Photo cutline: Dr. Sandeep Sobti is working to lower the reliance on antipsychotic medications in New Hampshire nursing homes.
For Alan Lancaster, the early signs of Alzheimer's disease emerged about a decade ago. He kept forgetting his ATM card in the machine. He started having trouble using the telephone. The disease quickly progressed, eventually stealing his ability to speak.
Then last winter, his wife Constance says, he started having outbursts.
"They began at home," she says. "They were one of the signs to us that something was wrong, because he had always been very mild mannered. Occasionally he would lose his temper and he would break something. Might be a pencil, might be his glasses. Or he might kick the wall. That was frustration - speaking."
Worn down from stress, Constance and her two grown children decided to place Alan in a nursing home in Vermont. That lasted all of three days. The staff said he was too combative, potentially violent. They transferred him to an emergency room, and eventually Alan landed in a hospital psych ward. He received a jumble of medications, including Seroquel, an antipsychotic.
"There were times when he was completely unresponsive. Not even an eyelid flutter," Constance says. "A day that my daughter and her children and I visited, we spent four hours there, waiting for him to respond, and he never woke up."
Alan lost the ability to walk. He came down with pneumonia. After what Constance calls a brutal month, he was transferred to Maplewood Nursing Home, a county-run facility on the banks of the Connecticut River in Westmoreland.
There, Dr. Sandeep Sobti (left), a geriatric psychiatrist, immediately started to wean Alan off the medications. Sobti says the use of powerful antipsychotics on Alzheimer's patients is the equivalent of handcuffing people to wheelchairs.
"That used to be a method that was relied on, the same way we are relying on medications right now to control the behaviors," Sobti says. "It was inhumane and I'm very glad it is in the past. And I hope someday this chemical restraint business will be in the past."
The federal government feels the same way. Last summer, it began publishing the rate of antipsychotic use at each nursing home in the country. Inside Maplewood, about 25 percent of all residents receive an antipsychotic drug. That's on par with the state average, though a wide range exists. Some facilities in New Hampshire approach 80 percent, others less than 5 percent.
Alice Bonner, with the Centers for Medicare and Medicaid Services, says publishing the data is one way to help drive down rates. But she cautions that a facility shouldn't be judged on this single statistic.
"Just seeing a high rate of antipsychotic use in a nursing home, by itself, doesn't mean that there is a problem in that nursing home. Because, for example, maybe they are not using those medications in people with dementia - maybe they have other types of mental health patients in that facility who really benefit from those drugs," Bonner says. "But it allows the family at least to say, 'Wait a minute, this is something that I want to ask about before I place my mother here.'"
Along with the ethical questions of simply sedating Alzheimer's patients, Bonner says the drugs pose a serious health risk: They increase a senior's chance of falling, of stroke, and risk of death.
At Maplewood, Dr. Sobti has pushed for alternatives to antipsychotics. He urges more patience among staff - more focus on what is causing poor behaviors, not just what medicine can be used to calm someone down.
It sounds simple, but he says caregivers don't get the needed training for behavioral issues. "It cannot be overstated. That issue cannot be overstated," Sobti says. "We need that and we need that a lot. Without that, any attempt at making a meaningful decrease of medications will not work as well as it would with that education."
Along with that better training, Dr. Sobti strongly encourages family to play an active role in treatment. He says they should ask questions, and question the need for each medication.
But figuring out how to better manage behaviors takes time, and that can be frustrating for loved ones. Kathyrn Kindopp is the chief administrator at Maplewood. She says people don't want to see a parent or spouse in distress.
"There is so much pressure to fix something now. And I think society has been pre-programmed, that for every ailment, there is a pill. And it is a quick fix," Kindopp says. "And sometimes we need everyone to be patient as we work through what are the alternatives that can occur."
For Alan Lancaster, it took a few months at Maplewood to get his other medications and care in order. His wife Constance says he had to relearn how to walk, how to eat solid foods.
"I don't fault them. They probably thought it's really important to get him to a point where he never raises a fist at anybody or ever acts out. But he's a human being, and if he is feeling that, it is going to happen," she says. "And it is better, in my assessment, for him to have real emotions and get past it. They wanted him to be perfectly behaved."
Constance says perfect isn't possible with Alzheimer's disease. In the fall, her husband was good enough, healthy enough, to leave Maplewood and move back home.
Photo by Todd Bookman.
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