CANHR recently received the results of the Department of Public Health’s 2015 special Dementia Care Focused Surveys. Four nursing homes were surveyed and myriad violations found related to dementia care. Many of the violations were quite serious and all of them demonstrate that dementia care in California nursing homes is still dangerously poor. Aside from the standard bad treatment for residents with dementia, the survey reports revealed several disturbing newer developments that need to be addressed by policy makers – immediately and firmly.
1) Avoiding Detection. The focused survey reports identified a number of residents with dementia who were prescribed and given Depakote. Depakote is an anti-seizure medication often prescribed for people with bipolar disorder, largely because it sedates them. Those sedative effects make Depakote an inviting off-label chemical restraint for people with dementia. What makes Depakote particularly tempting in the nursing home world is that its use is not reported or posted by the Centers for Medicare & Medicaid Services the way other restraint drugs are. Thus, Depakote is a hidden chemical restraint – perfect for nursing homes concerned about their reputation. An added bonus is that Depakote comes in a “sprinkle” form, enabling it to be concealed in a resident’s food. Any chemical restraint that avoids detection from the people who take it or the regulators who watch it deserves intense scrutiny.
2) Phony Diagnoses. Another way for a nursing home to hide its psychotropic drug use, particularly antipsychotics, is to turn off-label use “on-label.” The national campaign to reduce antipsychotic misuse in nursing homes has been driven by an antipsychotic use “quality measure” that excludes “on-label” use from the calculation. Diagnoses of schizophrenia or psychosis mean the use of an antipsychotic is not counted in the facility’s quality measure. The focused survey reports reveal many residents with dementia are given additional diagnoses of schizophrenia or psychosis – labels that are unchallenged and often flimsy at best. There is no doubt that some of these diagnoses are clinically unmerited and given in part because they “justify” the use of antipsychotics for residents with dementia.
3) Pseudobulbar, Pseudodiagnosis. At Highland Springs Center, a nursing home in Beaumont (Riverside County), the crass drug marketing for the next hollow “dementia behavior” drug seems to have paid off. Highland Springs staff were treated to an in-house training about “pseudobulbar affect,” a neurological condition marked by uncontrollable laughing and crying, and Nuedexta, a drug that supposedly treats it. A few months later, lo and behold, multiple residents at Highland Springs were prescribed Nuedexta for pseudobulbar affect “manifested by labile moods.” In other words, being moody meant a regimen of the newest chemical restraint on the block – one that is not monitored by CMS.
The tools for terribly poor and irresponsible dementia care are changing but the outcomes remain the same for nursing home residents: sedation, isolation, and unattended suffering. Let’s hope policy makers resolve to do something about it in 2016.