Some nursing home staff in the United States are over-diagnosing their dementia patients with schizophrenia so they can prescribe antipsychotics and make them easier to manage, according to a report from the US Department of Health and Human Services (HHS) Office of Inspector General (OIG).
MedPage Today reports that the nursing homes allegedly gave antipsychotic drugs to these patients so that staff could manage their behaviour, “despite FDA warnings that the medication may increase the risk of death”, the authors wrote in the document released last week.
“Even though antipsychotic drugs pose risks to residents’ health, nursing homes did not take the required steps to help protect those who were given these medications.”
In addition, the report noted that: “In response to concerns about the use of antipsychotic drugs, CMS (the Centres for Medicare & Medicaid Services) developed a quality measure that captures the percentage of residents in the nursing home who receive an antipsychotic drug.
“This quality measure factors into a nursing home’s star rating, which reflects the home’s overall performance”, (and which can be found on Medicare’s website).
But residents on antipsychotics are not counted toward the CMS quality measure if they have schizophrenia, which gives the facilities an incentive to label such patients as schizophrenic to improve their star rating, according to the report.
“Notably, OIG found that nursing homes’ reporting of schizophrenia diagnoses increased after the introduction of the quality measure,” the authors wrote.
The report was based on 40 survey reports focused on dementia care or schizophrenia that CMS conducted from 2018 to 2021.
The review focused on several key areas, including the addition of schizophrenia diagnoses to resident records; the impact on nursing homes’ star rating; company policy regarding the use of these diagnoses; and the role of the medical director.
The authors recommended that although CMS already has instructed its surveyors to consider referring clinicians to their state board if they inappropriately diagnose residents with schizophrenia, the agency “should expand these efforts and consider imposing additional remedies on nursing homes when they are found …to have inappropriately diagnosed schizophrenia”.
Jodi Eyigor, vice-president of health policy at LeadingAge, an association for non-profit nursing homes and other ageing service providers, called the report findings “inexcusable”.
“Antipsychotics should never be used as chemical restraints, and false diagnoses should never be applied to justify inappropriate use of a medication,” she said.
“These issues should be identified and promptly corrected at the individual level and addressed at the systems level to prevent future occurrences.
“Rather than making sweeping generalisations – that all antipsychotic usage is bad – and continuing to patch up an ineffective fix (i.e, such as implementing audits based on an influx of new diagnoses that result from a blunt-object quality measure), we need to solve the real problem,” she said.
“CMS must focus policies, practices, and metrics on better distinguishing between appropriate and inappropriate use of antipsychotic medications and then target resources to stop the practice.”
Apart from the report on inappropriate schizophrenia diagnoses, a separate OIG report also focused on the overprescribing of antipsychotics.
It found that “inadequate nursing home policies and procedures undermined safeguards meant to protect residents”, and recommended that CMS:
• Develop resources …and increase transparency to reduce inappropriate use of antipsychotic drugs and improve dementia care in nursing homes
• Ensure nursing home medical directors fulfil their role in reducing the inappropriate use of these drugs
• Ensure nursing home pharmacists fulfil their role in reducing the inappropriate use of antipsychotic drugs, among other measures.
The American Health Care Association/National Centre for Assisted Living (AHCA/NCAL), which represents nursing homes, criticised the study's methodology.
“These reports are based on a very small subset of specifically selected nursing homes and are not indicative of national trends,” said Holly Harmon, AHCA/NCAL’s senior VP of quality, regulatory, and clinical services.
“We support the appropriate use of medications to meet individual resident needs, with the right medications at the right times.
“In fact, nursing homes have been leading the way for more than a decade, working with CMS and other stakeholders through the National Partnership to Improve Dementia Care in Nursing Homes to reduce the unnecessary use of antipsychotics, with remarkable results that have improved the lives of tens of thousands of residents,” she added.
“Antipsychotic medications are sometimes deemed necessary and beneficial to certain residents based on their clinical condition and shared decision-making with the resident and their medical provider.”
See more from MedicalBrief archives:
Antipsychotic use increases mortality risk in Alzheimer’s patients
Experts flag dangers of anti-psychotics for dementia patients
Non-drug care the 'first choice' in dementia
Nurses who drugged patients to ‘keep them quiet’ found guilty