As the “gray wave” of aging baby boomers crowd into the country’s creaking long-term care system, many of them may unexpectedly end up in nursing home where anti-psychotic medication, rather than comprehensive social and mental health services, have become a standard way for some residential institutions to maintain order.
Yet, according to human rights investigators, anti-psychotic drugs are often administered to residents not with a doctor’s prescription, but the management’s. So-called “chemical restraints” have become a routine “fix” for behavioral problems, such as those who “resist” staff’s orders, or for dementia patients with a habit of wandering off. In reality, deliberately over-medicating elderly patients is not designed to help them as much as to help an overwhelmed workforce of clinicians struggling to care for too many patients with too little time and funding.
But the seemingly efficient solution comes at the expense of seniors' human rights.
A new report by Human Rights Watch (HRW), based on extensive surveys and interviews with nursing home residents and staff in California, Florida, Illinois, Kansas, New York, and Texas, found that “every week in US nursing facilities, more than 179,000 people, mostly older and living with dementia, are given anti-psychotic drugs without an appropriate diagnosis.”
Since the unregulated use of these drugs (which are generally intended for conditions like schizophrenia) takes place for the main purpose of suppressing and controlling patients' behavior, federal guidelines have largely been ignored due to lack of oversight and enforcement. Moreover, there is an acute lack of transparency in how individuals are being treated, particularly when patients are living isolated from their families.
Though the challenges of aging are inter-generational and universal, the chronic overuse of medication parallels wider social disparities facing the aging and a culture of medicine based on market incentives and pernicious segregation. Residential care homes today are financially drained, severely short-staffed, and often stratified by cruel inequality in the care quality and access.
Substandard care also intersects with a wealth gap across US society that deepens with age. Although Medicare broadly covers healthcare for seniors over age 65, Medicaid, which serves the poorest patients, is the primary federal support for long-term care services for seniors and people with disabilities. Those funds are dwindling as medical costs soar and elder care needs swell. In 2017, roughly a thousand nursing homes nationwide were severely understaffed (defined as having two-thirds or less of the federal minimum number of staffers). Meanwhile, under Trump, the Obama administration's staffing and care quality standards under the Affordable Care Act are being rolled back as healthcare spending is assaulted by the Republican-dominated government.
Those problems aggravate the situation HRW identifies: a rising population of Alzheimer's patients demand more attention than the harried staff can provide, which drives a culture of over-medication. In some counties, the rate of anti-psychotic drug use ranged as high as 40 to 60 percent of nursing home residents. An interviewee said that when staff interpreted her mother’s underlying issues with bipolar disorder as “acting out,” they dosed her with anti-psychotics to the point that “She wouldn’t talk. She wouldn’t laugh. She wouldn’t cry. She wouldn’t do anything. She would just sit and stare like she wasn’t even there.”
Yet people whose families bear witness to this maltreatment might be the “lucky ones.” At some facilities with high rates of anti-psychotic use, according to HRW researcher Hannah Flamm, just a fraction of residents ever received visitors. But it's not just a personal problem of disconnected families. At every level, the system lacks the resources to provide the social engagement and cultural sensitivity that all residents need. The gaps run even deeper in homes where the poor and people of color are concentrated. The medicine delivered in these human warehouses doesn't heal, it silences — allowing institutions to bandage structural gaps with chemical solutions.
For socially disadvantaged seniors, those with complex health needs or those labeled as difficult to manage, market forces drive care quality. Flamm points out that residents lacking family members or social networks to serve as “external advocates” for their rights may be “at a higher risk of being given anti-psychotic drugs inappropriately and ‘warehoused’ instead of provided adequate care.” And despite a general decline in the use of such medications in recent years, nursing-home management and staff have promoted a culture of medicating people who might otherwise be hard to manage to make them “docile.”
The underside of drug-induced “docility,” however, is a silent kind of violence: the terror of being plunged by your carers into a virtual coma; the pain that visiting loved ones feel when they encounter a shell of a human being in place of a grandmother or husband; the potential volatile side effects; and the residual trauma of over-medication. An 81-year old man in a Texas facility told researchers that when medicated until the point he even had trouble speaking, “They get me so I can’t think. I don’t want anything to make me change the person I am.”
For others, the imposed silence never ends: The overuse of drugs on average could double the risk of death for aging dementia patients.
The policy solutions are both straightforward and extraordinarily complex. HRW calls on authorities to enforce civil rights and federal regulations governing ethical care and the use of anti-psychotic drugs.
But we can only address chronic resource gaps across the elder-care infrastructure through a wholesale shift in healthcare priorities. We as a society must collectively reject a culture of medicalizing and institutionalizing the process of aging.
Beyond reforming nursing home standards, deeper investment in community-based homecare services is critical to help comprehensively deinstitutionalize the aging. In a system that pathologizes essential social needs of the most vulnerable, denying seniors humane care deprives ourselves of the rights we all deserve, at all stages in life: the right to dignity and human connection — the social entitlements that we too often abandon in our tattered welfare system.
Michelle Chen is a contributing writer at The Nation, a contributing editor at Dissent and a co-producer of the “Belabored” podcast and Asia Pacific Forum on WBAI FM.