David Blakeney died in a nursing home. Mr. Blakeney was a 63-year-old nursing home resident with dementia who died eight months after being prescribed an antipsychotic drug to address behaviors associated with dementia. Weight loss, pneumonia and loss of mobility occurred after the drug was administered daily.
His story is described in the Sept. 11, 2021, edition of the New York Times. The article describes the increasing use of psychiatric diagnoses in nursing homes since the 2012 introduction of regulations to prevent unnecessary use of antipsychotic drugs.
Antipsychotic medications may be used in the presence of a psychiatric diagnosis such as schizophrenia (vs. dementia, a neurological diagnosis). The increase in psychiatric diagnosis also correlates with an increase in use of antipsychotic medications in nursing homes, according to the article. Mr. Blakeney never had a documented psychiatric condition until the use of antipsychotics was initiated during his nursing home stay.
Federal laws require nursing home residents and /or a representative the right to be informed of, and participate in, healthcare decisions. However, the right to be informed is not consistently interpreted in regards to the use of drugs such as antipsychotics in nursing home residents with dementia.
The use of drugs, including drugs that are known to place the nursing home resident at risk of injury and death such as antipsychotics, may be administered without prior knowledge or informed consent of the nursing home resident and/ or representative. Unbeknown to the family of those with dementia, antipsychotics may be contributing to the death of their loved one. The authors of the New York Times article do not mention if Mr. Blakeney’s family were offered or provided consent prior to the use of the drug.
Antipsychotics are dangerous when used in older adults with dementia. In 2005, the Federal Drug Administration issued a black-box warning related to APM use in older adults with dementia due to a 1.6 to 1.7 increase in mortality when nursing home residents with dementia were administered an antipsychotic. The American Geriatrics Society Beers Criteria® (2019) identified APMs as potentially inappropriate medications for use with older adults due to a strong relationship between antipsychotics, falls, and fractures.
Despite the known negative health outcomes associated with antipsychotics, there are some circumstances that warrant the use of the drug. The laws governing APM use in nursing homes allow for the medication to be used in certain conditions, including the existence of a psychiatric diagnosis.
The Centers for Medicare & Medicaid Services has approved APMs for the treatment of chronic psychiatric conditions including schizophrenia, schizoaffective disorder, bipolar disorder, psychosis, psychotic mood disorders, Huntington’s chorea and Tourette’s Syndrome. When one of the psychiatric diagnoses exists, APM use may be justified and not restricted under the current nursing home regulations. Again, Mr. Blakeney was newly diagnosed as schizophrenic upon initiation of the antipsychotic medication.
Most nursing homes do not require providers to inform residents and/ or representatives of the associated risk of APMs, nor do most states require (written or verbal) consent for antipsychotics, according to the Long-Term Care Community Coalition (2013). Informed consent prior to the initiation of antipsychotics would provide evidence the nursing home resident (and/or representative) agree to the administration of the drug and acknowledge receiving information regarding the associated risks and treatment options.
Each state interprets federal regulations differently as it pertains to informed consent and antipsychotics. For example, Massachusetts requires written informed consent prior to antipsychotic medications as compared to the Commonwealth of Pennsylvania. Pennsylvania addresses informed consent with respect to experimental research and treatment, not antipsychotics.
Legal opinion proposes informed consent will reduce the unnecessary use of antipsychotics in nursing homes. Organizations may include the resident and/ or representative in the plan of care and inform one upon initiation of antipsychotics, not necessarily prior with a description of the known risks. One can only wonder if Mr. Blakeney’s family was offered or would have consented to the use of antipsychotics.
Prescribing antipsychotics to older adults may place one at risk for harm. Regulations are designed to improve the quality of life for nursing home residents. Regulations addressing antipsychotics in nursing homes need to be strengthened to require informed consent before prescribing this potentially dangerous class of drugs. Informed consent would support the right to self-determination and may prevent harm to our nation’s most vulnerable population, nursing home residents.
Karen Robson, DNP, RN-BC, RAC-CT, is a clinician with more than 27 years of experience in long-term care, including 10 years as a Doctor of Nursing Practice [DNP] clinician.
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.