The CHAIRMAN. Thank you. Mr. Grassley? STATEMENT OF REPRESENTATIVE CHARLES E. GRASSLEY Mr. GRASSLEY. Mr. Chairman, this committee has long worked to help older persons to avoid having to enter nursing homes if a reasonable alternative is available. To this end we have stressed family care, home health services, and other means to permit the elderly to choose between an institution and home setting when some degree of supportive care becomes necessary for that individual. The committee recognizes that nursing home care is of a highly variable quality. It also recognizes that for many of the elderly, adjustment to the environment of any nursing home, irrespective of quality, may be a difficult and traumatic experience. Even so, most elderly persons who enter a nursing home remain in one for the rest of their life while becoming increasingly dependent upon the institutional care provided by the management and staff of the nursing home. Eventually they grow to accept the quality of treatment they receive whether it be good or bad. A decent regard for the helplessness of the institutionalized aged and infirm would require that they be treated with proper medication and a compassionate respect for human dignity. Today we shall hear evidence that such is not always the case; that medication improperly prescribed, unprofessionally administered, and wrongly combined may, and often does, result in the injurious side effects. We shall also hear that sedatives and narcotics are sometimes used with callous design to induce passivity so that needy patients will require less attention. This committee does not contend that malpractice or deliberate neglect is characteristic of the entire nursing home industry. However, we cannot refute the findings that drugs are often administered in combinations which are harmful to the patient. Neither can we deny that some nursing homes observe a practice of deliberate oversedation and narcotics abuse. Our task is to learn how such practices can be curbed and to insure that corrective measures are taken. Thank you. The CHAIRMAN. Thank you, Mr. Grassley. Ms. Oakar? STATEMENT OF REPRESENTATIVE MARY ROSE OAKAR MS. OAKAR. Thank you, Mr. Chairman. I certainly want to commend you and this committee for having this very important hearing. I hope in the future we will address the problems of drugs and the elderly in general, and not limit it to just nursing homes, although this is especially important today because there is an awful lot of material that suggests that older people when they are given drugs in general are often not instructed properly and very often they are served by more than one doctor. The combination of drugs really is a problem in terms of how it effects them. But I would like to say that there have been very few studies on the use of drugs in nursing homes. I am very proud of the fact that one of the members of my staff did her master's in gerontological nursing. Her thesis was on this particular issue, and I would just like to cite a few things that she found from her study. Her investigation of the prescription and administration of psychotropic drugs in one nursing home identified the reasons that nurses administer or withhold psychotropic drugs which are ordered to be given at the discretion of the nurse. One significant conclusion was that the nurses expressed a high degree of concern about the side effects of the prescribed drugs. However, their knowledge of specific side effects for specific drugs was not always accurate or thorough. Additionally, none of the nurses interviewed for this study expressed any awareness of the need to observe for dependency when older patients received psychotropic drugs over a long period of time. And in addition, she found in her study that 80 percent of the tranquilizers issued were issued at night and more often to women than men. So I think that there is an awful lot that needs to be done in terms of seeing why this problem arises. One other point that she makes in her study is the fact that there is not a continuing education program for people who administer drugs with respect to their effects on nursing home patients. While I was very pleased with the GAO study, I was kind of amazed that when they recommended training, they left out LPN's in their study who administer 95 percent of the drug prescriptions. At least from my reading of it, they did. And this did mention, I believe, registered nurses and aides but not LPN's, and they do do an awful lot of administering of these drugs. Furthermore, I would like to also strongly recommend that rather than the Department of Health and Human Services weakening the regulations for nursing homes with respect to drug prescriptions, that they add a requirement for mandatory inservice education for all nurses, including RN's and LPN's who administer drugs in nursing homes. I think that could be a positive contribution by the Department of Health and Human Services. I certainly look forward to hearing the witnesses today. I would like to submit for the record, Mr. Chairman, the abstract of the thesis by the member of my staff who did an indepth study on this subject. The CHAIRMAN. Without objection it will be received. Thank you. [The information follows:] PRESCRIPTION AND ADMINISTRATION OF SELECTED DRUGS IN A NURSING HOME (BY CAROL ANN MILLER) ABSTRACT The responsibility for administering medications-particularly medications ordered on a discretionary basis (PRN)—to elderly nursing home patients lies with the nurse who decides whether or not to give the drug. Actual administration patterns for PRN tranquilizers and antidepressants have not been reported. Nor have the reasons given by nurses for administering or withholding these drugs been reported. The two-fold purpose of this study was to describe the prescription and administration of tranquilizers and antidepressants to elderly patients in one nursing home, and to identify the reasons nurses administer or withhold these drugs when ordered PRN. The survey consisted of: (1) a structured review of medication records for 31 consecutive days, and (2) the administration of a questionnaire to nurses. Records of 114 nursing home patients who were 65 years old or older were reviewed to identify the prescription patterns for tranquilizers and antidepressants and the administration patterns for those drugs ordered PRN. The questionnaire administered to nurses consisted of four vignettes describing fictitious patients with prescriptions for PRN tranquilizers and/or antidepressants, followed by open-ended questions designed to elicit reasons the nurses would administer or withhold the PRN medications. The medications records showed that: 44 percent of the patients had prescriptions for tranquilizers and/or antidepressants; 31 percent of these prescriptions were ordered PRN; 32 percent of the PRN medications were administered during January 1980; 80 percent of the PRN doses which were administered were given at 9 P.M.; and 49 percent of the female patients as compared to 34 percent of the male patients had prescriptions for tranquilizers and antidepressants were reported. The questionnaire administered to nurses revealed that nurses chose to administer 44 percent of the drugs and to withhold 56 percent of the drugs ordered PRN. Fifty-eight reasons were reported for giving the PRN drugs, and 38 reasons were reported for withholding the PRN drugs. Content analysis of the reasons resulted in 17 distinct categories of reasons. The action of the drug (e.g., "to relieve anxiety") was the most frequently reported reasons to give a PRN drug. A concern about the side effects of the medication was the most frequently reported reasons for withholding a PRN drug. Results of this survey suggested several areas for in-service education related to the action and side effects of psychotropic drugs. Data obtained from the medication records suggested several areas for further research, particularly in relation to the administration of psychotropic drugs to nursing home patients at bedtime. The CHAIRMAN. Mr. Hammerschmidt? STATEMENT OF REPRESENTATIVE JOHN PAUL HAMMERSCHMIDT Mr. HAMMERSCHMIDT. Thank you, Mr. Chairman. I appreciate your calling this hearing so the committee in its oversight capacity may monitor compliance with the medication review regulations for nursing homes. I have the highest respect for the medical professions. Advances in the knowledge of health care professionals and the increasingly sophisticated types of drugs at their disposal have made it possible for us to lead longer, healthier lives. We are becoming increasingly aware, however, that these drugs which have such tremendous potential to cure also have the potential to harm when self-prescribed or prescribed in the wrong combination or dosage. In the community the responsibility for the proper application of medications lies both with the elderly person taking the drug and the physician prescribing it, and educational efforts are beginning to focus in both these directions. In the nursing home, as we suggested earlier, the responsibility for the correct drug therapy lies solely with the staff of the institution. Elderly patients are totally dependent on others for their health care and oftentimes too frail to participate in that care. For this reason, enforcement of the medication review regulations is vitally important. I do not subscribe to the notion that all nursing home patients are turned into captive junkies to make them more manageable or are given medication without being monitored for side effects. But there are enough reports within the new GAO study and from other sources to give us reason for concern. I have noted GAO's recommendation that the regulations clearly define what is required in a medication review and the opposition of the Department of Health and Human Services and the American Pharmaceutical Association to defining a professional practice, and I do not presume to make a judgment in this instance. Regardless of the mechanics, the nursing home staff has a responsibility to insure that the patient is getting the right amount of the neces sary drugs and that those drugs are achieving the desired effects without adverse consequences. The fact that this is not being done in all institutions with the frequency or thoroughness required calls for action by the Federal Government in either clarifying what is expected of nursing homes with regard to medication or actively enforcing the regulations as they are presently written. The problem of drug misuse in nursing homes does not simply reflect a lack of compliance with the medication review regulations but a deficiency in the overall quality of care in some nursing homes. Nursing home residents need adequate numbers of trained staff to meet their needs, regular attention from physicians and physical and mental stimulation which may enhance their wellbeing. In closing, I would like to borrow a line from Senator Moss' report on long-term care: "Care for persons in need of longer-term attention should be one of the most tender and effective services a society can offer to its people." I think most of us would agree we have a long way to go before we can truthfully describe the longterm care we give elderly people in this country in this manner. Thank you. The CHAIRMAN. Thank you, Mr. Hammerschmidt. Mr. Bonker? STATEMENT OF REPRESENTATIVE DON BONKER Mr. BONKER. Thank you, Mr. Chairman. Mr. Chairman, I would like to join the others on the committee in commending you for scheduling these hearings and for the excellent panel that will be appearing later this morning. Drug abuse is something we traditionally think of in terms of this Nation's young people. But unwittingly, old people have been enslaved by being overmedicated. This is something over which they apparently have no control. I think, Mr. Chairman, your staff report to the members says it all by citing these statistics: The elderly are sick three times as often and three times as long as their younger counterparts and spend three times as much on health care. And while the elderly account for 11 percent of our population, they use more than 25 percent of the drugs produced. And when you look at a program like medicaid, the elderly comprise 17 percent of the program's beneficiaries but account for 44 percent of the $1 billion spent for prescription drugs. So I think the subject is timely for today's hearings. I think our concern is both with the dollar amount that is spent on medication, but also the overmedication which affects the quality of life of this Nation's elderly citizens. Thank you. The CHAIRMAN. Thank you. Mr. Hopkins. STATEMENT OF REPRESENTATIVE LARRY J. HOPKINS Mr. HOPKINS. Mr. Chairman, thank you very much. If I may expand briefly on the chairman's opening remarks and compliment him along with my colleagues for calling this hearing. I say to you ladies and gentlemen that we are living longer in this country, we are taking better care of ourselves as Americans, and the chairman gave you some figures. Briefly, let me run a couple by you that I find fascinating. Ten years ago there were only 3,000 Americans over age 100. Today there are over 13,000 Americans over age 100. These are the people that paved the way for the rest of us and I think this country owes them an obligation other than pushing them in a room somewhere. Very frankly, it is one of the reasons why I voted against some of the policies that came before Congress, some of them called foreign aid. It is very simple with me. I think it is time we started taking better care of the American people first. That is called economics, at least where I went to school. So I appreciate my chairman calling this hearing. I think it is vitally important that we take better care of those people who paved the way for the rest of us. Thank you. The CHAIRMAN. Thank you. STATEMENT OF REPRESENTATIVE WILLIAM R. RATCHFORD Mr. RATCHFORD. I, too, join in applauding you for scheduling these hearings, Mr. Chairman. I have had direct involvement in this area, as you know, having chaired a 2-year investigation in the State of Connecticut of the nursing homes of that State. One of the major findings of that investigation was regrettably that we are overmedicating those who are in our nursing homes. We took two people over the age of 60 with similar characteristics and looked at their drug use and we found that the person living at home took on an average 2 drugs a day. That same person, same problems, in a nursing home was taking 5 prescription drugs, 21⁄2 times as many as the person living at home. We also found a high incidence of these drugs were tranquilizers, that we were tranquilizing our population in the nursing home. We found regrettably in far too many instances that the pharmacy that was serving as the consultant-under Connecticut law nursing homes are required to have a consulting pharmacist-was also serving as the attendant pharmacist. So on the one hand they were consulting for the nursing home and on the other hand they were prescribing the drugs that the person in the nursing homes were taking, a clear conflict of interest as far as we were concerned. We recommended in that particular area that the law be changed so that the person serving as the consultant could not also be the attendant pharmacist. In addition, we found all too often, especially on the night shift, that there were people who simply were untrained handing out the drugs. In all these areas, obviously, changes were necessary both as far as regulation and as law, and a number of changes were put on the books in the State of Connecticut. But I would bet without having a survey that these problems that I described exist today in most States in America, overmedication, overreliance of tranquilizers, personnel who are not properly trained handing out the drugs. Therefore, Mr. Chairman, we have |