharmacists failed to “identify the inappropriate antipsychotic use upon their review.”

The criteria for the effectiveness of chemical restraints depends on temporary behavioral appeasements, not the health benefits of the patients. In 55% of the total investigations, the proper procedures, outlined in care plans (behavioral analyses, documentation of side effects, etc.), were incomplete, and in 81% of those cases, the physicians were unable to determine the difference between “therapeutic effectiveness” and “side effects to be monitored.”

According to Charlene Harrington, a University of California, San Francisco professor of nursing and sociology, “as many as 1 in 5 patients in the nation’s 15,500 nursing homes are given antipsychotic drugs that are not only unnecessary, but also extremely dangerous for older patients.” Nursing homes and pharmaceutical companies are profit-driven businesses. The vagueness and improper enforcement of laws involving chemical restraints condone improper uses of these drugs as cost effective restraints.

As a society, we have to determine whether we have been relinquishing the responsibility of our elderly’s quality of life to the impersonal and unsympathetic hands of lawmakers, pharmaceutical companies, and nursing homes. People have a natural, inherent fear of death and the unknown; thus, they often avoid talking about them. Being closer to death, the elderly, who may be physically or mentally weaker than they once were, remind us indirectly of death, and so they suffer from our selfish avoidance of the subject.