AP IMPACT: Mentally ill a threat in nursing homes

CHICAGO – Ivory Jackson had Alzheimer's, but that wasn't what killed him. At 77, he was smashed in the face with a clock radio as he lay in his nursing home bed.
Jackson's roommate — a mentally ill man nearly 30 years younger — was arrested and charged with the killing. Police found him sitting next to the nurse's station, blood on his hands, clothes and shoes. Inside their room, the ceiling was spattered with blood.
"Why didn't they do what they needed to do to protect my dad?" wondered Jackson's stepson, Russell Smith.
Over the past several years, nursing homes have become dumping grounds for young and middle-age people with mental illness, according to Associated Press interviews and an analysis of data from all 50 states. And that has proved a prescription for violence, as Jackson's case and others across the country illustrate.
Younger, stronger residents with schizophrenia, depression or bipolar disorder are living beside frail senior citizens, and sometimes taking their rage out on them.
"Sadly, we're seeing the tragic results of the failure of federal and state governments to provide appropriate treatment and housing for those with mental illnesses and to provide a safe environment for the frail elderly," said Janet Wells, director of public policy for the National Citizens' Coalition for Nursing Home Reform.
Numbers obtained through the Freedom of Information Act and prepared exclusively for the AP by the Centers for Medicare and Medicaid Services show nearly 125,000 young and middle-aged adults with serious mental illness lived in U.S. nursing homes last year.
That was a 41 percent increase from 2002, when nursing homes housed nearly 89,000 mentally ill people ages 22 to 64. Most states saw increases, with Utah, Nevada, Missouri, Alabama and Texas showing the steepest climbs.
Younger mentally ill people now make up more than 9 percent of the nation's nearly 1.4 million nursing home residents, up from 6 percent in 2002.
Several forces are behind the trend, among them: the closing of state mental institutions and a shortage of hospital psychiatric beds. Also, nursing homes have beds to fill because today's elderly are healthier than the generation before them and are more independent and more likely to stay in their homes.
No government agency keeps count of killings or serious assaults committed by the mentally ill against the elderly in nursing homes. But a number of tragic cases have occurred:
• In 2003, a 23-year-old woman in Connecticut was charged with starting a fire that killed 16 fellow patients at her Hartford nursing home. A court guardian said Leslie Andino suffered from multiple sclerosis, dementia and depression. She was found incompetent to stand trial and committed to a mental institution.
• In 2006, 77-year-old Norbert Konwin died at a South Toledo, Ohio, nursing home 10 days after authorities said his 62-year-old roommate beat him with a bathroom towel bar. Sharon John Hawkins was found incompetent to stand trial.
• In January, a 21-year-old man diagnosed with bipolar disorder with aggression was charged with raping a 69-year-old fellow patient at their nursing home in Elgin, near Chicago. A state review found that Christopher Shelton was admitted to the nursing home despite a history of violence and was left unsupervised even after he told staff he was sexually frustrated.
Jackson's roommate was 50 and had a history of aggression and "altered mental status," according to the state nursing home inspector's report. Solomon Owasanoye wandered the streets before he came to All Faith Pavilion, a Chicago nursing home, and he yelled, screamed and kicked doors after he got there.
On May 30, 2008, he allegedly picked up a clock radio, apparently while Jackson slept, and beat him into a coma. Exactly what set him off is unclear. Jackson died of his injuries less than a month later. Owasanoye pleaded not guilty to first-degree murder, and after a psychiatric review was ruled unfit to stand trial. He now lives in a state mental hospital.
All Faith Pavilion co-owner Brian Levinson said his staff is trained to deal with aggressive behavior, and he disputed state findings that Owasanoye had a history of aggression. The for-profit nursing home was fined $32,500 for failing to prevent the assault.
Under federal law, nursing homes are barred from admitting a mentally ill patient unless the state has determined that the person needs the high level of care a nursing home can provide. States are responsible for doing the screening. Also, federal law guarantees nursing home residents the right to be free from physical abuse.
Families have sued in hopes of forcing states to change their practices and pressuring nursing homes to prevent assaults. Advocates say many mentally ill people in nursing homes could live in apartments if they got help taking their medication and managing their lives.
The problem has its roots in the 1960s, when deplorable conditions, improved drug treatments and civil rights lawsuits led officials to close many state mental hospitals. As a result, some states have come to rely largely on nursing homes to care for mentally ill people of all ages.
Also, mixing the mentally ill with the elderly makes economic sense for states. As long as a nursing home's mentally ill population stays under 50 percent, the federal government will help pay for the residents' care under Medicaid. Otherwise, the home is classified a mental institution, and the government won't pay.
In Missouri, more than 4,400 younger mentally ill people are living in nursing homes, in part because of a state program that helps the elderly stay in their own homes longer.
Nursing homes "are looking at 60 to 70 percent occupancy, and the statistics tell us they've got to be in the 90s to operate successfully," said Carol Scott, the state long-term care ombudsman for 20 years. "They're going to take anybody they can."
Gaps in staff training leave the homes inept at handling the delusions and aggression of the mentally ill, said Becky Kurtz, the state long-term care ombudsman in Georgia, where nearly 3,300 younger mentally ill people live in nursing homes.
"Often they'll say, 'I hate it there. I'm angry. I don't want to be there.' Sometimes the behavioral issues are the result of being ticked off you're in a nursing home," Kurtz said.
Pat Willis of the Center for Prevention of Abuse said she has seen elderly residents terrified by younger, mentally ill residents who scream and yell, day and night. "The senior residents are afraid," Willis said. "They would prefer to sit in their rooms now and keep the doors shut."
Nursing home operators say protections against frivolous transfer or discharge keep the homes from throwing out some mentally ill residents.
"Many times, the nursing home's only option becomes dialing 911," said Lauren Shaham, a spokeswoman for the American Association of Homes and Services for the Aging.

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Drug industry advocates join chorus to split FDA

WASHINGTON – As momentum builds to rework the nation's food-safety system after a salmonella outbreak linked to peanuts, the drug industry is hoping for a happy side effect: faster approvals for new medicines.
Drug industry advocates are quietly allying with some of their longtime critics pushing to split the Food and Drug Administration into two agencies, one for food safety and one for medical products.
President Barack Obama bolstered hopes for a breakup last Saturday when he named two public health specialists to the agency's top positions and appointed an advisory group to reassess the nation's decades-old food safety laws.
Drug executives see a chance to speed up drug approvals that have lagged amid a drought of new products, provided their regulator is no longer distracted by high-profile food-safety breakdowns.
"Every CEO that I know in health care is in favor of this, but none that value their share prices will go on the record for fear of retribution from the FDA," said Steve Brozak, president of WBB Securities, an investment brokerage focused on drug and biotech companies.
While FDA's food and drug staffs are separate, Brozak and others believe the public lashings over food outbreaks have made senior officials even more risk-averse on drug approvals. Even before the recent food safety problems, FDA was under pressure from Congress for failing to catch problems with drugs like Merck's Vioxx, which was pulled from the market in 2004.
"The history of FDA is that the commissioner focuses on medical products and only turns to food safety when a crisis comes up," said Professor Michael Taylor, a former FDA and U.S. Department of Agriculture official now at George Washington University.
This year, the agency will spend just 73 cents on food safety for every dollar spent on drugs, according to the Institute of Medicine.
Recent outbreaks connected with spinach, lettuce, peppers and tainted milk from China have created a drumbeat for change.
Margaret Hamburg, a former New York City Health Commissioner, has been tapped to address these issues as Obama's pick for FDA commissioner. Her deputy will be Joshua Sharfstein, a pediatrician and critic of the safety of children's cold medicines.
One former FDA official said Obama's appointment of two safety experts suggests he favors splitting the agency.
"Peggy Hamburg is a safety and security expert, and it seems pretty clear she would become administrator of the food agency," said Peter Pitts of the Center for Medicine in the Public Interest, an industry-funded advocacy group. "Josh Sharfstein would then slide over" to head the drug agency.
The FDA's associate commissioner for food, Dr. David Acheson, would only say, "The agency welcomes all discussions about ways to make our food supply even safer."
The drug industry's lobbying group has not taken a position on a new drug agency. But the group's president says the status quo is unacceptable.
"One of our premier scientific agencies that's responsible for all of our health and safety is still living in the 19th century in many ways, and we shouldn't tolerate that," said Billy Tauzin, head of the Pharmaceutical Research and Manufacturers of America and a former congressman from Louisiana.
The distraction created by food crises is wreaking havoc on the drug industry and its investors, making it harder to predict which drugs the agency will approve, Brozak and others say.
"That makes for a completely untenable position for people trying to make decisions in the health care capital markets," said Brozak, who ran for Congress as a Democrat in 2004.
Last year the FDA missed review deadlines on more than 12 drugs, or more than 20 percent of those received, analysts estimate. The agency's internal goal is to miss no more than 10 percent. FDA officials have blamed one-time problems, including an influx of new staffers.
Experts say there's no reason the agency that assures the safety of complex, $3,000-a-month biotech drugs is also tasked with regulating $3 jars of peanut butter.
The Government Accountability Office endorsed a single food agency in 1999, and lawmakers have been trying unsuccessfully to realize it ever since.
Splitting FDA would likely mean reshuffling committees that oversee food and drug regulation, which could diminish clout and contributions for some lawmakers.
"Once you get an idea like this on Capitol Hill, it creates winners and losers in power and dollars, and when that happens, it usually results in a stalemate," said Patrick Ronan, a former FDA staffer and founder of GreenLeaf Health consultants.
Sen. Dick Durbin, D-Ill., and Rep. Rosa DeLauro, D-Conn., have narrowed their proposals in order to gain support.
DeLauro previously aimed to consolidate food responsibilities, including the USDA's, into one agency, which proved to be politically tricky. Her current bill would carve a separate agency out of FDA with additional powers, including ordering recalls, which are now voluntary, and increasing food inspections.
The Congresswoman said she welcomes Obama's formation of a food safety task force, but showed no sign of backing away from her proposal. The task force must not be "merely a cosmetic bureaucratic endeavor," she said in a statement.
"The working group must produce definitive recommendations that result in the modernization of our food safety regulatory structure."
Durbin's bill similarly would expand FDA powers and would add $775 million to its budget to bolster food safety. Currently, the FDA's $1.9 billion federal budget is supplemented by more than $300 million in application fees paid by drugmakers to fund speedy reviews.

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Brain injury victims can seem OK, symptoms delayed

At first, Natasha Richardson said she felt fine after she took a spill on a Canadian ski slope. But that's not unusual for people who suffer traumatic head injuries like the one that killed the actress.
Doctors say sometimes patients with brain injuries have what's called a "lucid interval" where they act fine for an hour or more as the brain slowly, silently swells or bleeds. Later, back at her hotel, Richardson fell ill, complained of a headache, and was taken to a hospital. She died Wednesday in New York.
An autopsy Thursday showed that the 45-year-old actress hit her head, which caused bleeding between the skull and the brain's covering, resulting in what's called an epidural hematoma. It's a type of injury often caused by a skull fracture.
Because of that lucid interval, doctors always tell patients who seem OK after a brain injury to have someone keep a close eye on them, in case symptoms emerge.
Symptoms — headache; loss of consciousness; vomiting; problems seeing, speaking or moving; confusion; drainage of a clear fluid from the nose or mouth — appear after enough pressure builds in the skull. By then it's an emergency.
"Once you have more swelling, it causes more trauma which causes more swelling," said Dr. Edward Aulisi, neurosurgery chief at Washington Hospital Center in the nation's capital. "It's a vicious cycle because everything's inside a closed space."
Pressure can force the brain downward to press on the brain stem that controls breathing and other vital functions, causing coma or death. Frequently, surgeons cut off a portion of the skull to give the brain room to swell. Or they drain the blood and remove clots that formed.
"This is a very treatable condition if you're aware of what the problem is and the patient is quickly transferred to a hospital," said Dr. Keith Siller of New York University Langone Medical Center. "But there is very little time to correct this."
Details of Richardson's treatment have not been disclosed.
A CT scan can detect bleeding, bruising or the beginning of swelling after an injury. The challenge is for patients to know whether to seek one.
"If there's any question in your mind whatsoever, you get a head CT," Aulisi advised. "It's the best 20 seconds you ever spent in your life."

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Attempting to zap Parkinson's through spinal cord

WASHINGTON – Implanting a pacemaker-like device deep in the brain helps some Parkinson's disease patients move better, but could less risky zapping of the spinal cord work instead? It did in mice and rats nearly immobilized with Parkinson's-like symptoms: Scientists at Duke University Medical Center turned on the electricity and videotaped the rodents immediately scurrying around almost like normal.
The research, reported in Friday's edition of the journal Science, is just a first step. More animal testing is needed to tell if the approach could be tried in people. Implants in marmosets, a type of primate, are to begin soon.
But sufferers of chronic pain already can have spinal cord stimulators implanted that send electrical currents to block the "I'm hurting" messages sent to and from the brain. For Parkinson's, the idea is similar.
The 1.5 million Americans with Parkinson's gradually lose brain cells that produce dopamine, a chemical key to the circuitry that controls muscle movement. The result: Haywire brain signaling that leads to increasingly severe tremors and periodically stiff or frozen limbs. Medication helps early in the disease. More severely affected patients may try "deep brain stimulation," where wires are implanted inside the brain to deliver tiny electrical zaps that disable overactive nerve cells and improve motor control.
Exploring a less invasive approach, the Duke team attached tiny wires to the spinal cords of mice and rats whose brains produced so little dopamine that they had the slow, stiff motions of advanced Parkinson's disease.
When the electricity was turned on, the animals became 26 times more active and movement visibly improved in seconds, Duke neuroscientist Dr. Miguel Nicolelis and colleagues wrote.
Why would it work?
Proper movement requires orderly nerve cell firing to different muscles at different moments in time, like members of an orchestra must play in proper sequence for a symphony.
There's increasing if circumstantial evidence that rhythmic waves of brain activity, called oscillations, play a role in Parkinson's movement problems — and that interrupting those abnormal waves allows the more normal, symphony-like brain cell firing to resume, said Dr. Walter Koroshetz, deputy director of the National Institute of Neurological Disorders and Stroke, which helped fund the work.
The spinal cord stimulation appears to have sent a signal up to the brain that interrupted those oscillations.
Koroshetz cautioned that much work remains, including testing whether the stimulator's effect might last long enough to be useful.
But, "it's something that has definitely got some scientific traction to it," he said. "It's a really good idea."

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Private inspections of food companies seen as weak

WASHINGTON – The mortgage meltdown exposed the weakness of self-regulation in financial markets. Now the salmonella outbreak is doing the same for the food industry.
A House subcommittee Thursday released new documents that showed how private inspectors contracted by Peanut Corp. of America failed to find long-standing sanitary problems at company facilities. Peanut Corp. is at the center of a nationwide outbreak that has sickened nearly 700 people and is blamed for at least nine deaths.
Lawmakers said the food industry's private inspection system failed to catch filthy conditions because the company itself hired the inspectors.
"There is an obvious and inherent conflict of interest when an auditor works for the same supplier it is evaluating," said Rep. Bart Stupak, D-Mich., chairman of the House Energy and Commerce investigations subcommittee. He termed it a "cozy relationship."
Last summer, Peanut Corp.'s private inspector, a company called AIB, awarded the peanut processor a certificate in 2008 for "superior" quality at its Plainview, Texas, plant. This year, salmonella was discovered there.
The outbreak was initially traced to a Peanut Corp. facility in Blakely, Ga. Later, contamination was found at the Texas plant. Peanut Corp. is under criminal investigation for allegedly shipping products it knew to be tainted.
Owner Stewart Parnell has refused to answer questions from lawmakers, citing constitutional protections against self-incrimination. On Thursday, Parnell told The Associated Press he couldn't comment on the allegations and referred questions to his attorney, who was not immediately available.
Federal law does not require food companies to pay for their own inspections of suppliers. Nor are industry labs and inspectors required to tell the government about any problems they find.
At least one food company that used its own inspectors, Nestle USA, ultimately decided not to do business with Peanut Corp. Nestle USA had no recalls. But a Nestle affiliate in Puerto Rico recalled some ice cream products, and Nestle HealthCare Nutrition — another affiliate — recalled a nutritional bar.
The committee released a 2002 Nestle USA inspection report of Peanut Corp.'s Blakely plant. "They found that the place was filthy," said Rep. Henry Waxman, D-Calif.
A second audit by Nestle USA of Peanut Corp.'s Texas facility in 2006 also found major pest control and other problems. The audit said that would disqualify the plant from supplying chopped peanut pieces to sprinkle atop Drumstick ice-cream cones.
Auditors found at least 50 mouse carcasses in and around the plant and also a dead pigeon "lying on the ground near the peanut-receiving door."
The audit also said the plant had no pathogen-monitoring plan and noted that one needed to be developed for the plant to be in compliance with audit standards.
Companies that bought ingredients from Peanut Corp. said they had no way of defending themselves against a supplier they accuse of deliberately breaking the rules and covering up.
"I think we did everything we could do," Kellogg Co. chief executive David Mackay told the committee.
"The issue was that (Peanut Corp.) acted in a dishonest and unethical way," he added.
Lawmakers and the Obama administration say the problem goes beyond a rogue company, and major reforms are needed. Legislation has been introduced in Congress to take food safety oversight away from the Food and Drug Administration and give it to a new agency with stronger legal powers and more funding.
Peanut Corp. produced not only peanut butter, but peanut paste, an ingredient found in foods from granola bars and dog biscuits to ice cream and cake. More than 3,490 products have been recalled, including some millions of Kellogg's Austin and Keebler peanut butter sandwich crackers.
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On the Net:
FDA salmonella page: http://tinyurl.com/8srctw

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