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Human Rights Watch (HRW) published a devastating report in February 2018, which found that over 179,000 nursing home residents were being administered off-label antipsychotic drugs every week.[1] Antipsychotic drugs are indicated to treat specific clinical conditions, such as schizophrenia, and not the behavioral symptoms of dementia. Nevertheless, the HRW report noted that most of the residents on antipsychotic drugs have Alzheimer’s disease or other forms of dementia.[2] According to the Food and Drug Administration’s “black box” warning, the use of antipsychotic drugs on elderly patients is associated with a significantly increased risk of death.[3]

As many reports have indicated, including those written by the Center for Medicare Advocacy,[4] one factor in the inappropriate use of antipsychotic drugs in nursing homes has been inadequate nurse staffing. A recently-published study in the Journal of Psychiatric and Mental Health Nursing (JPMHN), entitled “An observational study of antipsychotic medication use among long-stay nursing home residents without qualifying diagnoses,” has found further correlation between registered nurse hours and antipsychotic drug use.

The authors of the Study found that “[o]ne additional registered nurse hour per resident per day could reduce the odds of antipsychotic use by 52% and 56% for residents with and without a dementia diagnosis respectively.”[5] Looking at nursing facilities in the state of Missouri, the authors found that just meeting the national average for registered nurse hours (.8 hours) would result in a 22% reduction in the odds of inappropriate antipsychotic drug use in residents with dementia; the reduction increases to 25% for residents without dementia.[6]

The federal Nursing Home Reform Law states that every nursing home resident is entitled to services that attain or maintain his or her “highest practicable physical, mental, and psychosocial well-being.” As the JPMHN Study shows, sufficient registered nurse hours are essential to improving residents’ quality of care and quality of life and meeting the requirements of federal law.

NOTE: Nursing home residents have rights and protections under federal law. Nursing homes must not administer an antipsychotic drug unless it is medically necessary to “treat a specific condition as diagnosed and documented in the clinical record.”[7] When residents are already on antipsychotic drugs, nursing homes must undertake gradual dose reductions and behavioral interventions, unless clinically contraindicated, to discontinue the drug.”[8]

September 20, 2018 – D. Valanejad

[1] See Hannah Flamm et al., “They Want Docile”: How Nursing Homes in the United States Overmedicate People with Dementia, Human Rights Watch (Feb. 2018), (noting that “[t]he drugs are often given without free and informed consent . . . .”).
[2] Id.
[3] Atypical Antipsychotic Medications: Use in Adults, CMS, (last visited 9/19/2018) (“Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death.”).
[4] See e.g., Toby Edelman, Elder Abuse in Nursing Facilities: The Over-Administration of Antipsychotic Drugs to Nursing Home Residents, Center for Medicare Advocacy (Jun. 15, 2016), (“There is a solution to this form of elder abuse! Improve staffing levels in nursing facilities. Long-standing evidence confirms that nursing facilities employ too few nurses to meet residents’ needs.”). 
[5] Lorraine J. Phillips et al., An observational study of antipsychotic medication use among long-stay nursing home residents without qualifying diagnoses, Journal of Psychiatric and Mental Health Nursing (Jun. 17, 2018), (looking at 2015 long-stay residents in Missouri who lacked a qualifying or potentially qualifying diagnosis for antipsychotic drugs).
[6] Id.
[7] 42 C.F.R. § 483.45(e)(1).
[8] 42 C.F.R. § 483.45(e)(2).


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