“Drug ‘em Up” is No Way to Approach Dementia Care

Ever heard of “chemical restraints”? That’s the fancy term for the “drug ‘em up” culture that still exists in too many nursing homes today. It refers to nursing homes’ use of dangerous antipsychotic drugs as a way to control difficult behaviors displayed by people with dementia.

What, you say? We still do that? Yep, we sure do – even though giving these kinds of medications to older people with dementia sharply increases their risk of death.

If you’re starting to get mad, good. I’ve been mad about this for a long time. I’ve seen this despicable practice go on for years, with devastating consequences.

But perhaps the tides are turning, even though it’s not the nursing homes that are on the opposite end of the crackdown – it’s the pharmaceutical companies.

(c) Rakratchada Torsap

(c) Rakratchada Torsap

Earlier this month, Johnson & Johnson reached a plea deal to pay over $2.2 billion in penalties for marketing the antipsychotic drug Risperdal and other drugs for uses not approved by the FDA.

Risperdal was FDA-approved in 1993 for the management of psychotic disorders only. Hallucinations – sensing things that are not really there (usually via sight or sound) – and delusions – harboring false beliefs that are often paranoid or grandiose – are hallmarks of psychotic illnesses because they signal a loss of touch with reality.

While people with dementia can sometimes exhibit psychotic symptoms, this does not mean they have a psychotic disorder, nor does it mean that drugs like Risperdal can help them. Oftentimes, antipsychotic drugs like Risperdal only create dangerous side effects that lead to falls and other dangerous complications. I’ve seen this first-hand when I was a mental health clinician in Colorado and could do little but speak up and then be ignored.

Even worse, when the type of dementia is Lewy body dementia (often misdiagnosed as Alzheimer’s disease), the use of antipsychotic drugs can cause severe, life-threatening reactions.

The FDA has never approved Risperdal for the treatment of dementia, so this practice is considered an off-label, unapproved use. Yet in 1998, Johnson & Johnson created an “eldercare” sales force with the specific task of marketing Risperdal to nursing homes.

When I was a psychology intern at a VA hospital out East, I distinctly recall pharmaceutical companies coming to the medical center and catering in elaborate luncheons to promote their antipsychotic drugs to the physicians that treated older veterans. Later, while working for the Alzheimer’s Association in Utah, I heard stories from several families who were heartbroken over the “zombies” their older relatives had become since moving into the nursing home and being prescribed these kinds of medications.

So yes, I’m angry with the pharmaceutical companies for pushing their drugs on the long-term care sector and promulgating the use of “chemical restraints” to manage difficult dementia behaviors. But I’m also mad at the long-term care facilities, medical directors, and other physicians who fall into this trap.

Believe me, I get it – taking care of individuals with dementia is hard work. Dealing with behavior problems such as hallucinations, delusions, suspicion, wandering, and combativeness can be time-consuming and exhausting. But all too often, our society reaches for pills to deal with these kinds of problems when safer, more humane solutions are available.

Research studies have shown time and again that non-drug behavioral management strategies, such as environmental changes and adjustments to the ways we communicate with those with dementia, can work as well or even better than drugs as a way of managing difficult behaviors. To learn more about how to do this, see my articles on the A-B-C Approach to Dementia Care and the Caregiver’s Guide to the Brain and Behavior.

Based on my work with people with dementia, some of whom have exhibited the most challenging of behaviors, I would say that an antipsychotic drug is necessary for fewer than 5% of those affected. For the rest, non-drug behavior management is the way to go.

Thankfully, I have seen some fantastic nursing homes and staff members embrace the non-drug approach compassionately and effectively. If you are one of these organizations or individuals, thank you. But shame on Johnson & Johnson and the rest who are perpetuating the unsafe use of antipsychotic medications to treat one of our most vulnerable populations.

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