When Dorothy “Dottie” Morgan entered High Plains Retirement Village in Lakin, she was already on at least one anti-psychotic medication.
Risperdal — and the other anti-psychotic medications she received on an as needed basis — has a “black box” warning for elders, the strictest warning from the U.S. Food and Drug Administration.
In 2016, 20 percent of all Kansas long-term nursing home residents had an anti-psychotic medication at some point in the year. That tied Kansas for the highest rate with Oklahoma and Mississippi.
Those medications, which are intended for serious mental health issues such as psychosis and schizophrenia, can increase the risk of falls, heart attacks, strokes and more, particularly for the elderly. They are not recommended for someone with dementia, like Morgan.
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Today, those rates have declined across the country, throughout Kansas and at High Plains Retirement Village, which is located at Kearny County Hospital.
As Morgan’s dementia worsened, it was hard for family to know whether the medicine or her disease was changing her. She was lethargic, “kind of zombie like,” uninterested in anything, said Ted Morgan, her husband. She had difficulty moving and hardly seemed to notice when people walked by.
For years, prescribing anti-psychotics for nursing home residents who were difficult to control was common practice, said Mary Chipley, director of nursing at the hospital. When physical restraints ceased to be used in the late 80s and early 90s, nursing homes moved to chemical restraints.
Chipley first learned that the hospital had high rates of anti-psychotic usage shortly after becoming the new director of nursing. In a short period of time, she received a state survey, heard from the Kansas Partnership to Improve Dementia Care and was surveyed by federal regulators.
With 38 percent of residents on anti-psychotics, Kearny County had the second highest rate in Kansas — a state that, at the time, had the highest rates in the nation. (Nursing home advocates point out that Kansas has nine designated Nursing Facilities for Mental Health, which are unique to Kansas and make up nine of the top 10 homes in the state for anti-psychotic use. That has raised Kansas’ ranking).
In just 18 months, rates at Kearny County Hospital have dropped from 38.2 percent to 8 percent. The one resident remaining on anti-psychotic medications has a psychiatric diagnosis for which the medications are approved.
With the physicians on board, they began to gradually reduce the medications. Chipley required nurses to receive approval from her before asking a physician for anti-psychotic medications for a resident. Consultants came in to offer training on how to handle difficult behaviors without medication.
One of the most important elements was completing a “life story” for each resident. In it, staff met with family members to find out about the resident’s personality, history, comfort foods and more.
That allows staff to better manage behaviors if they know the root cause. Perhaps a favorite comfort food can be used to help someone calm down. When a resident tries to get out of the locked area, staff might take him for a walk rather than making him immediately return indoors.
Siemsen, the Morgans’ daughter, said one of the greatest successes was explaining to the staff that her mother didn’t like being ordered around.
“If you ask her, ‘Hey Miss Dottie, would you like to go have an ice cream?’ if you ask Miss Dottie and approach it that way, she’s much, much more receptive than if you just tell her it’s time for lunch,” Siemsen said.
It can be hard to understand the needs and desires of someone with dementia, Chipley said. Knowing their histories helps people to understand how they think and behave.
“A please and a thank you go a long way with her (Miss Dottie),” Chipley said. “That’s still there. She still wants you to use your manners.”
Another resident was a homemaker. In the past, if she had become upset after lunch, staff might not have known why and opted for anti-psychotic medication. Now, they know she wants to wash dishes every day, so they let her.
No nursing home wants to put their residents on these medications, said Benjamin Anderson, CEO of the hospital, but they sometimes don’t have the tools to do otherwise.
“The difference (here) has been a nurse leader who was willing to say there’s another way,” Anderson said.
It takes a while for people to change the mindset of “that’s just the way they’ve always done it,” said Tim Keck, secretary of the Kansas Department for Aging and Disability Services.
“It really starts with focusing on the person, person-centered care, and thinking about what would you want for yourself or your family member,” Keck said. “You start there.”
Debra Zehr, CEO of LeadingAge Kansas, the statewide association of nonprofit long term and aging care providers, also referenced creating “a person centered place for people to call home” when she recognized Kearny County Hospital for the decrease in medications last week.
What’s being done at the hospital is also happening around the state as people become better educated, Zehr said.
Data from the Centers for Medicare & Medicaid Services shows that anti-psychotic use for long-term nursing home residents has declined in Kansas from about 26 percent when the rate was first measured in 2011 to 18.4 percent in the fourth quarter of 2017, moving Kansas to 45th in the country.
Ted Morgan said he’s seen a world of difference in his wife since she stopped taking the anti-psychotic medications.
On Tuesday, “Miss Dottie” was alert, curious about a Wichita Eagle photographer’s camera and eager to show off her pastel pink fingernails.
She might not know who residents, staff and visitors are, said Ted Morgan, but she pays attention to them once again. Before the medications, she loved the outdoors, flowers, grass, books, reading, family photos, pictures and paintings. Those interests have returned, her family say.
“If she can be off the antipsychotic medication and function fine in her environment and have a little more response to her environment, then absolutely, why wouldn’t you do that?” Ted Morgan asked.
Chipley says others have had similar reactions to being taken off their medications. At first there was some resistance among staff, but they came on board when they noticed the change.
“It was like they were coming alive again,” Chipley said. “It wasn’t just people sitting in recliners anymore sleeping. It was going outside. It was doing an activity. It was being up and moving around, having a conversation. It was almost becoming a person again.”