a long way to go as a country to see to it that we are not abusing those Americans who reside in the nursing homes of this country.

I hope as a result of this hearing that we can catalyze at changes in regulations, that we can get at changes in the law, so that we can guarantee to the Americans going into a nursing home that they are not simply going to be put on drugs for the sake of making it easier for the attendants who work in those nursing homes to take care of those people. They should be receiving the same care they could get at home and they shouldn't, obviously, be subject to drug abuse simply to facilitate their care in nursing homes.

I applaud you and hope we can get at these problems this morning.

The CHAIRMAN. Thank you very much. I would like to insert the prepared statements of our colleagues, Congressman Roybal and Congressman Biaggi at this point in the record. Hearing no objections, it is so ordered.

[The prepared statements of Representatives Edward R. Roybal and Mario Biaggi follow:]

PREPARED STATEMENT OF REPRESENTATIVE EDWARD R. ROYBAL

The over prescription of drugs to the elderly is an extremely serious and dangerous problem. The elderly, in proportion to the rest of the population use a greater percentage of the drugs produced. Medicaid statistics show that the elderly comprise 17 percent of the program's clients but account for 44 percent of the $1 billion spent on prescription drugs. These figures raise the question of whether the elderly are being over-prescribed medication, in some cases needlessly and in other cases with fatal results.

There are various reasons why elderly persons are over-medicated. Pharmacologic problems of aging results from physical and metabolic changes of the body. The medical profession lacks full understanding of these changes and the interplay of multiple medication. For example, it is believed that a person over 65 years of age can lose up to 50 percent of the nephrons in the kidneys, therefore, the body takes longer to eliminate any medicinal residue.

Older people are less able to metabolize drugs than younger patients. Therefore, the levels of drug potency and dosage need to be measured according to special requirements of the patient population. Drug potency and dosage often increase the potential of incompatible drug combination. Drug interaction and individual metabolic changes in older persons, if not taken into account in dosage recommendation can lead to over-medication, sometimes the extent that the older patient may become depressed or is incorrectly diagnosed as suffering from senility.

Another reason for the over-prescription of medication to the elderly is controlled by the medical profession. Doctors in partnership with pharmacists will prescribe drugs with little or no medicinal value.

Finally, we must consider the "blind faith" the elderly have in their doctors which creates a situation where the need for prescriptions is not questioned. Due to infirmities associated with advancing age, the elderly are more tolerant of symptoms than younger people and may fail to speak-up when drug toxicity is suspected. The hearing today is concerned with drug abuse in nursing homes. But the problem is much more extensive than the 5 percent of the elderly residing in nursing homes. The 95 percent who live out in the community are also prone to drug abuse or misuse.

There is a need for geriatric training and education in the field of medicine. Geriatrics has long been wrongly considered a synonym for nursing home medicine. Geriatrics cuts across the daily living of elderly people, most of whom are coping at home. Geriatric training should include the following:

1. Formal pharmacological training in medical schools.

2. More education regarding the abuse and misuse of drugs should be required for pharmaceutical salesmen.

3. Appropriate levels of drug potency and dosage for older people.

4. Health care personnel who provide treatment to older people need to be trained in the psychological and physiological changes associated with age.

Appropriate teaching programs should involve not just long-term care facilities but also medical health clinics, family health and senior citizens centers and adult day care centers. Consumer and drug management eduction is the responsibility of all practitioners working with the elderly. This is all within the purview of preventive health care.

It is my hope that this testimony presented today by the General Accounting Office and other experts will provide us with a better insight on how to deal with this serious problem.

PREPARED STATEMENT OF REPRESENTATIVE MARIO BIAGGI

I would like to commend my distinguished colleague, Claude Pepper, for conducting this important hearing on the problem of drug abuse in nursing homes. As a member of this committee, as well as the Select Committee on Narcotics, I have a special interest in the topic before us.

Increased drug use has become an inescapable part of growing old in America. Despite the fact that senior citizens make up only 11 percent of our population, they use 25 percent of all drugs prescribed in the United States and each year spend approximately $2.6 billion on drugs alone.

Statistics indicate that 60 percent of all physician visits, including those for psychological counseling, result in the writing of at least one prescription. In a drugoriented society where medication is often viewed upon as the magic formula to ease pain and loneliness, the increased drug use by older Americans may in some instances prove to be more harmful than helpful.

Today the focus is on drug abuse in nursing homes, a long-standing and well documented problem. According to a recent study by Dr. James Cooper, a professor of gerontology at the University of Georgia, for example, 95 percent of all institutionalized elderly patients are reported to be taking prescription drugs. This is an astounding figure and warrants closer investigation. How many of these drugs, for instance, are ill-prescribed? Based on a survey of 100 consecutive nursing home admissions, Dr. Cooper found that the primary diagnosis of 64 percent of incoming patients was inaccurate and 84 percent of the secondary diagnosis was either lacking or inaccurate. Unfortunately for these people, the admitting diagnosis serves as the basis on which drugs can be prescribed. If these are incorrect, then it logically follows that the drugs prescribed will be inappropriate as well. Thus we see one element of abuse.

Another significant factor contributing to drug abuse in nursing homes is the disturbing tendency to overmedicate certain patients. In one recently completed survey it was estimated that about 25 percent of the drugs prescribed in nursing homes were not considered effective, needed, or given for their FDA approved use. Investigations, including one completed for the Narcotics Committee in 1974, indicate that the problem of oversedation is one of the most prevalent and blatant examples of overmedication.

Certainly the paucity of research conducted in this field is a contributing factor to the problems elderly individuals experience with regard to drugs. More studies are needed to ascertain the effect of drug-disease and drug-drug interactions. The fact that elderly persons often receive multiple drug therapy underscores the need to better comprehend the effects of their prolonged use.

Drug abuse in nursing homes is a far-reaching problem that will not be solved overnight. However, if we are to ensure the health and well-being of our growing elderly population, then it is the duty of all involved to see that drug therapy is adequately coordinated; that physicians who prescribe drugs and nursing home staff that dispense them are properly trained and advised on the medical history of each patient; and that federal regulations designed to monitor the flow of drugs are promptly enforced.

The CHAIRMAN. Now we will call our first panel. Our first panel is comprised of individuals who have had to deal with drug abuse in nursing homes.

Our first witness, and as I call your name, if you will kindly come up, the first is Mrs. Esther Stanley of Santa Cruz, Calif., accompanied by her daughter, Mrs. Joyce Lile. Mrs. Stanley will relate her 1-year experience in nursing homes where she continually had to fight against the effort of the system to make her drug dependent.

Our second panel member is Mrs. Arlene Summer of Marietta, Ga. I had the honor and pleasure of being on an ABC program this morning with Mrs. Summer. She made a very fine presentation. Mrs. Summer will discuss her father's experience with oversedation in a nursing home. She will tell how her father came close to losing his life by excessive use of drugs which the nursing home wished to impose upon him.

Our third panel member is Mrs. June Lewis, president of the Pennsylvania Advocates for Better Care in Philadelphia. Mrs. Lewis has worked on a daily basis with nursing home patients and their problems for several years. She will relate the story of Mrs. W., a nursing home patient who could not be with us here today on account of severe arthritis.

We are very glad to have all of you present and Mrs. Stanley, if you would like, we would like you to proceed with your statement. By the way, insofar as you can, so that we can hear all of the important witnesses who are here today, if you have a written statement, we will be glad if you offer it for the record and it will be carried in full, and then summarize your testimony.

But if you feel that you would rather read it, of course, we will be pleased to have you do so.

Mrs. Stanley.

STATEMENT OF ESTHER STANLEY, SANTA CRUZ, CALIF.,

ACCOMPANIED BY HER DAUGHTER, JOYCE LILE

Mrs. STANLEY. I would like to thank you for giving me this opportunity to tell about my personal experience in various nursing homes in a year's period from 1974 to 1975. The reason for going there was a fractured pelvis which made me unable to walk or sit up. The doctor said I could not be admitted to a hospital as medicare refused to pay for this type of injury under their rules. After 10 days in my daughter's home I was transferred to a 55bed skilled nursing facility at the doctor's request. When I was admitted I was nonambulatory. In a short time I became confused and declared mentally incompetent and extremely depressed. This was because of overmedication that had been given to me. The family asked the staff why this should happen to a person who had been alert and active just a short time ago and had only a fractured pelvis. No logical answers were given by the staff or the doctor.

In entering a nursing home you are under their control and they are given their orders over the telephone by the doctor. And this is considered standard procedure, at that time and at the present time. The drugs used by the nurses were at their discretion, any amounts they decided, with no regard to the constitution of the individuals or age. I was 77 at this time and weighed about 92 pounds. I was not used to taking medication in such large doses. In a short time I began to suffer great depression because of the following drugs: valium, elavil, placidyl, and a tranquilizer called capla. My daughter has a record of other drugs, three or four other drugs, too. When we asked why all this medication was given, the nurses said I was just on maintenance. The doctor was asked to consider giving me less medication. Temporarily the dosage was lowered.

At this time I was paying for all of my nursing home expenses. I had no local, State or Federal agency to give me any financial help. My social security payment at this time was $155 a month. I had a reserve of only a few thousand dollars which was going rapidly so my daughter applied for a pension from the VA because I was a World War I widow. This was given to me for a year and then stopped. Besides being confused, I was unable to walk without help, even to the toilet, although the doctor said the fracture had been healed. So even though my physical injury for which I entered the nursing home had been healed, my mental capacity had deteriorated due to the great amount of drugs administered to me. If it had not been for my daughter standing by me and doing all she could in her power to get me out from under this system, I would not be here today.

I am 83 next Tuesday. At the present time I am living in an apartment where I am able to take care of myself. I am active in programs relating to preventive health care. I walk two miles a day and I have a state of mental alertness and I am in reasonably good health.

Because this system still exists there is a great need for a change. If you are able to do anything to prevent others from going through this completely unnecessary nightmare, then my testimony here today will not have been in vain.

Before I leave, I would like to leave you a letter from a good friend of mine, whom I have known for some 12 years.

The CHAIRMAN. Thank you. It will be received for the record. [The letter submitted by Mrs. Stanley follows:]

To Whom It May Concern:

COUNTY OF SANTA CRUZ,

HEALTH SERVICES AGENCY, Santa Cruz, Calif., June 24, 1980.

It has been my privilege to have known Esther Stanley for about twelve years. I was in close contact with her during the period of her hospitalization and her stay in various local Nursing Homes.

It was distressing to observe that during the time she was a patient in the Nursing Homes she deteriorated from an intelligent and capable person to a depressed and confused individual, incapable of functioning normally.

Since leaving the Nursing Homes she is again her usual, bright self.

Now she functions normally in her own home and is actively engaged in Church work and in many community activities.

Sincerely,

The CHAIRMAN. Thank you.

(Chaplain) FRED B. WHALE.

Mrs. Lile, would you like to supplement the statement?

STATEMENT OF JOYCE LILE, PRESIDENT, CITIZENS FOR

BETTER NURSING HOME CARE, SANTA CRUZ, CALIF. Mrs. LILE. I am from Santa Cruz, also. I am current president of the Citizens for Better Nursing Home Care. This was started really because of 12 people that were concerned about their families in nursing homes and so we established this institute in 1974 and we do have an ombudsman program at the present time.

What I would like to read you is the doctor's description of my mother's medical condition. It says, "patient is confused, mentally incompetent, at times paranoid, along with mild anxiety, depressive reaction, thus requiring hospitalization on a continuing basis."

67-680 0-80--2

Then she has got "chronic brain syndrome with dementia; anxiety-depressive reaction; hypertension; cerebral vascular insufficiency, and she is now requiring hospitalization because of chronic brain syndrome."

The nurse says, "very confused this past week, complained almost constantly about nonexistent things, prefers to remain in bed, stating she is not strong enough to be up but is encouraged to get up."

Then she says, too, "very confused, emotionally unstable person, quite hyperexcitable at times, talks very rapidly, some days moody and withdrawn. Moods are subject to change very suddenly."

And right then and there you would think that would have alerted them to the fact that something was going on as far as the drug medication.

But the problem is that many of the drugs are PRN and PRN means that they are at the discretion of the people who give them as needed, and many of the nurses are not, I would not say not capable but they do not use good judgment in many cases.

In fact, we had an older nurse on at night and she was so wrought up about her son being in an automobile accident that she was mixing the drugs up and my mother said, it makes me so nervous I do not know if she is even going to give me the right drug. That is one particular nursing home.

The other nursing home did have unlicensed staff giving medication. The owner also tried to give my mother the same medication so she was moved out of that nursing home. I think you will see that in this statement that I wrote with the doctor's assessment attached.

So we moved her to this other skilled nursing facility, 55 bed, but I think the solution lies in, like you say, monitoring the combination of drugs. Even the general public is urged to check with their pharmacist if they are taking several different medications and you are not sure whether they are going to interact. You call your druggist or your doctor.

Many patients have no families to speak up for them. So this continues because it is not caught, they are never caught, so they do not see it.

So in California we have an ombudsman advocate program that attempts to solve some of these problems and also a new access law allowing qualified personnel to review the patient's medical records. We just caught one the other day. The woman was sent out on a problem that came into the ombudsman office. She was sent out and said it sounds like it is drug overdose. They checked through the records and sure enough that is what it proved to be. I said, that was great that she picked up on that.

But the remedy would be also less paperwork for the RN's. The RN's, activity directors, have to fill out form after form and they get very little time to be involved in direct patient care mostly nursing assistants, the aides give the direct care. In California they are supposed to be certified. Most of them are certified. But the training given in the nursing home is sadly lacking. They need much more training regarding medication, regarding how to treat the patient. I would say they make the patient feel like a nonperson. He is more of a number than a person.