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Chemical Restraints and overmedication

Published on November 26th, 2009

Chicago Tribune had an article that is a good follow-up or counter balance to yesterday’s blog entry.  The article discusses the overmedication of nursing home residents including Delores Fleming.  She moved into Heritage Manor of Mount Zion and scored 23 out of 30 on a mental exam and was deemed to be "moderately impaired," state inspection records show.  Fleming had few problems her first week in the nursing home, according to her medical records, which her family provided to the Tribune.  But after she repeatedly had crying spells and tried to wander away, the nursing home doctor prescribed two anti psychotic drugs, even though she was not psychotic. Her family had given consent for the Seroquel, but the medical records show the permission sheet erroneously described the drug as an anti-anxiety medication. Seroquel is an anti psychotic drug intended for serious mental illnesses, such as schizophrenia.

Records show that Fleming briefly improved on the Seroquel, but over the next three months she had episodes of extreme anxiety.  The doctor doubled the dosage of one medication no fewer than four times, putting her above the recommended limit.  Once she thought she was possessed, nursing notes state. Another time she thought her brother had left her $50 million.

Her doctor ordered multiple injections of the anti psychotic drug Haldol and the anti-anxiety medication Ativan, state inspection records show. Fleming’s dose of Seroquel also was repeatedly doubled, putting her above the recommended limit for that drug.

After Fleming’s family complained that she had grown lethargic, the staff referred her to a neurologist. According to a state inspection report, the neurologist found her catatonic and believed she had developed tremorlike "Parkinson’s symptoms, due to the Haldol."  When he gave her the same mental exam she had previously taken, she scored zero out of 30. The neurologist recommended that her drugs be curtailed, and her condition dramatically improved. When she retook the test, she scored a 30 out of 30.

Both her family and the facility decided she should live elsewhere. The family wanted her in a home that specialized in Alzheimer’s care; Heritage Manor believed Fleming was endangering other residents, records show, and gave her 30 days to leave.

When the Tribune reviewed 40,000 state and federal inspection reports filed since 2001 on 742 Illinois nursing homes, numerous instances emerged in which regulators cited facilities for misusing psychotropics even though the patients’ doctors had created the problems.

When physicians or psychiatrists prescribe a drug for a patient, facilities must administer it as long as the order is consistent with state and federal nursing home regulations. If inspectors determine a violation occurred, they cite the nursing facility, not the doctor.

The Tribune found that inspectors documented many cases in which doctors prescribed powerful anti psychotic drugs without adequate justification or in doses that were too high.  The doctors also sometimes failed to provide adequate follow-up care, the inspection records show. They are required to see their nursing home patients only once every 60 days, though some do not visit even that often.  Several nursing home owners interviewed by the Tribune said they have struggled with doctors who rarely make time to visit patients.

Nursing homes are required to have pharmacists visit the facilities regularly and review prescriptions. If they discover irregularities, such as a patient placed on a drug without cause, they notify the nursing staff and doctor. But the Tribune found that when pharmacists recommended that a psychotropic be discontinued or the dosage reduced, physicians sometimes ignored the advice.

The difficult task of monitoring for side effects is left to nurses who are poorly trained in the use of psychotropic drugs. Experts say the situation can affect quality of care, and the Tribune’s review of inspection reports shows that is true — sometimes with tragic consequences.

The Chicago Tribune has done a great job researching, investigating, and writing about the use and abuse of anti-psychotics in nursing homes. See full article here.
 

Joe Pioletti
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