The nation’s nursing homes, battered by the coronavirus pandemic, are under more fire for their resurgent reliance on powerful and risky psychiatric drugs and shaky diagnoses of mental illness to treat elderly residents, as well as for the institutions’ inability to safeguard the old, sick, and injured in their care by ensuring their staff are vaccinated against Covid-19.
Facilities across the country have recorded a 70% spike in dubious designations of elderly residents as schizophrenic. This means they may be dosed with potent antipsychotic drugs, which, critics say, act akin to pharmaceutical restraints and can reduce the vulnerable to near vegetative states, the New York Times reported, based on its investigation of the issue.
The newspaper noted that federal regulators and mental health professionals have campaigned for years to get nursing homes and other long-term care facilities to stop using certain medications, which once were more routinely administered and pack more than a wallop for the old:
“Antipsychotic drugs — which for decades have faced criticism as ‘chemical straitjackets’ — are dangerous for older people with dementia, nearly doubling their chance of death from heart problems, infections, falls, and other ailments. But understaffed nursing homes have often used the sedatives, so they don’t have to hire more staff to handle residents. The risks to patients treated with antipsychotics are so high that nursing homes must report to the government how many of their residents are on these potent medications. But there is an important caveat: The government doesn’t publicly divulge the use of antipsychotics given to residents with schizophrenia or two other conditions.”
This has resulted in an unforeseen institutional response, the newspaper reported:
“A New York Times investigation found a … pattern of questionable diagnoses nationwide. The result: The government and the industry are obscuring the true rate of antipsychotic drug use on vulnerable residents. The share of residents with a schizophrenia diagnosis has soared 70% since 2012, according to an analysis of Medicare data. That was the year the federal government, concerned with the overuse of antipsychotic drugs, began publicly disclosing such prescriptions by individual nursing homes. Today, 1 in 9 residents has received a schizophrenia diagnosis. In the general population, the disorder, which has strong genetic roots, afflicts roughly 1 in 150 people. 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,’ said Dr. Michael Wasserman, a geriatrician and former nursing home executive who has become a critic of the industry. ‘It’s used to skirt the rules.’”
The newspaper, based on its investigation, offered homes some defenses for the reported increase in mental illness among residents:
“Some portion of the rise in schizophrenia diagnoses reflects 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 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. For nursing homes, money is on the line. High rates of antipsychotic drug use can hurt a home’s public image and the star rating it gets from the government. Medicare designed the ratings system to help patients and their families evaluate facilities using objective data; a low rating can have major financial consequences. Many facilities have found ways to hide serious problems — like inadequate staffing and haphazard care — from government audits and inspectors. One result of the inaccurate diagnoses is that the government is understating how many of the country’s 1.1 million nursing home residents are on antipsychotic medications. According to Medicare’s web page that tracks the effort to reduce the use of antipsychotics, fewer than 15% of nursing home residents are on such medications. But that figure excludes patients with schizophrenia diagnoses.”
The newspaper’s sleuthing, assisted by an advocacy group, estimates that “at least 21% of nursing home residents — about 225,000 people — are on antipsychotics.”
Maintaining safety or creating desperate warehouses?
The audience comments raise intriguing points based on the news investigation. Some readers have defended the drugging of residents with dementia, noting that such individuals can become agitated and a safety concern for others in homes. Readers, however, also argued that institutions are so obsessed with profits that they have slashed health worker staffing, leaving residents, especially those with dementia and other conditions that require intensive attention, adrift and more likely to worsen. Indeed, commentators suggested that too many nursing homes have become little more than warehouses for the sick, ill, and injured in conditions so dismal that they may launch or aggravate mental conditions.
Experts and resident advocates interviewed by the newspaper slammed nursing homes both for having medical staff make sham schizophrenia diagnoses and for using those to drug up people in their care. The experts questioned how medical professionals so readily could diagnose a complex mental illness in residents with other serious problems like dementia and then order powerful antipsychotics in almost routine response. One favored diagnosis, schizophrenia, is almost never seen for the first time when someone is elderly; it is a chronic condition that typically emerges in young adulthood.
Advocates assailed the drugging up of residents, noting this not only posed high risks to those with common accompanying heart conditions but also that it too often leaves them groggy and disoriented. They become compliant or adherent, easier for staff to handle. But the elderly — in whom drug dosages can be trickier to get right — can decline rapidly as they stay inert and bed-ridden, developing infections, bedsores, and losing their claim on life.
Too many unvaccinated facility staff
Nursing homes, in the meantime, seem to be in as great a panic about their staff as their residents.
The pandemic has publicly exposed how facilities overwork, underpay, under rain, and overstress nurses and especially the health aides who provide most of the direct care for residents of nursing homes and other long-term care facilities. The aides make so little money that many work at multiple jobs, often traveling for shifts between different nursing homes. They, like home residents, suffered a terrible toll of infections, hospitalizations, and deaths due to the coronavirus.
But the aides, a new study has found, were among the least likely by as recently as mid-July to get vaccinated, especially as federal and local officials have campaigned to get vulnerable residents the safe and highly effective shots. As the New York Times reported of this research:
“The findings are ‘alarming and reason for pause,’ said Brian McGarry, a health researcher at the University of Rochester and one of the authors of the analysis, which appeared in a research letter in JAMA Internal Medicine [on Sept. 16]. Low vaccination rates among nursing home workers in some areas have fueled concern about fresh outbreaks among staff and residents in these facilities, even with high numbers of vaccinated residents. Covid deaths among nursing home staff and residents accounted for nearly one third of the nation’s pandemic fatalities as of June 1, and vaccination rates among staff average around 63%, according to the latest federal data.
“But slightly under half of the certified nursing assistants were fully vaccinated, according to the analysis, which looked at federal vaccination data through July 18. That was before many nursing homes, states and cities began imposing mandates. According to the study, in nursing homes overall, 61% of nurses, both registered nurses and licensed practical nurses, were vaccinated, compared with 71% of therapists and 77% of doctors and independent practitioners like physician assistants or nurse practitioners.”
Facilities themselves, especially those in chain ownership, have started to require their staff to get vaccinated. The Biden Administration has mandated this federally for facilities nationwide, especially as they are so dependent on U.S. money via the Medicare and Medicaid programs. Owners and operators have beefed about the requirement, arguing it might cost them staff. That worry may have eased some as the mandate stretches to so many facilities. But as the New York Times reported:
“David Grabowski, a professor of health care policy at Harvard Medical School and one of the study’s authors, said few nursing homes have mandates in place so far. While homes’ vaccination rates have ticked up slightly, the overall rate for nursing homes has hovered at just a little above 60% in the last couple of months even as the Delta variant took hold and drove up new cases among staff and residents.”
It’s also worth noting this information from the newspaper:
“Genesis HealthCare, one of the nation’s largest nursing-home operators, required vaccinations in August and said it had ‘met our deadline of 100% vaccinated staff, as promised — excluding the small number of individuals who received medical or religious exemptions.’”
In my practice, I see not only the harms that patients suffer while seeking medical services, but also the damage that can be inflicted on them and their loved ones by neglect and abuse in nursing homes and other long-term care facilities.
The pandemic became a deadly way for the public to see the many unacceptable ways that nursing home owners and operators pursued profits at the expense of residents and their loved ones. The industry claims it did the best it could under tough, unforeseen circumstance.
But after dumping billions of dollars in taxpayers’ hard-earned money into them, where is the accountability for the debacle that occurred with them? And after the hard work that so many put into efforts to get facilities to halt their ill-advised use of psychiatric drugs on residents, what will regulators do to crackdown on the return of this sketchy practice?
Critics love to slam malpractice lawyers and the civil justice system. But many nursing home residents and their families, struggling still with the consequences of the pandemic, are thinking hard if their best recourse may be lawsuits to seek justice for wrongs done to them. As a colleague of mine who specializes in legal matters affecting nursing homes and their residents pointed out, civil lawsuits may be crucial for those harmed (patients and loved ones) because skilled lawyers often can dig out concrete facts and evidence faster and far better during a court case than many regulators might.
We have a lot of work to do to make nursing homes and other long-term care facilities safe, hygienic, affordable, accessible, and welcoming to the vulnerable — not places for them to be turned into zombies or to be infected with diseases and to die in sad and unacceptable fashion.
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