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Additional material received for the record-Continued

Richard Penna, director of professional affairs, American Pharmaceutical

Association, Washington, D.C., letter ......
Sanford Luger, R. P., chief, Bureau of Pharmacy Services, Division of

Medical Assistance and Health Services, State of New Jersey Depart

ment of Human Services, Trenton, N.J., letter Dr. Michael Creedon, Center for the Study of Pre-Retirement and Aging,

The Catholic University of America, Washington, D.C., prepared state

ment.. Thomas Abrams, director, Research Division, the Gerus Society, Washing

ton, D.C., letter and prepared statement.
Valery A. Portnoi, M.D., Director, Division of Geriatric Medicine, and L.

Gregory Pawlson, M.D., Director, Center for Aging Studies and Serv-
ices, The George Washington University Medical Center, Washington,
D.C., letter......

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DRUG ABUSE IN NURSING HOMES

WEDNESDAY, JUNE 25, 1980
U.S. HOUSE OF REPRESENTATIVES,
SELECT COMMITTEE ON AGING,

Washington, D.C. The committee met, pursuant to notice, at 10 a.m., in room 2237, Rayburn House Office Building, Hon. Claude Pepper (chairman of the committee) presiding.

Members present: Representatives Pepper, of Florida; Roybal, of California; Bonker, of Washington; Evans, of Indiana; Oakar, of Ohio; Gudger, of North Carolina; Byron, of Maryland; Ratchford, of Connecticut; Atkinson, of Pennsylvania; Grassley, of Iowa; Hammerschmidt, of Arkansas; and Hopkins, of Kentucky.

Staff present: Charles H. Edwards III, chief of staff; Val J. Halamandaris, senior counsel; David Holton, chief investigator; Nancy Smythe, investigative researcher; Kathy Gardner, professional staff member; Henry Hicks, communications director; Marie Brown, executive secretary; and Walter A. Guntharp, Ph. D., minority staff director.

The CHAIRMAN. The committee will come to order, please.
Our general counsel, Mr. Edwards, wishes to make a statement.

Mr. EDWARDS. We would like for the record to reflect that subpenas issued by the Subcommittee on Health and Long-Term Care were returnable this morning and the following organizations have not returned the subpenas and are therefore not in compliance with them: Park Avenue Home for the Aged of Baltimore, Md.; Hope Village of Washington, D.C.; Caldwell Homes of Washington, D.C., facilities located at 561 and 553 East Chestnut in Coatesville, Pa. And also the facility located at 571 East Chestnut, also in Coatesville, Pa.

The following organizations have submitted the records pursuant to subpenas: L. & S. Rest Home of Atco, N.J.; Windsor House of Philadelphia, Pa.; and Alcazar Home for the Aged is about to submit the material pursuant to agreement with the committee.

The CHAIRMAN. What do you recommend?

Mr. EDWARDS. I would recommend that the committee schedule a meeting to consider the consequences of the organizations having not complied with the subpenas, and I would recommend that we consider scheduling that meeting some time before the Congress enters into its district work period in July.

The CHAIRMAN. Were those subpenas issued by the full committee or subcommittee?

Mr. EDWARDS. They were issued by the Subcommittee on Health and Long-Term Care.

The CHAIRMAN. Will you arrange for a proper notice of a convening of the Subcommittee on Health and Long-Term Care, of which I am chairman, and we will look into the failure of these facilities to respond to our subpenas and see whether they have willfully refused to respond or whether there was some inevitable delay in their response.

We don't want to be unfair to anybody, of course. On the other hand, we want them to be sure that they understand, and that the public understands that a subpena issued by a committee of the Congress is like a subpena issued by a court, it must be observed or there must be some explanation given for its nonobservance. I am sure those people will have a fair opportunity to state what the reason is that they have not responded.

Mr. EDWARDS. As judicial cases have repeatedly held, the congressional right of inquiry is coextensive with and inherent in its right to legislate. Where legislation on a subject can be had, the inquiry is valid and can be pursued.

Further, Congress has inherent constitutional power to inquire broadly, searching for information for use in the legislative process without prior pinpointing or prejudging the facts which it wishes to ascertain. That was held in Eastland v. United States Serviceman's Fund, 421 U.S. 491, 1975, and McGrain v. Dougherty, 273 U.S. 135, 1927.

The CHAIRMAN. Very well. Thank you very much.

I would like to make a brief statement, and then, if there are no objections, I would like to insert my prepared statement into the record. Hearing no objections, so ordered.

OPENING STATEMENT OF CHAIRMAN CLAUDE PEPPER The CHAIRMAN. Ladies and gentlemen, we appreciate your being here with us this morning. The purpose of this hearing is to examine the matter of the use and abuse of drugs in the nursing homes of our country

Over a million people over 65 years old are in the nursing homes of our country; our committee thinks far too many. Many, many more of those people could receive more appropriate care and more effective assistance, if they were permitted and helped to get necessary care in their own homes.

The elderly population has grown in this country at an astonishing rate. When I was born in 1900 there were 3 million people in this country over 65 years old, constituting 4 percent of our population. Now, 80 years later, there are 24 million people over 65 years old in this country and they make up 11 percent of our population. And we are told that by the year 2000 there will be at least 30 million who will be over 65 years old who make up a part of our population.

Now, the elderly person, on the average, is in a hospital three times as long as a person in the 30- to 40-year-old group. They ordinarily stay about three times as long.

Elderly people take a great many more drugs than younger people. For example, on the average, elderly people, and I mean people over 65, take from 4 to 7 different drugs a day and on the average about 15 administrations; that is, the taking of the drugs is done 15 different times during the day. Now that includes the nonnursing home population.

In the nursing homes the amount is increased over that. There are 7 to 10 or 12 drugs on the average taken by the persons there and therefore they run the risk of there being errors made in the administration, of experiencing side effects or adverse reactions from a combination of these drugs.

There is a figure that the staff developed that was shocking to me. That is, that there are twice as many people who are the victims of accidents and who die from prescription drugs than there are people who have accidents or die from automobile accidents.

I would have not thought that possible. Twice as many people dying and having accidents from erroneous effect or use of drugs than those that die from automobile accidents, which are on the pages of our papers all the time.

Now, the nursing home situation is one of the most serious instances of where people are subject to the misuse or the erroneous use of these drugs. For example, the GAO has conducted a study of this subject. Their report is being released today. They found that in six of our great States, 82 percent of the drugs administered in nursing homes were given without a proper determination and proper ascertainment as to whether the drugs given were the proper drugs or whether there would be interaction among the drugs given which would have a dangerous effect upon the patient or not.

The Federal requirement for nursing homes is that there only be one registered nurse for every nursing home. Well, a nursing home may have several hundred people. One nurse under those circumstances can hardly monitor the administration of drugs to all those people.

So most of the personnel which procure and administrate these drugs are nonnursing, nonskilled technical personnel. They are assistants or aides, sometimes literally hired off the street. Too often, nursing homes are friendly with the drugstore that appreciates their large business. If they need a replacement or need some more drugs for a patient, too often these aides, or the assistants there who are not medical specialists, just call up the drugstore and get a refill or get a new drug sent over. Sometimes they forget to tell the doctor who prescribed the drug originally that they have ordered a refill.

And so the result is that in the nursing homes people are very much more susceptible to accident and danger from the interaction of drugs and from the ill effects of the administration of drugs without adequate knowledge of their being given, than one is subjected to outside the nursing home. So what we are going to do today is determine what the facts are and then to make recommendations.

I will mention only one other thing. The Department of Health and Human Services has proposed to issue new regulations, which, among other things will affect drugs in the nursing home. We hear from sources friendly to the elderly, that what they propose to do is diminish the restrictions already in effect which, goodness knows, are too few. We have asked the Secretary of HHS not to issue those regulations. So far they have agreed to take our request under advisement. So that will be one of the things that we will be engaged in considering in the future.

Šo that is a little bit of the background for this hearing that we propose to have today.

PREPARED STATEMENT OF CHAIRMAN CLAUDE PEPPER Good morning ladies and gentlemen. I would like to welcome you to this hearing by the House Select Committee on Aging. We are here to learn about possible drug abuse in the Nation's 23,000 nursing homes.

The fact that more and more people are living longer can be credited in large part to modern miracle drugs, many of which have been developed in the past 25 years. However, while drugs can be life sustaining, there is no drug which does not have potential side effects and dangers associated with its use. Obviously, the use of medications is a serious matter and must be monitored carefully.

Senior citizens must carefully watch their use of drugs. The average senior takes from 4 to 7 different medications, and the elderly account for 25 percent of all the drugs used in the United States. Because they take such large quantities of medications and because of physiological changes, the average senior citizen has twice the chance of suffering a drug-related accident than a 30-year-old American.

Those older Americans who live in nursing homes taken even more drugs-an average of 7 to 10 different drugs each day-and they generally suffer from four or more disabilities. Many nursing home patients are particularly vulnerable to drug abuse because they cannot protect themselves.

Newspaper exposes over the past 5 years are replete with references to excessive tranquilization of patients. More recently, studies have appeared suggesting that 25 percent or more of the drugs taken by nursing home patients may be administered in error. Even more recently, we have learned that certain drugs or foods taken together may nullify each other or may result in serious adverse reactions. Here are some examples:

Some antibiotics can be nullified if a person takes an amphetamine at the same time or if the person consumes certain foods such as cheese or chicken livers.

Certain drugs prescribed for depression and high blood pressure also react violently with the chemical tyramine, forcing the blood pressure to dangerous levels, causing severe headaches, brain hemorrhage and, in extreme cases, even death.

Various medications given simultaneously inactivate each other.

It should be obvious that drug abuse in nursing homes can only result if the physicians, nurses and pharmacists neglect their responsibilities. In the report we are releasing today, the General Accounting Office has delivered a devastating indictment. GẠO says that in their 6 State study, essential tests which are necessary to detect adverse drug reactions and serious side effects were not carried out in 82 percent of the patients in their sample.

GAO places responsibility squarely with the Department of Health and Human Services. GAO says that HHS has known for more than a decade of the need to collect information and publish a comprehensive directory for nursing home personnel about drug interaction and side effects.

I am anxious to hear the GAO testimony. I think GAO's report is particularly important in view of the fact that the Department of Health and Human Services, on its own initiative, plans to publish new regulations for nursing homes participating in medicare and medicaid. I want to learn what effect these new regulations will have not only on the supervision of medications but in all areas. It would seem to me that any regulations which reduce the amount of physician and nursing coverage would not be in the best interest of nursing home patients.

The CHAIRMAN. Now, Mr. Gudger, do you have a statement to make?

STATEMENT OF REPRESENTATIVE LAMAR GUDGER Mr. GUDGER. Mr. Chairman, I want to thank you for that excellent expression of the purpose of the meeting. I want to commend you for having these witnesses before us.

I suspect that the need for extended education in geriatrics and training of nursing home attendants and personnel is an area which testimony developed today will indicate the Congress should address. I am gratified to see that you are taking the initiative in this committee to see that we look into this matter.

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