The handwritten doctor’s order was just eight words long, but it solved a problem for Dundee Manor, a nursing home in rural South Carolina struggling to handle a new resident with severe dementia.
David Blakeney, 63, was restless and agitated. The home’s doctor wanted him on an antipsychotic medication called Haldol, a powerful sedative.
“Add Dx of schizophrenia for use of Haldol,” read the doctor’s order, using the medical shorthand for “diagnosis.”
But there was no evidence that Mr. Blakeney actually had schizophrenia.
Antipsychotic drugs — which for decades have faced criticism as “chemical straitjackets” — are dangerous for older people with dementia, nearly doubling their chance of death from heart problems, infections, falls and other ailments. But understaffed nursing homes have often used the sedatives so they don’t have to hire more staff to handle residents.
one in 150 people.
Schizophrenia, which often causes delusions, hallucinations and dampened emotions, is almost always diagnosed before the age of 40.
“People don’t just wake up with schizophrenia when they are elderly,” said Dr. Michael Wasserman, a geriatrician and former nursing home executive who has become a critic of the industry. “It’s used to skirt the rules.”
refuge of last resort for people with the disorder, after large psychiatric hospitals closed decades ago.
But unfounded diagnoses are also driving the increase. In May, a report by a federal oversight agency said nearly one-third of long-term nursing home residents with schizophrenia diagnoses in 2018 had no Medicare record of being treated for the condition.
hide serious problems — like inadequate staffing and haphazard care — from government audits and inspectors.
One result of the inaccurate diagnoses is that the government is understating how many of the country’s 1.1 million nursing home residents are on antipsychotic medications.
According to Medicare’s web page that tracks the effort to reduce the use of antipsychotics, fewer than 15 percent of nursing home residents are on such medications. But that figure excludes patients with schizophrenia diagnoses.
To determine the full number of residents being drugged nationally and at specific homes, The Times obtained unfiltered data that was posted on another, little-known Medicare web page, as well as facility-by-facility data that a patient advocacy group got from Medicare via an open records request and shared with The Times.
The figures showed that at least 21 percent of nursing home residents — about 225,000 people — are on antipsychotics.
The Centers for Medicare and Medicaid Services, which oversees nursing homes, is “concerned about this practice as a way to circumvent the protections these regulations afford,” said Catherine Howden, a spokeswoman for the agency, which is known as C.M.S.
“It is unacceptable for a facility to inappropriately classify a resident’s diagnosis to improve their performance measures,” she said. “We will continue to identify facilities which do so and hold them accountable.”
significant drop since 2012 in the share of residents on the drugs.
But when residents with diagnoses like schizophrenia are included, the decline is less than half what the government and industry claim. And when the pandemic hit in 2020, the trend reversed and antipsychotic drug use increased.
A Doubled Risk of Death
For decades, nursing homes have been using drugs to control dementia patients. For nearly as long, there have been calls for reform.
In 1987, President Ronald Reagan signed a law banning the use of drugs that serve the interest of the nursing home or its staff, not the patient.
But the practice persisted. In the early 2000s, studies found that antipsychotic drugs like Seroquel, Zyprexa and Abilify made older people drowsy and more likely to fall. The drugs were also linked to heart problems in people with dementia. More than a dozen clinical trials concluded that the drugs nearly doubled the risk of death for older dementia patients.
11 percent from less than 7 percent, records show.
The diagnoses rose even as nursing homes reported a decline in behaviors associated with the disorder. The number of residents experiencing delusions, for example, fell to 4 percent from 6 percent.
A Substitute for Staff
Caring for dementia patients is time- and labor-intensive. Workers need to be trained to handle challenging behaviors like wandering and aggression. But many nursing homes are chronically understaffed and do not pay enough to retain employees, especially the nursing assistants who provide the bulk of residents’ daily care.
Studies have found that the worse a home’s staffing situation, the greater its use of antipsychotic drugs. That suggests that some homes are using the powerful drugs to subdue patients and avoid having to hire extra staff. (Homes with staffing shortages are also the most likely to understate the number of residents on antipsychotics, according to the Times’s analysis of Medicare data.)
more than 200,000 since early last year and is at its lowest level since 1994.
As staffing dropped, the use of antipsychotics rose.
Even some of the country’s leading experts on elder care have been taken aback by the frequency of false diagnoses and the overuse of antipsychotics.
Barbara Coulter Edwards, a senior Medicaid official in the Obama administration, said she had discovered that her father was given an incorrect diagnosis of psychosis in the nursing home where he lived even though he had dementia.
“I just was shocked,” Ms. Edwards said. “And the first thing that flashed through my head was this covers a lot of ills for this nursing home if they want to give him drugs.”
Homes that violate the rules face few consequences.
In 2019 and 2021, Medicare said it planned to conduct targeted inspections to examine the issue of false schizophrenia diagnoses, but those plans were repeatedly put on hold because of the pandemic.
In an analysis of government inspection reports, The Times found about 5,600 instances of inspectors citing nursing homes for misusing antipsychotic medications. Nursing home officials told inspectors that they were dispensing the powerful drugs to frail patients for reasons that ranged from “health maintenance” to efforts to deal with residents who were “whining” or “asking for help.”
a state inspector cited Hialeah Shores for giving a false schizophrenia diagnosis to a woman. She was so heavily dosed with antipsychotics that the inspector was unable to rouse her on three consecutive days.
There was no evidence that the woman had been experiencing the delusions common in people with schizophrenia, the inspector found. Instead, staff at the nursing home said she had been “resistive and noncooperative with care.”
Dr. Jonathan Evans, a medical director for nursing homes in Virginia who reviewed the inspector’s findings for The Times, described the woman’s fear and resistance as “classic dementia behavior.”
“This wasn’t five-star care,” said Dr. Evans, who previously was president of a group that represents medical staff in nursing homes. He said he was alarmed that the inspector had decided the violation caused only “minimal harm or potential for harm” to the patient, despite her heavy sedation. As a result, he said, “there’s nothing about this that would deter this facility from doing this again.”
Representatives of Hialeah Shores declined to comment.
Seven of the 52 homes on the inspector general’s list were owned by a large Texas company, Daybreak Venture. At four of those homes, the official rate of antipsychotic drug use for long-term residents was zero, while the actual rate was much higher, according to the Times analysis comparing official C.M.S. figures with unpublished data obtained by the California advocacy group.
make people drowsy and increases the risk of falls. Peer-reviewed studies have shown that it does not help with dementia, and the government has not approved it for that use.
But prescriptions of Depakote and similar anti-seizure drugs have accelerated since the government started publicly reporting nursing homes’ use of antipsychotics.
Between 2015 and 2018, the most recent data available, the use of anti-seizure drugs rose 15 percent in nursing home residents with dementia, according to an analysis of Medicare insurance claims that researchers at the University of Michigan prepared for The Times.
in a “sprinkle” form that makes it easy to slip into food undetected.
“It’s a drug that’s tailor-made to chemically restrain residents without anybody knowing,” he said.
In the early 2000s, Depakote’s manufacturer, Abbott Laboratories, began falsely pitching the drug to nursing homes as a way to sidestep the 1987 law prohibiting facilities from using drugs as “chemical restraints,” according to a federal whistle-blower lawsuit filed by a former Abbott saleswoman.
According to the lawsuit, Abbott’s representatives told pharmacists and nurses that Depakote would “fly under the radar screen” of federal regulations.
Abbott settled the lawsuit in 2012, agreeing to pay the government $1.5 billion to resolve allegations that it had improperly marketed the drugs, including to nursing homes.
Nursing homes are required to report to federal regulators how many of their patients take a wide variety of psychotropic drugs — not just antipsychotics but also anti-anxiety medications, antidepressants and sleeping pills. But homes do not have to report Depakote or similar drugs to the federal government.
“It is like an arrow pointing to that class of medications, like ‘Use us, use us!’” Dr. Maust said. “No one is keeping track of this.”
published a brochure titled “Nursing Homes: Times have changed.”
“Nursing homes have replaced restraints and antipsychotic medications with robust activity programs, religious services, social workers and resident councils so that residents can be mentally, physically and socially engaged,” the colorful two-page leaflet boasted.
Last year, though, the industry teamed up with drug companies and others to push Congress and federal regulators to broaden the list of conditions under which antipsychotics don’t need to be publicly disclosed.
“There is specific and compelling evidence that psychotropics are underutilized in treating dementia and it is time for C.M.S. to re-evaluate its regulations,” wrote Jim Scott, the chairman of the Alliance for Aging Research, which is coordinating the campaign.
The lobbying was financed by drug companies including Avanir Pharmaceuticals and Acadia Pharmaceuticals. Both have tried — and so far failed — to get their drugs approved for treating patients with dementia. (In 2019, Avanir agreed to pay $108 million to settle charges that it had inappropriately marketed its drug for use in dementia patients in nursing homes.)
‘Hold His Haldol’
Ms. Blakeney said that only after hiring a lawyer to sue Dundee Manor for her husband’s death did she learn he had been on Haldol and other powerful drugs. (Dundee Manor has denied Ms. Blakeney’s claims in court filings.)
During her visits, though, Ms. Blakeney noticed that many residents were sleeping most of the time. A pair of women, in particular, always caught her attention. “There were two of them, laying in the same room, like they were dead,” she said.
In his first few months at Dundee Manor, Mr. Blakeney was in and out of the hospital, for bedsores, pneumonia and dehydration. During one hospital visit in December, a doctor noted that Mr. Blakeney was unable to communicate and could no longer walk.
“Hold the patient’s Ambien, trazodone and Zyprexa because of his mental status changes,” the doctor wrote. “Hold his Haldol.”
Mr. Blakeney continued to be prescribed the drugs after he returned to Dundee Manor. By April 2017, the bedsore on his right heel — a result, in part, of his rarely getting out of bed or his wheelchair — required the foot to be amputated.
In June, after weeks of fruitless searching for another nursing home, Ms. Blakeney found one and transferred him there. Later that month, he died.
“I tried to get him out — I tried and tried and tried,” his wife said. “But when I did get him out, it was too late.”
“We went into the study thinking we might be able to see these financial indicators,” said Lauren Hersch Nicholas, a co-author of the study who is an associate professor of public health at the University of Colorado. “But we were sort of surprised and dismayed to find that you really could. That means it’s sufficiently common, because we’re picking it up in a sample of 80,000 people.”
For decades, Pam McElreath kept the books for the insurance agency that she and her husband, Jimmy, owned in Aberdeen, N.C. In the early 2000s, she started having trouble with routine tasks. She assigned the wrong billing codes to expenditures, filled in checks with the wrong year, forgot to pay the premium on her husband’s life insurance policy.
Everyone makes mistakes, right? It’s just part of aging, her friends would say.
“But it’s not like my friend that made that one mistake, one time,” Ms. McElreath, 67, said. “Every month I was having to correct more mistakes. And I knew something was wrong.”
She received diagnoses of mild cognitive impairment in 2011, at age 56, and early-onset Alzheimer’s two years later. In 2017, doctors changed her diagnosis to frontotemporal dementia.
Getting a devastating diagnosis is hard enough, but learning to cope with it is also hard. Eventually both Ms. McElreath and Ms. Turner put mechanisms in place to keep their finances on an even keel.
Ms. Turner, who has two adult children, lives alone. After her diagnosis, she hired a financial manager, and together they set up a system that provides her with a set amount of spending money every month and doesn’t allow her to make large withdrawals on impulse. She ditched her credit cards and removed eBay and Amazon from her phone.
Though not a micromanager, the financial adviser keeps an eye on Ms. Turner’s spending and questions her when something seems off.
LOS ANGELES — In a break with tradition, the Academy of Motion Picture Arts and Sciences decided to end its Oscars ceremony on Sunday with the prize for best actor instead of the one for best picture.
It was easy to understand why. The late Chadwick Boseman, nominated for his visceral performance in “Ma Rainey’s Black Bottom,” was the runaway favorite, and an acceptance speech by his widow was sure to be an emotional moment. Further, the best actor prize had gone to a Black man only four times in 93 years, and celebrating Mr. Boseman at the night’s climax — after a year in which racial justice was at the forefront of the country’s consciousness — would put an exclamation point on the academy’s aggressive diversity and inclusion efforts over the past few years.
It backfired in spectacular fashion.
The film establishment instead went with Anthony Hopkins, rewarding his performance in “The Father” as a man suffering from dementia. Apparently certain that Mr. Boseman would win, Mr. Hopkins had decided not to attend the ceremony. With no one there to accept the award, the Oscars telecast abruptly ended, leaving the academy to face questions about whether it had misjudged its voting body.
“At 83 years old, I did not expect to get this award — I really didn’t,” Mr. Hopkins said in a video speech released Monday morning from his hometown in Wales and during which he paid tribute to Mr. Boseman.
all-white slates of acting nominees in both 2015 and 2016. It has scrambled to enact diversity-focused reforms, most notably inviting about 4,000 artists and executives — with a focus on women and people from underrepresented groups — to become members. The organization now has about 10,000 voters. It says that about 19 percent of its members are from underrepresented racial and ethnic communities, up from 10 percent in 2015.
This year’s ceremony had a chance to be a showcase for those efforts. Going into Sunday night, some awards handicappers predicted that movie history would be made, with all four acting Oscars going to people of color for the first time. Along with Mr. Boseman, Viola Davis was seen as a leading contender for the best actress prize for playing a blues singer in “Ma Rainey’s Black Bottom.” Best actress instead went to Frances McDormand for playing a dour van dweller in “Nomadland.” It was her third best-actress statuette.
Daniel Kaluuya, who played the Black Panther leader Fred Hampton in “Judas and the Black Messiah,” and Yuh-Jung Youn, for her comically cantankerous grandmother in “Minari.” She was the first Korean performer to win an acting Oscar, and only the second Asian woman. Chloé Zhao, who is Chinese, took home the best director prize, only the second woman to do so in Oscar history and the first woman of color.
Two Black women, Mia Neal and Jamika Wilson, won Oscars for makeup and hairstyling for the first time. Emerald Fennell (“Promising Young Woman”) was the first woman to take home a solo screenwriting Oscar in 13 years. And the director Travon Free was the first Black man to win in the best live-action short category. He was recognized for “Two Distant Strangers,” a film about police brutality that he made with Martin Desmond Roe.
revealed that he did not accept the academy’s overtures.
Last year, the academy announced a plan that will require films to meet diversity criteria to be eligible for a best-picture nomination, starting with the 2024 awards.
Still, those who have been critical of the way the film industry operates are not ready to heap too much praise on the academy’s efforts.
“What we have to constantly recognize is that an institution like the academy didn’t give anything to Black people,” said Rashad Robinson, president of the racial justice organization Color of Change. “What the academy has done over the years is have a system and a set of rules that has stalled Black careers, which has prevented people from being able to be fully seen, which has had an economic impact on folks. Now that they are working to make some changes, let’s acknowledge those changes but let’s not give them any awards that they haven’t earned.”
resigned from the academy’s board in 2018.
“We have settled on numeric answers to the problem of inclusion, barely recognizing that this is the industry’s problem far, far more than it is the academy’s,” Mr. Mechanic wrote in his resignation letter, which was leaked to the news media. “Instead we react to pressure. One governor even went as far as suggesting we don’t admit a single white male to the academy, regardless of merit!”
At the same time, some people have turned away from the Oscars because of its lack of diversity. Under 10 million viewers tuned into Sunday night’s telecast, according to Nielson, a 58 percent drop compared with last year. One member of the academy’s board of governors, who spoke on the condition of anonymity because of confidentiality rules, said that market research had shown that people of color, upset about the racial disparity of nominees (and tired of seeing many of the same people get nominated over and over), had become less interested in the ceremony. A couple of smaller civil rights groups have called for viewing boycotts.
That was the case for April Reign, the campaign finance lawyer who originated the #OscarsSoWhite hashtag in 2015. Despite the changes at the organization, she said she believed the academy’s efforts to diversify its voting body had fallen short.
“It’s still a popularity contest among all the white men,” she said.
Others see reason for optimism in this year’s Oscars, no matter how they ended.
“To have a film about Fred Hampton that doesn’t demonize him but instead celebrates him, and provides this broader story from a group of Black filmmakers is, you know, kind of hard to believe that it would even be made much less be nominated,” Mr. Boyd said of “Judas and the Black Messiah.” “And we could go through each of these examples. It’s great. It’s wonderful. I just don’t want it to be an isolated incident.”
LOS ANGELES — A surreal 93rd Academy Awards, a stage show broadcast on television about films mostly distributed on the internet, got underway on Sunday with Regina King, a former Oscar winner and the director of “One Night in Miami,” strutting into a supper-club set.
“It has been quite a year, and we are still smack dab in the middle of it,” she said, referencing the pandemic and the guilty verdict in the George Floyd murder trial. “Our love of movies helped to get us through.”
With little more preamble, Oscar statuettes were handed out, with Emerald Fennell, a first-time nominee, winning best original screenplay for “Promising Young Woman,” a startling revenge drama. The last woman to win solo in the category had been Diablo Cody (“Juno”) in 2007.
“He’s so heavy and so cold,” Fennell said about the gold-plated Oscar statuette in an impromptu speech that revisited one she wrote when she was 10 and loved Zack Morris in the television series “Saved By the Bell.” “They said write a speech. I’m going to be in trouble with Steven Soderbergh,” she said.
overwhelmingly white and male, but the organization has invited more women and people of color into its ranks following the intense #OscarsSoWhite outcries in 2015 and 2016, when the acting nominees were all white. This year, nine of the 20 acting nominations went to people of color.
As expected, Daniel Kaluuya was named supporting actor for playing the Black Panther leader Fred Hampton in “Judas and the Black Messiah.”
“Bro, we out here!” Kaluuya shouted in celebration before growing serious and crediting Hampton (“what a man, what a man”) and ending with the cri de coeur, “When they played divide and conquer, we say unite and ascend.”
Hollywood wanted the producers of the telecast to pull off an almost-impossible hat trick. First and foremost, they were asked to design a show that prevented the TV ratings from plunging to an alarming low — while celebrating movies that, for the most part, have not connected widely with audiences. The producing team, which included the Oscar-winning filmmaker Steven Soderbergh (“Traffic”), also hope to use the telecast to jump-start theatergoing, no small task when most of the world has been out of the box office habit for more than a year. Lastly, the producers needed to integrate live camera feeds from more than 20 locations to comply with coronavirus safety restrictions.
red carpet had to be radically downsized and the extravagant parties canceled.
For the first time, the academy nominated two women for best director, recognizing Chloé Zhao for “Nomadland,” a bittersweet meditation on grief and the American dream, and Fennell for “Promising Young Woman,” about the aftermath of a sexual assault. The other nominated directors were David Fincher for “Mank,” a black-and-white love letter to Old Hollywood; Lee Isaac Chung for “Minari,” a semi-autobiographical tale about a Korean-American family; and, in a surprise, Vinterberg for “Another Round.”
Zhao had already been feted for her “Nomadland” direction by nearly 60 other organizations, including the Directors Guild of America and the British Academy of Film and Television Arts. In 93 years of the Academy Awards, only one woman, Kathryn Bigelow, has ever won. (Bigelow was celebrated in 2010 for directing “The Hurt Locker.”) The directing category has also been dominated over the decades by white men, giving the nomination of Zhao, who is Chinese, even greater meaning.
Netflix was back in the best picture race.
sharp-elbowed awards campaigners keep whiffing in the end.
Last year, the company’s best-picture hopes rested on “The Irishman.” It failed to convert even one of its 10 nominations into a win. In 2019, Netflix pushed “Roma.” It won three Oscars, including one for Alfonso Cuarón’s direction, but lost the big prize.
ending his popular, nine-film “Madea” series in 2019, Perry has focused on making television shows like “Bruh,” “Sistahs” and “The Oval” for BET. He owns a studio in Atlanta.
The Dolby Theater, which holds more than 3,000 people and has been the home of the Academy Awards since 2001, was not the epicenter of the telecast. This year, with just the nominees and their guests in attendance, an Art Deco, Mission Revival train station in downtown Los Angeles served as the main venue.
The correlation also held whether or not people were taking sleep medication and whether or not they had a mutation called ApoE4 that makes people more likely to develop Alzheimer’s, Dr. Sabia said.
“The study found a modest, but I would say somewhat important association of short sleep and dementia risk,” said Pamela Lutsey, an associate professor of epidemiology and community health at the University of Minnesota, who was not involved in the research. “Short sleep is very common and because of that, even if it’s modestly associated with dementia risk, it can be important at a societal level. Short sleep is something that we have control over, something that you can change.”
Still, as with other research in this area, the study had limitations that prevent it from proving that inadequate sleep can help cause dementia. Most of the sleep data was self-reported, a subjective measure that isn’t always accurate, experts said.
At one point, nearly 4,000 participants did have sleep duration measured by accelerometers and that data was consistent with their self-reported sleep times, the researchers said. Still, that quantitative measure came late in the study, when participants were about 69, making it less useful than if it had been obtained at younger ages.
In addition, most participants were white and better educated and healthier than the overall British population. And in relying on electronic medical records for dementia diagnoses, researchers might have missed some cases. They also could not identify exact types of dementia.
“It’s always difficult to know what to conclude from these kinds of studies,” wrote Robert Howard, a professor of old age psychiatry at University College London, one of several experts who submitted comments about the study to Nature Communications. “Insomniacs — who probably don’t need something else to ruminate about in bed,” he added, “shouldn’t worry that they are heading for dementia unless they get off to sleep immediately.”
There are compelling scientific theories about why too little sleep might exacerbate the risk of dementia, especially Alzheimer’s. Studies have found that cerebrospinal fluid levels of amyloid, a protein that clumps into plaques in Alzheimer’s, “go up if you sleep-deprive people,” Dr. Musiek said. Other studies of amyloid and another Alzheimer’s protein, tau, suggest that “sleep is important for clearing proteins from the brain or limiting the production,” he said.