‘They try to keep people quiet’: An epidemic of antipsychotic drugs in nursing homes

Mississippi consistently ranks in the top five in the nation for its rates of antipsychotic drugging in nursing homes, data from the federal government shows.

More than one in five nursing home residents in the United States is given powerful and mind-altering antipsychotic drugs. That’s more than 10 times the rate of the general population – despite the fact that the conditions antipsychotics treat do not become more common with age.

In Mississippi, that goes up to one in four residents.

“The national average tells us that there are still a large number of older residents who are inappropriately being prescribed antipsychotics,” explained Dr. Michael Wasserman, a geriatrician and former CEO of the largest nursing home chain in California.

“The Mississippi numbers can not rationally be explained,” continued Wasserman, who has served on several panels for the federal government and was a lead delegate in the 2005 White House Conference on Aging. “They are egregious.”

The state long-term care ombudsman, Lisa Smith, declined to comment for this story.

Hank Rainer, who has worked in the nursing home industry in Mississippi as a licensed certified social worker for 40 years, said the problem is two-fold: Nursing homes not being equipped to care for large populations of mentally ill adults, as well as misdiagnosing behavioral symptoms of dementia as psychosis.

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Both result in drugging the problem away with medications like antipsychotics, he said.

Antipsychotics are a special class of psychotropics designed to treat psychoses accompanied by hallucinations and paranoia, such as schizophrenia. They have also been found to be helpful in treating certain symptoms of Tourette syndrome and Huntington’s disease, two neurological diseases. All of these conditions are predominantly diagnosed in early adulthood.

The drugs come with a “black box warning,” the highest safety-related warning the Food and Drug Administration doles out, that cautions against using them in individuals with dementia. The risks of using them in patients with Alzheimer’s and other forms of dementia include death.

Yet more than a decade after a federal initiative to curb antipsychotic drugging in nursing homes began, 94% of nursing homes in Mississippi – the state with the highest rate of deaths from Alzheimer’s disease – had antipsychotic drug rates in the double digits.

Long-term care advocates and industry experts have long said that the exponentially higher number of nursing home residents on these drugs – 21% in the country and 26% in the state – is indicative of a deeper and darker problem: the substandard way America cares for its elders.

“If the nursing homes don’t have enough staff, they try to keep people quiet, so they give them sedatives or antipsychotics,” said gerontologist and nursing home expert Charlene Harrington.

And the problem, she emphasized, isn’t going away.

“Over the last 20 years we’ve had more and more corporations involved and bigger and bigger chains, and 70% are for-profit, and they’re really not in it to provide health care,” Harrington said. “… It’s a way to make money. And that’s been allowed because the state doesn’t have the money to set up their own facilities.”

‘It’s just not right to give someone a drug they don’t need’

On a late Thursday morning in August, Ritchie Anne Keller, director of nursing at Vicksburg Convalescent Center, pointed out a resident falling asleep on one of the couches on the second floor of the nursing home.

The resident, who nurses said was previously lively and would comment on the color of Keller’s scrubs every day, had just gotten back from another clinical inpatient setting where she was put on a slew of new drugs – including antipsychotics.

One or more of them may be working, Keller explained, but the nursing staff would need to eliminate the drugs and then reintroduce them, if needed, to find the path of least medication.

“How do you know which ones are helping her,” Keller asked, “when you got 10 of them?”

The home, which boasts the second-lowest rate of antipsychotic drug use in the state, is led by two women who have worked there for decades.

Keller has been at the nursing home since 1994 and entered her current position in 2004. Vicksburg Convalescent’s administrator, Amy Brown, has been at the home for over 20 years.

Low turnover and high staffing levels are two of the main reasons the home has been able to keep such a low rate of antipsychotic drug use, according to Keller. These two measures allow staff to be rigorous about meeting individual needs and addressing behavioral issues through non-medicated intervention when possible, she explained.

Keller said she often sees the effects of unnecessary drugging, and it happens because facilities don’t take the time to get to the root cause of a behavior.

“We see (residents) go to the hospital, they may be combative because they have a UTI or something, and (the hospital staff) automatically put them on antipsychotics,” she said.

Urinary tract infections in older adults can cause delirium and exacerbate dementia.

It’s important to note, said Wasserman, that Vicksburg and other Mississippi nursing homes with the lowest rates are not at zero. Medicine is always a judgment call, he argued, which is why incentivizing nursing homes to bring their rates down to 0% or even 2% could be harmful.

Schizophrenia is the only mental illness CMS will not penalize nursing home facilities for treating with antipsychotics in its quality care ratings. However, there are other FDA-approved uses, like bipolar disorder.

“As a physician, a geriatrician, I have to use my clinical judgment on what I think is going to help a patient,” Wasserman said. “And sometimes, that clinical judgment might actually have me using an antipsychotic in the case of someone who doesn’t have a traditional, FDA-approved diagnosis.”

In order to allow doctors the freedom to prescribe these drugs to individuals for whom they can drastically improve quality of life, Wasserman says the percentage of residents on antipsychotics can have some flexibility, but averages should stay in the single digits.

When 20 to 30% of nursing home residents are on these drugs, that means a large portion of residents are on them unnecessarily, putting them at risk of deadly side effects, Wasserman explained.

“But also, it’s just not right to give someone a drug they don’t need,” he said.

Experts have long said that staffing is one of the strongest predictors in quality of care – including freedom from unnecessary medication – which makes a recent federal action requiring a minimum staffing level for nursing homes a big deal.

The Biden administration finalized the first-ever national minimum staffing rule for nursing homes in April. The requirements will be phased in over two to three years for non-rural facilities and three to five years for rural facilities.

In Mississippi, all but two of the 200 skilled nursing facilities – those licensed to provide medical care from registered nurses – would need to increase staffing levels under the standards, according to data analyzed by Mississippi Today, USA TODAY and Big Local News at Stanford University.

Even Vicksburg Convalescent Center, which has a five-star rating on CMS’ Care Compare site and staffs “much above average,” will need to increase its staffing under the new regulations.

Mississippi homes with the highest antipsychotic rates

The six nursing homes with the highest antipsychotic rates in the state include three state-run nursing homes that share staff – including psychiatrists and licensed certified social workers – with the state psychiatric hospital, as well as three private, for-profit nursing homes in the Delta.

The three Delta nursing homes are Ruleville Nursing and Rehabilitation Center in Ruleville, Oak Grove Retirement Home in Duncan, and Cleveland Nursing and Rehabilitation Center in Cleveland. All have percentages of schizophrenic residents between 26 and 43%, according to CMS data.

Ruleville, a for-profit nursing home, had the highest rates of antipsychotic drugging in the state at 84% the last quarter of 2023. Slightly more than a third – or 39% – of the home’s residents had a schizophrenia diagnosis, and nearly half are 30-64 years old.

New York-based Donald Denz and Norbert Bennett own both Ruleville Nursing and Rehabilitation Center and Cleveland Nursing and Rehabilitation Center.

CMS rated the Ruleville facility as one out of five stars – or “much below average” – partly due to its rates of antipsychotic drugging.

But G. Taylor Wilson, an attorney for the nursing home, cited the facility’s high percentages of depression, bipolar and non-schizophrenic psychoses as the reason for its high rate of antipsychotic drug use, and said that all medications are a result of a physician or psychiatric nurse practitioner’s order.

While CMS has identified high antipsychotic drug rates as indicative of potential overmedication, Ruleville appears to be an exception, though it’s not clear why it accepts so many mentally ill residents or why its residents skew younger.

It is unclear what, if any, special training Ruleville staff has in caring for people with mental illness. Wilson did say the home contracts with a group specializing in psychiatric services and sends residents to inpatient and outpatient psychiatric facilities when needed.

There is no special designation or training required by the state for homes that have high populations of schizophrenic people or residents with other mental illnesses. Nursing homes must conduct a pre-admission screening to ensure they have the services needed for each admitted resident, according to the Health Department.

An official with the State Health Department, which licenses and oversees nursing homes, said there are more private nursing homes that care for people with mental illness now because of a decrease in state-run mental health services and facilities.

Agency officials pointed specifically to the closure of two nursing homes run by the Department of Mental Health after the Legislature slashed millions from the agency’s budget two years in a row.

“Due to the lack of options for many individuals who suffer from mental illness, Mississippi is fortunate that we have facilities willing to care for them,” said State Health Department Assistant Senior Deputy Melissa Parker in an emailed statement to Mississippi Today.

However, the Health Department cited Ruleville Nursing and Rehabilitation Center in May after a resident was allegedly killed by his roommate.

The resident who allegedly killed his roommate had several mental health diagnoses, according to the report. The state agency said that the facility for months neglected to provide “appropriate person-centered behavioral interventions” to him, and that this negligence caused the resident’s death and placed other residents in danger.

Wilson, the attorney for Ruleville, said his clients disagree with the state agency’s findings.

“The supposed conclusions reached by the (state agency) regarding Ruleville’s practices are not fact; they are allegations which Ruleville strongly disputes,” he said.

Oversight of nursing homes is limited

In 2011, U.S. Inspector General Daniel Levinson said “government, taxpayers, nursing home residents, as well as their families and caregivers should be outraged – and seek solutions” in a brief following an investigative report that kickstarted the movement against overprescription of antipsychotics in nursing homes.

“It was pretty striking,” said Richard Mollot, executive director of the Long Term Care Community Coalition, a nonprofit advocacy group dedicated to improving the lives of elderly and disabled people in residential facilities. “The Office of the Inspector General … They’re pretty conservative people. They don’t just come out and say that the public should be outraged by something.”

That landmark report showed that 88% of Medicare claims for atypical antipsychotics – the primary class of antipsychotics used today – were for residents diagnosed with dementia. The black box warning cautioning against use in elderly residents with dementia was introduced six years earlier in 2005.

But the problem persists today – and experts cite lack of oversight as one of the leading causes.

“CMS has had that whole initiative to try to reduce antipsychotics, and it’s been 10 years, and basically, they’ve had no impact,” Harrington said. “Partly because they’re just not enforcing it. Surveyors are not giving citations … So, the practice just goes on.”

In Mississippi, 52 nursing homes were cited 55 times in the last five years for failing to keep elderly residents free of unnecessary psychotropics, according to State Health Department data.

Barring specific complaints of abuse, nursing homes are generally inspected once a year, according to the State Health Department. In Mississippi, 54% of nursing home state surveyor positions were vacant in 2022, and 44% of the working surveyors had less than two years of experience.

During an inspection, a sample group usually consisting of three to five residents is chosen based on selection from surveyors and the computer system. That means if a nursing home is cited for a deficiency affecting one resident, that’s one resident out of the sample group – not one resident in the entire facility.

The state cited Bedford Care Center of Marion in 2019 for unnecessarily administering antipsychotics. The inspection report reveals that four months after a resident was admitted to the facility, he was prescribed an antipsychotic for “dementia with behaviors.”

The resident’s wife said her husband started sleeping 20 hours a day after starting the medication, according to the inspection report, yet the nursing home continued to administer the drug at the same dose for six months.

CMS mandates that facilities attempt to reduce dose reductions for residents on psychotropic drugs and incorporate behavioral interventions in an effort to discontinue these drugs, unless clinically contraindicated.

The facility did not respond to a request for comment from Mississippi Today.

In another instance, Ocean Springs Health and Rehabilitation Center was cited in 2019 after the facility’s physician failed to decrease three residents’ medications as a pharmacy consultant had recommended. The inspection report says there was no documentation as to why.

Officials with the nursing home did not respond to a request for comment from Mississippi Today.

These two incidents – and all citations for this deficiency in the last five years – were cited as “level 2,” meaning “no actual harm” as defined by federal guidelines. Facilities are not fined for these citations, and their quality care score is only minimally impacted.

“If they don’t say there’s harm, then they can’t give a fine,” Harrington said. “And even when they do give fines, they’re usually so low they have no effect. A $3,000 fine is just the cost of doing business. They don’t pay any attention to it.”

“Level 3” and “Level 4” are mostly used in extreme and unlikely situations, explained Angela Carpenter, director of long-term care at the State Health Department.

“For example,” she said, a Level 4 would be “if a person was placed on Haldol (an antipsychotic), he began having seizures, they still continued to give him the Haldol, they didn’t do a dose reduction, and the person ended up dying of a heart attack with seizures when they didn’t have a seizure disorder.”

“Actual harm” is supposed to also include psychosocial harm, according to federal guidelines, but Carpenter said psychosocial harm “can be very difficult to prove,” as it involves going back to the facility and doing multiple interviews to figure out what the individual was like before the drugs – not to mention many symptoms are attributed to the cognitive decline associated with the aging process instead of being seen as possible symptoms of medication.

Experts say the bar for “harm” is far too high.

“And that sends a message that ‘Well, you know, we gave them a drug that changes the way their brain works, and we did it unnecessarily, but you know, no harm’ – and that’s where I think the regulators really don’t have a good understanding of what is actually happening here,” said Tony Chicotel, an elder attorney in California.

‘Looking at the person as a whole’: More humane solutions

Hank Rainer, a licensed certified social worker, has worked in Mississippi nursing homes for decades. Nursing homes contract with him to train social services staff in how best to support residents and connect them with services they need.

Rainer believes there are several solutions to mitigating the state’s high rates of antipsychotic drugs. Those include training more physicians in geriatrics, increasing residents’ access to psychiatrists and licensed certified social workers, and creating more memory care units that care for people with dementia.

The nation is currently facing a severe shortage of geriatricians, with roughly one geriatrician for every 10,000 older patients. The American Geriatrics Society estimates one geriatrician can care for about 700 patients.

Because it’s rare for a nursing home to contract with a psychiatrist, most residents are prescribed medication – including for mental health disorders – by a nurse practitioner or family medicine doctor, neither of which have extensive training in psychiatry or geriatrics.

Rainer also said having more licensed certified social workers in nursing homes would better equip homes to address residents’ issues holistically.

“LCSWs are best suited to help manage behaviors in nursing homes and other settings, as they look at the person as a whole,” he said. “They don’t just carve out and treat a disease. They look at the person’s illness and behaviors in regard to the impact of environmental, social and economic influences as well as the physical illness.”

That’s not to say, he added, that some residents might not benefit most from pharmacological interventions in tandem with behavioral interventions.

Finally, creating more memory care units that have the infrastructure to care for dementia behaviors with non-medicated intervention is especially important, Rainer said, given the fact that antipsychotics not only do not treat dementia, but also pose a number of health risks to this population.

Dementia behaviors are often mistaken for psychosis, Rainer said, and having trained staff capable of making the distinction can be lifesaving. He gave an example of an 85-year-old woman with dementia who kept asking for her father.

The delusion that her father was still alive technically meets the criteria for psychosis, he said, and so untrained staff may think antipsychotic medication was an appropriate treatment.

However, trained staff would know how to implement interventions like meaningful diversional activities or validation therapy prior to the use of medications, he continued.

“The father may represent safety and they may not feel safe in the building because they don’t know anyone there,” Rainer said. “Or the father may represent home and security and warmth and they may not feel quite at home in the facility. You don’t ever agree that their dad is coming to get them. That is not validation therapy. But what you do is you try to key in under the emotional component and get them to talk about that, and redirect them at the same time.”

With more people living longer with conditions such as Alzheimer’s, good dementia care is becoming increasingly more important.

But first the nursing homes would need to find the staff, Chicotel said.

As it stands, with the vast majority of nursing homes in the country staffing below expert recommendations – nearly all nursing homes would have to increase staffing under not-yet-implemented Biden regulations, which are less stringent than federal recommendations made in 2001 – non-pharmacological, resident-centered care is hard to come by.

“Trying to anticipate needs in advance and meeting them, spending more time with people so they don’t feel so uncomfortable and distressed and scared – that’s a lot of human touch that unfortunately is a casualty when facilities are understaffed,” Chicotel explained.

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This story was originally published by Mississippi Today and distributed through a partnership with The Associated Press.