Articles Posted in Restraints

The job of prescribing medications requires balance. The goal must be to improve the health of the patient as much as possible while minimizing risks, taking into account any negative side-effects or quality of life issues. Such considerations are especially important for elder care in nursing homes, as the residents generally have more delicate systems. The US Food and Drug Administration (FDA) puts out guidelines for best practice prescribing based on scientific studies about efficacy and side-effects. And yet a poor prescribing policy can be found in most nursing homes. A study published in The American Journal of Geriatric Pharmacotherapy looked at this problem specifically through the lens of antipsychotic medications.

Antipsychotic medications are developed to treat patients with psychotic episodes, such as can been seen in bipolar disorder and schizophrenia. These medications include haloperidol and clozapine and generally act as sedatives. In nursing homes, use is usually off-label, frequently to subdue patients with dementia-related agitation. Off-label use is not supported by the FDA. Up to 80% of all antipsychotic use in nursing homes is off-label, for behavioral management. But with off-label use there are no FDA guidelines regulating prescription. Less testing for efficacy and side-effects is carried out for off-label usage. Such prescribing can be risky, even with the “black box” labels that the FDA puts on to warn nursing home staff of the drugs’ dangers.

Hundreds of thousands of nursing home residents are currently being prescribed antipsychotic medications. Most of this use is non-recommended. The issue of nursing home overuse of antipsychotics is important as the clinical studies conducted for off-label use of these medications report that there are little to no medical benefits, while there are many side-effects including strokes and increased morbidity and mortality. Such use is generally just for the purpose of subduing or restraining patients, to make caring for them an easier task. But the use of any type of restraint, physical or chemical, that is not for the direct medical benefit of the patient is prohibited by federal and state law.

Off-label use of antipsychotic drugs for non-medical purposes is commonly found in conjunction with understaffing in nursing homes. The belief is that more subdued and compliant patients mean that fewer nurses can perform the same care tasks in less time. But this assumption is not fact based, and is a violation of patient rights. Studies have shown that nursing homes that do not use any type of restraint with such patients do not actually need more staff to complete daily assistance and care activities. Nursing homes seem to act without much regard for scientific evidence in their use of antipsychotic drugs. Even with federal regulation of antipsychotic medication use, with sanctions for improper prescription, many facilities still refuse to change their policies. There is a financial motivation for such drug use, as Medicaid pays out billions each year for such prescriptions. And unfortunately, nursing homes placing finances ahead of patient welfare and health is not an unknown phenomenon.

Such actions are not only immoral, they are illegal. Both state and federal legislation speak to the quality of care and treatment that nursing homes must provide. This includes a fully staffed home with a hygienic and safe environment. But if a nursing home fails to meet these legally proscribed standards, under California Health and Safety Code 1430(b), you are allowed to sue for damages to health and wellbeing.

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Medication is intended to improve the quality of a patient’s life by reducing uncomfortable symptoms or by curing a disease. However, taking more medication does not equal to receiving more benefits. In fact, the consequences of using too many medications at once, or polypharmacy, can be extremely harmful and counterproductive. An article published by Hovstadius and Petersson looks at the different factors that lead to excessive polypharmacy and discusses the alarming finding that polypharmacy is most lethal and occurs most commonly in adults aged over 65 in nursing homes.

The article says that one of the most common risk factors for excessive polypharmacy is age. As the prevalence of disease increases with age, the amount of medication prescribed also increases. The prevalence of polypharmacy has also been increasing as new medications and technology are being discovered. In the entire national population, the prevalence of polypharmacy in the age group 80 to 89 years is 75.1%, and the percentage continues to rise as age increases. Elderly adults also often forget to take certain medications as they already have so many types of medications to keep track of, which is another reason why polypharmacy can be so dangerous.

Another factor associated with polypharmacy other than age is poor self-perceived health, poor life satisfaction, declining ability to function and declining cognitive capacity. Many nursing home residents who suffer from dementia also suffer from depression. This depression can usually be treated by non-pharmacological methods, such as daily social activities, simple exercises, and independence tasks. Unfortunately, many nursing homes do very little to ensure that their residents have a good quality of and good outlook on life as many nursing homes do not have these options of activities available for their residents. Rather than treating patients with non-pharmacological methods, nursing homes often use drug treatments or chemical restraints,which in turn leads to a higher likelihood of polypharmacy occurring.

Perhaps the most common consequence of polypharmacy is harmful drug-drug interactions. The effect of one medication can be influenced by another medication, and result in a harmful side effect. The risk for drug-drug interactions increase greatly as a patient is taking more medications. For example, a patient on 10 different drugs has 45 possible one-to-one drug interactions. Even more harmful is a disease-drug interaction, which occurs when a disease is worsened by a drug prescribed for a reason other than to treat the disease. This is highly common in nursing homes because many nursing home residents have diseases such as Alzheimer’s, but are also given unrelated medications such as nutritional supplements or urinary tract infection antibiotics.

Due to the severe consequences of polypharmacy, it is important to be aware of the risk factors that lead to polypharmacy and ensure that you or your loved one are not being prescribed unnecessary medications. Unfortunately, as many nursing homes are understaffed, instead of providing the proper care and treatment, unnecessary drugs such as chemical restraints are often improperly used.

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A study published by The Gerontologist found that nursing homes that focused on creating a culture of patient safety which involves using less physical restraints, resulted in lower mortality rates, lower rates of failure to rescue, decreased chances of medical errors, and more days between serious safety events. A culture of patient safety involves ensuring that the nursing home or hospital is engineered both physically and systematically to enhance the safety of the patients and residents. It also involves a blame-free environment in which individuals are able to report errors with fear of punishment. Lack of a culture of patient safety can lead to staff that is afraid of reporting mistakes, which leads to the increased use of physical restraints.

Physical restraints are a controversial care process used on individuals with difficulties transferring and with behavioral disorders. Nursing homes often resort to the simple method of using physical restraints to limit falls rather than attempting to fix the underlying problems in management that lead to these falls in the first place. In reality, physical restraints do not prevent falls. In fact, the study found that nursing homes that use less physical restraints report less falls per year. Physical restraints have also been shown to increase the likelihood of death, injuries, and functional decline. Nursing homes often resort to physical restraints because they are uneducated about better safety methods. Staff should be trained in teamwork, documentation, and reporting and discussing safety issues. Each resident has different health needs, and so a specific care plan should be adopted for each individual to prevent falls, rather than resorting to the use of physical restraints.

The study also found that the nursing homes that heavily rely on physical restraints and less on a patient safety culture also tend to be understaffed. Unfortunately, understaffing is a problem in most nursing homes, and so many nursing homes are not providing the proper quality of care for their residents to ensure their safety from falls and critical errors made by staff. The use of physical restraints due to understaffing is also a direct violation of a patient’s rights, and is simply inexcusable.

The results from this study show that there needs to be an obvious push in nursing homes towards building and the importance of adopting a proper patient safety culture and hiring enough properly trained staff to give quality care to the residents. A nursing home should not only provide resident autonomy, and a comfortable living environment, but also a safe culture to ensure that its residents are kept at the highest level of physical and mental well-being as possible.

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A recent article titled, “Comparative Safety of Antipsychotic Medications in Nursing Home Residents” was published by the Journal of American Geriatrics Society. As reported by the article, an entire third of nursing home patients are prescribed antipsychotics at some point during their residence. Because such a large population of nursing home patients take these drugs, it is important to understand the risks associated with antipsychotic medications. This study breaks down the two types of antipsychotics and compares the risks associated with using each one. Typical antipsychotics, also commonly known as conventional antipsychotics, were developed in the 1950s. A second generation of antipsychotic drugs was later developed, and today these medications are called atypical antipsychotics.

The study concluded that in general, the use of atypical antipsychotics is more dangerous, as it was more often associated with negative side effects. These included an increase in cardiac problems, infections, and hip fractures. However, an exception to this was found with cerebrovascular issues, in which case, atypical antipsychotics appeared to pose less of a risk. We hope that your loved one never finds the use of antipsychotic medications necessary, but if he or she does, it is important to understand risks and side effects, in order to do an educated cost-benefit analysis of taking such drugs.

The study also notes that the effectiveness of antipsychotics in Alzheimer’s patients is outweighed by the risks. Although symptoms for various cognitive diseases may appear to be similar, effective treatments for each one are often very different. Inaccurately diagnosing and treating a cognitive disease can be very dangerous, and even lead to death of a patient. Because there are so many fine details that must be understood and considered prior to beginning an antipsychotic drug regimen, it is important that the nursing home staff is trained and knowledgeable in such matters. As many nursing homes are, unfortunately, extremely understaffed, it is common to find nurses who are unable to properly and accurately diagnose and treat various medical problems. It is important that you are aware of this widespread problem, so that you and your loved one can hopefully avoid its many consequences.

One such consequence is the use of chemical restraints. Because the nurses in understaffed facilities are usually pressed for time, they will often automatically resort to the use of drugs, instead of first assessing the patient and considering other treatments that may be safer and more effective. This is especially important in dementia patients. In 2005, the FDA issued a warning of excess mortalities associated with antipsychotic use in adults with dementia. Since then, many studies have been conducted on the various uses of antipsychotics and their overall effect on quality of life in patients who suffer from dementia. The results have all suggested that behavioral therapies are the most effective treatment for dementia patients. In fact, the use of antipsychotics has actually been proven to worsen symptoms of dementia, such as agitation. It is important that you consider the many alternative methods that exist for treating dementia before resorting to the use of antipsychotic medications.

The study concludes by emphasizing the importance of monitoring a patient’s dosage of medications. Close and careful monitoring can prevent consequences of polypharmacy from occurring. The most efficient way to monitor drug use and antipsychotic treatments is to maintain organized and detailed medical records. Studies have actually proven that improper documentation of antipsychotic drug usage leads to a higher rate of death in skilled nursing facilities.

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A study in the March 2012 issue of the Western Journal of Nursing Research, titled “Nursing Home Deficiency Citations for Physical Restraints and Restrictive Side Rails” brings attention to the use of physical restraints in skilled nursing facilities. The study is unique because it includes restrictive bed rails in its definition of a physical restraint, whereas most studies conducted previously have not.

Nursing homes often justify the use of physical restraints by making the claim that they prevent falls. However, the study confirms that restraints do not actually prevent falls. Instead, they actually pose a safety hazard to patients who often become entangled in or strangled by these devices.

Furthermore, they are often linked to health complications such as pressure sores and incontinence. Physical restraints can also be emotionally damaging to elder adults who already feel embarrassed by their loss of independence in activities of daily living. The use of physical restraints can also lead to psychological problems such as depression, isolation, agitation, and a loss of dignity.

In its analysis of the facility’s staffing levels, the study broke down the different types of caregivers. High staffing levels of Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) were correlated to fewer deficiencies for physical restraints and bed rails. However, when the facility employed a high number of nurse aides, with a relatively low level of RN and LPN staffing, it was found that the nursing home was more likely to receive deficiency citations for physical restraints. These results show that merely looking at overall staffing levels is not always sufficient in determining the quality of care that a nursing home will be able to provide. In addition to looking at numbers and ratios, one must also consider the types of staffing before making a decision to reside at a skilled nursing facility. Previous studies have also proven the importance of direct care from RNs, specifically, to prevent pressure ulcers and other health complications.

The study also showed that homes with large bed sizes were more likely to receive deficiencies for physical restraints. In discussion, the study suggested that this is due to the fact that communication between staff and patients is better in smaller homes because they allow for a tight-knit community that fosters interaction between patient and staff. However, this does not mean that larger nursing homes cannot provide the care that your loved one needs. It simply means that larger nursing homes need to employ a sufficient amount of staff to replicate the one-on-one, individualized care that is provided by smaller facilities.

Our belief, as supported by this study, that the use of physical restraints can be significantly reduced through proper staffing is also recognized by the Code of Federal Regulations. Title 42 part 483 has prohibited physical restraint use for purposes of discipline or convenience and maintains that restraints may only be used for medical reasons.

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While we are fortunate to be living in a modern world that is constantly making advancements in the field of medicine, the side effects of pharmaceuticals can often be dangerous and have implications that must be assessed. The March issue of the Journal of American Medical Directors published an article titled “Exploring Variation in Rates of Polypharmacy Across Long Term Care Homes.” The study on polypharmacy, which the article defines as “the use of multiple, concurrent drug therapies” produced startling results on just how many medications nursing home residents today are taking on average.

If a patient was on nine or more drug regimes at once, the study considered this a practice of polypharmacy and compared the quality of life of these patients to those who were taking fewer medications. The study found that patients subject to polypharmacy were more likely to have comorbidities. This group comprised about 15.5% of nursing home patients taking nine or more drugs simultaneously. Only 2.9% of patients were taking no drugs, and the remaining 81.6% were using anywhere between one and eight drugs at once. The most commonly used drugs include diuretics, proton pump inhibitors, and enzyme inhibitors.

Additionally, the study noted that in general, psychoactive drugs are also one of the most frequently used drugs in nursing homes. Previous studies have established that psychoactive drugs, although intended for treatment of illnesses such as schizophrenia, are often administered to patients who suffer from dementia. Because dementia patients may have episodes of agitation, nursing homes often find it convenient to sedate these residents with psychoactive drugs in order to prevent these episodes from occurring. However, this improper use of pharmaceuticals is an example of a chemical restraint and is in direct violation with the Patients’ Bill of Rights. Furthermore, studies have concluded that the use of psychoactive drugs in dementia patients has reciprocal effects and can actually cause agitation and worsen the overall condition of the patient.

In addition to triggering agitation in dementia patients, drug use can also cause delirium. It is important that you monitor your loved one’s drug intake, as well as the staff that is administering these drugs to him or her. Sometimes, understaffing and disorganization among staff can lead to mix-ups between patients’ drugs. Taking another patient’s drugs can have detrimental effects on health, and may even cause death. The study also noted that the more prescribing physicians a patient had, the more likely polypharmacy was to occur. This can be attributed to that fact that care facilities may not be properly documenting medical records. In terms of administration and management, documentation of medical charts is extremely important. All attending physicians must be able to clearly and easily see every medication that a patient is taking, in order to assess the costs and benefits of prescribing additional drugs.
Unfortunately, not all skilled nursing facilities have your loved one’s best interests at heart. What you can do is make frequent visits to check up on your loved one’s health and well-being. It is recommended that you have a general awareness of medications that are more likely to cause adverse drug reactions and overdoses. Also ensure to assess the facility’s staffing levels and closely monitor nurses, because tampering with patients’ drugs can sometimes occur in healthcare facilities.

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While polypharmacy, the use of multiple drugs simultaneously, is known to have dangerous effects on the physical and psychological health of patients, other causes of adverse drug reactions among the elderly population are lesser known. A study, titled “Geriatric Conditions and Adverse Drug Reaction in Elderly Hospitalized Patients,” published in the February 2012 issue of the Journal of American Medical Directors Association, seeks to discover another explanation for the occurrence of adverse drug reactions, focusing on the relationship to geriatric conditions.

After assessing 506 patients, the study concluded that hematologic, neuropsychiatric, and respiratory drugs are the most likely to lead to adverse drug reactions. With respect to geriatric conditions, patients who experienced adverse drug reactions suffered from cardiovascular, dermatologic, gastrointestinal, and psychiatric disorders. They also experienced a loss of independence, including incontinence and an inability to perform other activities of daily living.

Fortunately, incontinence is not a disease, but a symptom, that can be improved with the proper care. One treatment technique is called prompted voiding and involves the coordination of a patient’s bathroom schedule with a schedule of food and liquid intake. Nurses and dieticians also need to manage the nutrition and fluid intake of their residents. According to Patients’ Rights, the nursing staff is obligated to maintain the hygiene and dignity of your loved one if he or she suffers from incontinence. When proper care is not provided and patients who soil themselves are not changed immediately, incontinence can have serious consequences, such as the development of pressure ulcers. Needless to say, adequate staffing is absolutely necessary in order for treatment to be successfully executed and for hygiene and dignity to be preserved.

According to the study, falls, in particular, were strongly linked to the usage of neuropsychiatric drugs. Because falls are so dangerous, as they can lead to injuries, such as hip fractures and head trauma, and sometimes death, caregivers need to be even more careful with patients who are using neuropsychiatric drugs. This requires communication between the patient’s physician and the nursing staff. Unfortunately, the nursing staff does not always have your loved one’s best interest at heart, so it is important for you to ensure that such communications are taking place and that physician’s orders are being followed.

On the contrary, nurses sometimes use drugs as restraints, in an attempt to prevent falls. Often, antipsychotic drugs are used as chemical restraints to sedate patients. The use of chemical restraints is not only a violation of rights, but is also dangerous, as it puts patients at a higher risk for death. You should check that your loved one’s medications are prescribed for medically sound reasons, and also ensure that your loved one is not being physically restrained either.

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On January 10, 2012, Bloomberg News featured a story about Omnicare, a pharmaceutical company, that adjusted its billing records and reported false information to government health programs, such as Medicare and Medi-Cal, in order to increase its own profits. According to the report, the government may have lost millions of dollars from Omnicare’s fraud. Despite the story making it to news headlines, the truth of the matter is that health facilities cheat the government fairly often. Previously, Bloomberg News reported another situation that involved nursing homes that were incorrectly billing Medicare. To read more about that story, click here.

Incentives for cheating the government vary. In some cases, such as this most recent one, companies are simply seeking profit. In other situations, health facilities take advantage of Medicare by unnecessarily ordering drugs that were never prescribed by doctors. These drugs are usually used by nurses to chemically restrain patients. Antipsychotic drugs are the most common chemical restraints because of their power to sedate patients. However, these drugs that are intended to treat mental illnesses are more often used to treat patients with dementia. Because dementia patients are often subject to episodes of aggravation, nurses find it more convenient to subdue them with antipsychotics rather than to take the time to calm them down with behavioral techniques.

Specialists confirm that the best treatment for dementia-related aggravation is therapeutic, not pharmacological. Because aggravation is often caused by polypharmacy, or the excessive use of multiple drugs simultaneously, it only makes sense that adding more medications will only worsen patients’ conditions. Some types of treatments that have proven effective are pet and music therapy, as well as encouraging social interaction among patients, especially during mealtimes.

Beyond the ethical implications of using drugs to restrain patients, the improper use of antipsychotic drugs also poses many risks. Studies have shown that the use of antipsychotics in dementia patients more than doubles their chances of death. Additionally, patients are put at a higher risk for falls, depression, and isolation. You should also learn more about the dangers of physical restraints, and make sure that your loved one is not being restrained in any way by his or her nursing home, either physical or chemical.

Although the use of chemical restraints is an undoubtedly cruel act, nurses sometimes feel that they are left with no other choice. Nursing homes are often so understaffed that caregivers must take shortcuts in order to provide enough time to tend to each of their patients. Unfortunately, this abbreviated care is never sufficient in providing your loved one with the quality of care that he or she needs.

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On November 30, 2011, the Associated Press and Bloomberg news both reported that Medicare money was being used to improperly prescribe antipsychotics to nursing home patients. These drugs, which include AstraZeneca Plc (AZN) and Eli Lilly & Co. (LLY), are used to treat schizophrenia and bipolar disorder. However, they are also commonly used in nursing homes for patients with dementia. Although specialists recommend that patients with dementia seek non-pharmacological treatments, most nursing homes inappropriately prescribed antipsychotics in order to subdue patients. Of the 14 percent of residents who were prescribed antipsychotics, it was found that 83 percent were for residents with dementia. In 2007, these wrongly prescribed antipsychotics amounted to $116 million of taxpayers’ money. This money could have been used to fund other nursing home projects that are very necessary and would significantly improve quality of life for elderly adults.

The improper use of taxpayers’ money is not the only issue at stake here, however. Patients’ lives are being put at risk by nursing homes who are unnecessarily prescribing antipsychotics. The Food and Drug Administration cautions that the use of antipsychotics increases the risk of death among seniors. Additional side effects include an increase in blood sugar and cholesterol, which may also lead to weight gain, and a higher risk of falls, mortality, and hip fractures.

The use of antipsychotics, known for their sedative effects, to subdue dementia patients is exemplary of the use of drugs to chemically restrain nursing home residents. Not only is this a direct violation of patients’ rights, but it also brings to light issues of understaffing in nursing homes. The inadequate staffing of nursing homes prevents caregivers from providing sufficient care for all their residents and often leads to the use of drugs as chemical restraints. Even if your loved one’s nursing home is adequately staffed, quality of care is another issue that must be addressed. Caregivers must be well-trained, especially in matters such as how to best care for a patient suffering from dementia. Sometimes, dementia patients are prescribed antipsychotics because caregivers are not knowledgeable and are unaware of any other methods of treatment for dementia.

Previous studies have shown that the use of antipsychotics actually triggers aggressive behavior in dementia patients. Because a common cause of agitation is delirium, which is often a consequence of polypharmacy, the excessive use of multiple prescribed drugs simultaneously, it is only logical to conclude that agitation should not be treated by using additional drugs. Specialists confirm that the best treatment for agitation is behavioral, not chemical.

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Studies show that one in five adults residing in nursing homes experience agitation, which can manifest itself as irritability, apathy, or depression. While agitation occurs in adults who are relatively healthy, it becomes problematic when adults who have dementia become agitated because these cases of agitation are more likely to progress into more serious phases. In a study titled “Dementia-Related Agitation,” available in the November 2011 Journal of American Medical Directors Association, John B. Morley studies the relationship between dementia and agitation in nursing home residents and proposes some solutions to this issue.

One cause of agitation is pain. Therefore, it is very important for nursing homes to have high-quality pain management programs such as music therapy, dance therapy, and pet therapy. Psychosocial interactions and exercise therapy have proven to be the most effective treatments for pain management. However, for any of these treatments to reach their full potential in terms of effectiveness, caretakers must be thoroughly educated in these areas and must be provided the tools and resources necessary to implement such programs by the nursing home’s owners and operators. For this and for many other reasons stressed in the series of articles published in this nursing home and elder abuse blog, It is critical for you to ensure that your loved one’s care facility is adequately staffed and that your loved one is being properly cared for by a knowledgeable and well trained staff. If you watch your loved ones like a hawk, you will instinctively know when a facility is not only understaffed, but also undertrained and not properly supplied with the resources it needs.

Malnutrition also factors in to the causes of agitation. A lack in nutrients can cause visual and oratory problems that may hinder the ability to see or hear and consequently increase the risk of agitation. Additionally, studies have proven that there is little evidence to support that the use of feeding tubes helps to improve nutrition in elderly adults.

A final common cause of agitation is delirium. It is often a consequence of polypharmacy, which is the excessive use of multiple prescribed drugs simultaneously. Since the use of drugs is a direct cause of delirium, and thus agitation as well, it is only logical to conclude that agitation should not be treated by using additional drugs. Specialists confirm that the best treatment for agitation is behavioral, not chemical.

However, some nursing homes may not have your loved one’s best interest at heart. Such facilities may be using drugs such as antipsychotics to chemically restrain elderly adults who suffer from agitation in order to subdue them and make them easier to handle. Furthermore, evidence has shown that use of antipsychotics may increase the risk of falls, mortality, and hip fractures. Not only is this is a direct violation of your loved one’s Patients’ Rights, but it can also be detrimental to his or her physical and mental well-being.

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