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Drugging dementia: Are antipsychotics killing nursing home patients?

‘America Tonight’ investigates why a third of long-term nursing home patients with dementia receive antipsychotics

In a special program Drugging America, America Tonight investigates the overprescription of powerful medication, the harm it's causing and who's benefiting from it. Tune in Friday at 10 p.m. ET/7 PT.

MISSION VIEJO, Calif. – When Gerry Gilgan left the hospital after brain surgery in February 2013, the 78-year-old went into hospice care at Irvine Cottages, south of Los Angeles. He had dementia, but was in good spirits and lucid when he arrived.

The next day, daughter Patrice Gilgan’s cellphone video shows a different man.

“Daddy, wake up! Daddy, wake up!” Patrice Gilgan says, unable to rouse her father, a retired New York City firefighter, who has since died.

Gerry Gilgan’s widow, Marie, was shocked by the sudden change.

“We took him into this home thinking this would be the best place for him,” she said. “[After] a day or two, he’s a different person. It was like he was a vegetable. There was nothing to him. Staring in space, drugged out.”

Within hours of his arrival, records show Gerry Gilgan began receiving the powerful antipsychotic medications Haldol and Seroquel.

Nursing homes justify the use of antipsychotics, saying they calm agitated, anxious or combative residents. According to the facility, Gerry Gilgan was “combative,” though closed-circuit cameras in the nursing home show no evidence of belligerent behavior.

Antipsychotic drugs are approved for patients with bipolar disorder or schizophrenia, not for dementia. In fact, the FDA has given its strongest warning – a so-called black box warning – telling physicians not to prescribe antipsychotics to people with dementia because they can cause heart failure, infection and death.

Despite the FDA warning, a Government Accountability Office report released this month found one-third of long-term nursing home residents with dementia have received antipsychotics. 

‘Zonked out’

Antipsychotics are often given to patients for the benefit of the officials at the facility, in order to control them, said Carole Herman, founder of the Foundation Aiding the Elderly in Sacramento.

“The patient can’t walk anymore. The patient can’t talk anymore, and so there’s less care because basically the patient is incapacitated,” she said. “They’re zonked out all the time, so you don’t have to be bothered with them.”

Gerry Gilgan’s prescription for Haldol was "as needed," as frequently as every six hours.

St. Joseph Health managed Gerry Gilgan’s care, which was paid for by Medicare. St. Joseph declined to speak with “America Tonight” but released a statement:

“Each patient’s condition is unique and often has many factors to consider in determining the appropriate medications. We place high priority on a patient’s right to privacy, and out of respect for that privacy we are unable to discuss the specifics of this case.”

‘The patient can’t walk anymore. The patient can’t talk anymore, and so there’s less care because basically the patient is incapacitated. They’re zonked out all the time, so you don’t have to be bothered with them.’

Carole Herman

founder, Foundation Aiding the Elderly

Five days after he arrived at Irvine Cottages, Gerry Gilgan fell and was taken to the hospital. He didn’t open his eyes for two and a half weeks, his daughter said. A state investigation later concluded Gerry Gilgan was “overmedicated.” [PDF]

Patrice Gilgan said her father was never the same after the overdose. 

Black box warning

Antipsychotics have carried the FDA’s black box warning since 2005. Even so, in 2011, the U.S. Department of Health and Human Services' inspector general issued a report saying dangerous and "off label" use of the drugs was widespread in nursing homes.

Gerry Gilgan with his daughter Patrice in happier times.
America Tonight

"These powerful and, at times, dangerous drugs are too often prescribed for uses that are not approved by the FDA and do not qualify as medically accepted for Medicare coverage," Daniel Levinson testified in a Senate committee hearing. "The FDA has imposed a black box warning emphasizing an increased risk of death when used by elderly patients with dementia. Yet 88 percent of the time, antipsychotics were prescribed for elderly patients with dementia."

Pressuring nursing homes to reduce use of the powerful drugs, Medicare requires nursing homes to report the percentage of long-term residents receiving antipsychotics.

Antipsychotic use in nursing homes has decreased since 2011, but some nursing homes still report using these medications for 70 percent or more of residents. 

“America Tonight” filed a Freedom of Information Act request with the FDA for adverse events related to the antipsychotics Seroquel, Risperdal and Zyprexa. While this doesn't prove causation, there have been dozens of cases of patients with dementia dying fter receiving an antipsychotic.

‘An incident last night’

Marisa Conover’s mother, Genine Zizzo, was an independent, alert 82-year-old. She still drove, lived at home and did her own laundry. One morning in 2012, she tripped over tubing for an oxygen machine she’d started using for congestive heart failure. X-rays showed her back was badly bruised.

A doctor recommended about a week of physical therapy. Roseville Point Health and Wellness in Roseville, California, had a room available.

Before Zizzo checked in, Conover said she went to look at the home – to make sure her mother wouldn’t be getting antipsychotics. She said she’d heard about the dangers of the drugs from a neighbor.

“I went there specifically to tell them if that was their policy, to use antipsychotic drugs on an elderly person, then that would not be the facility for us,” Conover said.

The next morning, Conover went to the nursing home. A staff member approached and said they needed to talk because there had been an incident the previous night.

Genine Zizzo in the days after she was given antipsychotics at Roseville Point Health and Wellness in Roseville, California.
America Tonight

“The hair on the back of my neck went up, and I said, ‘I hope you’re not going to say what I think you’re going to say,’” Conover said. “She said, ‘Oh yes. Your mother was psychotic. She was agitated, combative. She was assaulting the staff. She was kicking and scratching and hitting the staff, and we had no choice but to give her Haldol.’”

Roseville Point's administrator wouldn't speak to “America Tonight,” but a doctor’s note says Zizzo couldn’t walk without two people helping her. Roseville Point records also note Zizzo as unable to walk without “two or more persons” assisting.

Conover said she suspects the facility gave her mother the Haldol to get her to stop pressing the call button. Conover said the Haldol injection was the beginning of the end for her mother.

“We started noticing cognitive issues, major cognitive issues,” Conover said. “And then it just started going downhill rapidly after that.”

Genine Zizzo died 17 days after checking into Roseville Point Health and Wellness.

‘Prescribe something’

Herman of the Foundation Aiding the Elderly said doctors usually prescribe antipsychotics without ever seeing the patient.

“The person at the other end of the phone, which is usually the director of nursing or the charge nurse, will call and say, ‘Mrs. Smith is acting out. Prescribe something.’ And they’ll prescribe an antipsychotic because it knocks them out,” Herman said.

Prescribing drugs “off label” is legal, but drug companies are not supposed to promote or market drugs for uses not approved by the FDA. Three major drug companies have paid enormous fines to the U.S. government for just that.

Even despite reports on the adverse effects of administering antipsychotics to patients with dementia, numerous cases are popping up nationwide.
America Tonight

In 2013, Johnson and Johnson agreed to pay fines of more than $2.2 billion for marketing the off-label use of the anti-psychotic drug Risperdal and two other drugs. The Justice Department said the company urged doctors and prescribers treating elderly dementia patients to use the antipsychotic for anxiety, agitation, depression, hostility and confusion.

Eli Lilly paid the federal government $1.4 billion in 2009 to settle charges it illegally marketed the antipsychotic Zyprexa. Among the marketing tactics was a "5 at 5” campaign that urged nursing homes to administer five milligrams of Zyprexa at 5 p.m. to induce sleep.

In 2010, AstraZeneca paid a $520 million fine for off-label marketing antipsychotic Seroquel for conditions including Alzheimer’s and dementia, giving doctors illegal kickbacks to serve as authors for articles actually written by the drug company. 

Five-star rating

Nursing home residents have a right to be involved in their health care planning and to be free from unnecessary medication, said Thomas Hamilton, director of the survey and certification group at the Centers for Medicare and Medicaid Services, known as CMS.

Hamilton said federal and state inspectors conduct 49,000 nursing home investigations every year, imposing fines or other sanctions when the facilities are deemed to be overprescribing antipsychotics. Since 2011, the overall use of antipsychotic drugs in long-stay nursing home residents has dropped from 24 percent to 20 percent, according to CMS.

Last month, Medicare began including antipsychotic use as a factor in a nursing home’s five-star quality rating. The new formula for calculating quality cut the number of nursing homes receiving four or five stars almost in half. 

Thomas Hamilton of CMS.
America Tonight

The results, posted on Medicare’s Nursing Home Compare website, will help motivate nursing homes to do better, CMS' Hamilton said.

“We need to do much more, and we’re mobilizing to do that,” Hamilton said. “We are working overall not only in nursing homes but in other settings we are looking at ways to reduce reliance on antipsychotic medications.”

Medicare Prescription Drug Plan spent a total of $7.6 billion on antipsychotic drugs in 2011, the most recent figures available, according to CMS.

In nursing homes, Hamilton said lowering antipsychotic use takes more than hiring additional staff.

“There’s a body of research that has shown a correlation between lower staffing levels and higher use of antipsychotics,” he said. “But it’s not only the level of the staff, the training of the staff and the leadership.”

‘Listen differently’

At Ecumen Pathstone Living in Mankato, Minnesota, the use of antipsychotics has dropped from 18 percent to 6 percent after the staff received special training funded by a state grant. Behaviors like agitation or anxiety are seen as efforts to communicate, not as problems to medicate.

“They’re trying to get a message out. You just have to listen differently than you did in the past,” said Shelly Cornish, Ecumen’s housing director.

‘There’s a body of research that has shown a correlation between lower staffing levels and higher use of antipsychotics.’

Thomas Hamilton

Centers for Medicare and Medicaid Services

Sometimes, it’s a matter of diverting attention. In the memory care unit, each resident has a box with memorabilia – photographs and other small objects that carry a connection to the past. There’s also a crib with two lifelike baby dolls. On one occasion, Cornish said a patient was hallucinating that she could hear a baby crying. A staffer gave the woman a doll.

“She held it for literally two and a half hours and she was completely fine,” Cornish recalled. 

Cornish says that reducing antipsychotics has given residents their lives back.

“You give back that gift of the loved one to the family members,” she said. “And what I mean by that is, if you’re sleeping all day, you’re not having that relationship anymore.”

Before he died, Gerry Gilgan went to stay in a nursing home that didn’t believe in drugs, and his widow recalled seeing glimpses of the man she loved.

“I remember one night, I got a phone call about 10 o'clock. I said, ‘Oh, something happened,’” Marie Gilgan said. “And the nurse says, ‘Oh, Gerry's here with me in the office. He wanted to call you.’ And he sounded so like the old Gerry. ‘Gerry,’ I said. ‘How ya' doing?’ He said, ‘Good.’ He says, ‘How ya doing?’ He said, ‘I'm hanging out here with the nurse.’ I said, ‘Oh good for you.’ I said, ‘I'll see you tomorrow. He said, ‘OK, goodnight.’ And that was it.” 

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