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This Nursing Home Calms Troubling Behavior Without Risky Drugs

It's a sunny autumn afternoon and a good time to make apple crisp at Pathstone Living, a memory care facility and nursing home in Mankato, Minn. Activities staffer Jessica Abbott gathers half a dozen older women at a counter in the dining area, where the soundtrack is mostly music they could have fox-trotted to back in the day.

It seems residents can always find something to do around here. That can help to relieve the agitation common in some people with Alzheimer's or other forms of dementia — agitation that in other nursing homes might be managed with antipsychotic drugs.

Though antipsychotics are approved to treat serious mental illnesses like schizophrenia and bipolar disorder, the FDA says the drugs can increase the risk of death for people with dementia. Still, they're prescribed for nearly 300,000 nursing home residents nationally.

All U.S. residents of nursing homes have specific legal rights, detailed in the Nursing Home Reform Act of 1987. Some of the most important rights include:

  • The right to be free from physical or mental abuse, corporal punishment, involuntary seclusion, and any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms.
  • The right to confidentiality of personal and clinical records.
  • The right to current clinical records of the resident upon request , and to get those records within 24 hours (excluding hours occurring during a weekend or holiday) of when the resident or a legal representative makes the request.
  • The right to choose a personal attending physician, to be fully informed in advance about care and treatment, and to be fully informed in advance of any changes in care or treatment that may affect the resident's well-being. Also, the resident (or a legal representative) has the right to participate in planning care and treatment or changes in care and treatment.

Finally, psychoactive drugs (including antipsychotics as well as drugs for depression and anxiety) may be administered only on the orders of a physician and only as part of a written plan designed to eliminate or modify the symptoms for which the drugs are prescribed. Such drugs may be given only if, at least annually, an independent, external consultant reviews the appropriateness of the drug plan of each resident receiving such drugs.

Source: Cornell University Law School Legal information Institute

A few years ago, antipsychotics were used frequently at Pathstone, too.

"We saw these as medications that were supposed to help the patient and, of course, we gave them to them with the feeling that we were doing good," says Shelley Matthes, a registered nurse who is head of quality assurance for the nonprofit Ecumen, which runs Pathstone and about a dozen other nursing facilities in Minnesota.

Dr. Tracy Tomac is a psychiatrist and medical consultant at Pathstone. In the old days, a resident might have been started on antipsychotics to deal with an emergency, Tomac says, "but they would just stay on it. They would never be taken off for many months or even years."

So in 2009, she and a colleague at a small Ecumen nursing home near Duluth decided to see if they could reduce the use of antipsychotics there.

"At the end of six months or so," Tomac says, "we were able to get them all off any antipsychotics."

The next year they extended the policy to all of Ecumen's nursing homes. "Our goal, Matthes says, "was to reduce our antipsychotic use by 20 percent. And in the first year we reduced it by 97 percent."

At Pathstone these days, around 5 to 7 percent of residents get antipsychotic drugs. Not all of the Ecumen nursing homes have numbers that low, but they're almost all well below the national average. And Matthes says the changes in the residents were as dramatic as the drop in the numbers.

"They started interacting," recalls Matthes, "and people who hadn't been speaking were speaking. They came alive and awakened."

Which is why they decided to call their program Awakenings.

A resident called Mac is definitely awake as he meanders around the skilled nursing wing at Pathstone.

"Yeah," he says with confidence to no one in particular. "I know what it is, where it is, what it is."

When he arrived at Pathstone, Mac was on antipsychotic drugs. He also had a tendency to fall, which meant he wasn't allowed to walk around on his own. That upset him. So, first the staff weaned him off the antipsychotics, which can increase the risk for falls. But they also needed to deal with what was making Mac unhappy. The answer was a device called a Merry Walker (sort of a walker on wheels, but with railings and a chair). It's given Mac some of his independence back, so he's happier and so is everyone around him.

Maria Reyes, who's in charge of the Awakenings program for all of Ecumen's nursing homes, says everyone on the staff is trained to know and understand the residents' likes, dislikes and life stories.

Whether working in dining services or maintenance, any staff member who spots a problem behavior by one of the residents is expected to try to figure out the rationale behind it, Reyes says.

"And once we figure that out, we can often times curb it," she says, "or eliminate it completely."

Ecumen doesn't take credit for inventing the techniques it uses. There's a lot of information out there on individualized care for people with dementia, and Reyes says the Awakenings program has borrowed something from just about all of them, including aromatherapy, white noise, pet therapy and validation.

Back in the dining room, apple crisp is still a work in progress. While utensils clatter, Shelly Cornish, director of the memory care unit, points out a vintage chest of drawers in the far corner.

"Every drawer you open," she says, "you're going to find a treasure."

They're treasures like an old-fashioned hat, for instance, or a book of recipes that hails from the days when meatloaf was king.

"The meaning behind that," Cornish explains, "is that people with dementia are frequently looking for something. But they don't necessarily know what they're looking for."

In some nursing homes, that constant searching would be a problem behavior to be managed with risky antipsychotic drugs. Here, it's just another need — one that can be satisfied with a trifle from days gone by.

Check NPR's interactive database below to see the history of antipsychotic drug usage at nursing homes in your area and how they compare to national and state averages.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.

Transcript

ROBERT SIEGEL, HOST:

One in five people in nursing homes are given powerful antipsychotic drugs. That's even though those drugs are approved mainly for serious mental illnesses such as schizophrenia and bipolar disorder. And this happens despite warnings from the FDA that the drugs can increase the risk of death for people with dementia and Alzheimer's disease. Nationwide, almost 300,000 nursing home residents are given antipsychotics.

AUDIE CORNISH, HOST:

NPR's Ina Jaffe covers aging. This morning she reported the federal government has pushed nursing facilities to reduce their use of these drugs by 15 percent. Now she takes us to Minnesota, where a few years ago, a group of nursing homes figured out how to cut their use of antipsychotics by more than 90 percent.

JESSICA ABBOT: Elaine do you want to come out and bake some apple crisps with me? We're going to get a group of people together.

INA JAFFE, BYLINE: About half a dozen older women join staffer Jessica Abbot at a long counter in the dining room at Pathstone Living. It's a memory care center and nursing home in Mankato, Minnesota.

ABBOT: There's no hurry. I'll see you in a little bit. Dorothy?

JAFFE: Seems there's always something to do around here. It helps relieve the agitation common in some people with Alzheimer's or other dementias - agitation that, in other nursing homes, might be managed with antipsychotic drugs. In fact, around the country, nearly 20 percent of nursing home residents get those drugs even though the FDA says they can be deadly for people with dementia. A few years back, Pathstone also used antipsychotics frequently.

SHELLY MATTHES: We saw these as medications that were supposed to help the patient. And, of course, we gave them to them with the feeling that we were doing good.

JAFFE: That's nurse Shelly Matthes. She's the director of quality assurance for the nonprofit that owns Pathstone and about a dozen other nursing facilities in Minnesota. It's called Ecumen. Psychiatrist Tracy Tomac, a medical consultant at Ecumen, says a resident might have been started on antipsychotics to deal with an emergency.

TRACY TOMAC: But then they would just stay on it. It would never be taken off for many months or even years.

JAFFE: So in 2009, Tomac and a colleague at a small Ecumen nursing home near Duluth decided to see if they could reduce the use of antipsychotics there.

TOMAC: At the end of six months or so, we were able to get them all off of any antipsychotics successfully.

JAFFE: So the next year, they extended the policy to all of Ecumen's nursing homes, says Shelley Matthes.

MATTHES: Our goal then was to reduce our antipsychotic use by 20 percent. And in the first year, we reduced it by 97 percent.

JAFFE: At Pathstone these days, around 5 to 7 percent of residents get antipsychotic drugs. Not all of the Ecumen nursing homes have numbers that low, but they're almost all well below the national average. And Matthes says the changes in the residents were as dramatic as the drop in the numbers.

MATTHES: They started interacting, and people who hadn't been speaking were speaking. They came alive and awakened.

JAFFE: Which is why they decided to call their program Awakenings.

MAC: Yeah. I know what it is, where it is, why it is.

JAFFE: A resident called Mac talks to staff members and sometimes himself as he meanders around the skilled nursing wing at Pathstone.

MAC: And we got a perfectly good house sitting down at the bottom of the hill.

JAFFE: When he arrived at Pathstone, Mac was on antipsychotic drugs. He also had a tendency to fall, which meant he wasn't allowed to get around on his own, and that upset him. So first, the staff weaned him off antipsychotics. But they also needed to deal with what was making him unhappy. The answer was a device that's - well, it's hard to describe. It's sort of a walker on wheels but with railings and a chair. Anyway, the important part is that Mac's got some independence back with a little encouragement from nurses like Joel Berglund.

JOEL BERGLUND: Do you want to walk, Mac? Can you take a step?

MAC: OK.

BERGLUND: There we go.

JAFFE: Nurses aren't the only ones here expected to help. Maria Reyes, who's in charge of the Awakenings program for all of Ecumen's nursing homes, says everyone on the staff is trained to know and understand the residents' likes, dislikes and life stories.

MARIA REYES: We want everyone to know, whether they are working in the dining services or maintenance, that when you see something that is, quote, quote, "a behavior," try to figure out the rationale behind it. And once we figure that out, we can oftentimes eliminate it completely.

JAFFE: Ecumen doesn't take credit for inventing the techniques they use. There are a lot of approaches to individualized care for people with dementia. And Reyes says the Awakenings program has borrowed something from just about all of them.

REYES: Aromatherapy, white noise, pet therapy, validation - all the different principles that we infuse in our care.

SHELLY CORNISH: Tina, you're just going to watch, right? That's fine.

JAFFE: Back in the dining room, apple crisp is still a work in progress. Meanwhile, Shelly Cornish, director of the memory care unit, points out a vintage chest of drawers in the far corner.

S. CORNISH: Every drawer that you open, you're going to find a treasure.

JAFFE: Treasures like an old-fashioned hat, for instance, or a book of recipes that hails from the days when meatloaf was king.

S. CORNISH: And, really, the meaning behind that is that sometimes people who have dementia are looking for something, but they don't necessarily know what it is they're looking for.

JAFFE: In some nursing homes, that constant searching would be a problem-behavior to be managed with risky antipsychotic drugs. Here, it's just another need that can be satisfied with a trifle from days gone by. Ina Jaffe, NPR News.

SIEGEL: If you want to know how nursing homes in your area rate when it comes to using antipsychotic drugs, go to npr.org. You can search for information on antipsychotic drug use at more than 15,000 facilities around the country. Transcript provided by NPR, Copyright NPR.

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