HHS-OIG Calls for Crackdown on Overuse of Psychtropic Drugs in Nursing Homes

The findings of a new government report suggests that nursing homes are increasingly using epilepsy drugs as “chemical restraints”, which is widely considered a form of nursing home abuse, as the medications are administered to subdue patients in lieu of antipsychotic drugs linked to increased risks of death.

The U.S. Department of Health and Human Services, Office of Inspector General (OIG) issued a new report earlier this month, focusing on nursing home chemical restraint practices. The November 2022 report, Long-Term Trends of Psychotropic Drug Use in Nursing Homes, highlights gaps in care at nursing homes across the U.S. and gaps in oversight by the Centers for Medicare & Medicaid (CMS).

For years, nursing homes have faced scrutiny surrounding the common practice of administering antipsychotic drugs as a way to restrain “unruly” patients, even though the drugs serve no medical purpose and may increase the risk of serious side effects. Following efforts to curb the practice in recent years, it appears that facilities are now increasing the use of unnecessary epilepsy drugs in nursing homes instead.

In this new report, federal investigators studied drugs given to nursing home residents from 2011–2019, measuring the effect of a government program launched in 2012 to reduce the widespread use of antipsychotic drugs in nursing homes. They studied prescribing patterns for drugs that work on the brain, psychotropics.

The OIG investigation determined that overall, following the scrutiny and program launch, the use of psychotropic drugs did not decrease. The use of antipsychotic drugs instead shifted toward other types of psychotropics.

Nursing Home Anticonvulsant Prescriptions May Be New Form of Chemical Restraint

Psychotropic drug use in nursing homes remained constant from 2011–2019, with 80% of residents given some type of psychotropic, often anticonvulsants used to treat conditions like epilepsy, to sedate nursing home patients, investigators found.

In a study published earlier this month, researchers from the University of Pennsylvania found more nursing home residents with Alzheimer’s disease and related dementia (ADRD) are being given antiepileptic drugs, like Depakote and Neurontin, which have shown little scientific benefit for such conditions.

While the study indicates antipsychotic prescribing rates declined from 32.1% to 27.9%, and opioid prescribing rates declined from 39.8% to 31.7% from 2015 through 2019, researchers identified an increase in the use of the antiepileptic drugs Depakote (valproic acid) and Neurontin (gabapentin), increasing from 29.5 % in 2015 to 31.3 % in 2019.

Researchers raised concerns over the increased use of antiepileptic drugs on patients with ADRD, as little scientific evidence has been provided to show any medical benefit for symptoms of dementia. Given the lack of clinical benefit, the authors questioned the reasoning behind the increase in prescribing of antiepileptic drugs, and whether there is a hidden intent behind their administration.

Nursing Home Pyschotropic Drug Overuse

Nursing homes with fewer hours worked by a registered nurse and those with more low-income residents used more psychotropic drugs. They also used other categories of drugs which affect the brain, including antidepressants.

Furthermore, the number of unsupported schizophrenia diagnoses increased across the study period. Patients were reported as having the condition, but not having a confirmed diagnosis. Using a CMS loophole, nursing homes can misreport residents as having schizophrenia in order to give them antipsychotics without reporting it to the CMS.

Antipsychotics carry a black box warning from the Food and Drug Administration because they increase the risk of stroke, heart attack, diabetes, Parkinson’s disease, and falls. Some carry the risk of liver toxicity and inflammation of the pancreas. Elderly patients already face an increased risk of suffering from various health conditions and a heightened risk of falling, which can lead to serious consequences like bone fractures and infections.

Many nursing homes treat violent behavior with psychotropics, but that can lead to the overuse of other drugs. The unnecessary use of chemical restraint among nursing home patients is widely criticized and often considered a form of nursing home abuse.

OIG Recommendations

Protecting residents of nursing homes is critical, according to the OIG. They are an already at-risk population, but it can be challenging to provide that protection without the ability to determine how these drugs are truly being used and how they may lead to long-term side effects.

The OIG recommends the CMS take three steps: evaluate nursing homes to determine those that have higher use of psychotropic drugs and improve oversight, evaluate psychotropic use among residents to determine additional oversight action in general, and expand claims data to include diagnosis codes to improve oversight and tighten loopholes.

The OIG report indicates CMS agreed with the recommendations for evaluating psychotropic drug use and use data to identify nursing homes which may be using the drugs as chemical restraints. However, the report indicates CMS does not concur with the OIG recommendation to add a diagnosis code to Medicate Part D claims.