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.”
President Biden and President Vladimir V. Putin of Russia have agreed to meet on June 16 in Geneva for a face-to-face encounter that comes at a time of fast-deteriorating relations over Ukraine, cyberattacks and a raft of new nuclear weapons Mr. Putin is deploying. The summit is the first in-person meeting between the two leaders since Mr. Biden became president.
The one-day meeting is expected to focus on ways to restore predictability and stability to a relationship that carries a risk of nuclear accident, miscalculation and escalation. Geneva was also the site of the 1985 summit between Mikhail Gorbachev, the Soviet leader, and Ronald Reagan that was focused on the nuclear arms race.
The meeting comes at the worst point in Russian-American relations since the fall of the Soviet Union about 30 years ago. To say that the two leaders have a tense relationship is an understatement: Mr. Biden called Mr. Putin a “killer” in a television interview in March, leading Mr. Putin to dryly return the accusation and wish the new president “good health.”
Russia, despite its aggressive language toward the West, has shown optimism about the talks. For Mr. Putin, a high-profile presidential summit can help deliver what he has long sought: respect for Russia on the world stage. And he is sure to repeat his message that the United States must respect Russian interests — especially inside Russia, where the Kremlin claims Washington is trying to undermine Mr. Putin’s rule, and in Eastern Europe.
new round of financial sanctions against the country.
That list includes the prosecution and jailing of Aleksei A. Navalny, the opposition leader Mr. Putin’s intelligence services tried to kill with a nerve agent. And Mr. Biden plans to spend considerable time on cybersecurity in hopes of limiting the rising tide of cyberattacks directed at the United States.
Such attacks have dogged Mr. Biden since December, with the disclosure of SolarWinds, a sophisticated hack into network management software used by most of the United States’ largest companies and by a range of government agencies and defense contractors.
Mr. Biden vowed a full investigation and a proportionate response, though it is unclear whether those moves — which his aides said would be “seen and unseen” — are sufficient to deter the low-cost attacks.
Two weeks ago, Mr. Biden said he would raise with Mr. Putin the more recent ransomware attack on Colonial Pipeline, which shut down nearly half of the supply of gasoline, diesel and jet fuel to the East Coast. That attack was the work of a criminal group, the Biden administration said, but Mr. Biden accused Russia of harboring the ransomware criminals.
The summit will come at the end of Mr. Biden’s first international trip as president, to Europe, where he will meet with the Group of 7 allies — a group the Russians had been part of for several years when integration with the West seemed possible — and NATO allies.
President Biden visited former President Jimmy Carter, an old friend, as he traveled to Georgia on Thursday to pitch his $4 trillion economic agenda.
A day after using his first address to Congress to urge swift passage of his plans to spend heavily on infrastructure, child care, paid leave and other efforts meant to bolster economic competitiveness, Mr. Biden was set to hold a drive-in car rally in Duluth, Ga., for his 100th day in office.
White House officials indicated that the president would promote the $1.9 trillion economic aid bill he signed into law in March and pitch the two-part plan for longer-term investments in the economy that he has rolled out over the past two weeks.
Mr. Biden, Vice President Kamala Harris and the president’s cabinet are embarking on a post-speech tour to push the economic plans through next week. Administration officials said the focus would include celebrating the increased pace of Covid-19 vaccinations since Mr. Biden took office and the rebound in economic activity.
free community college, universal prekindergarten and expanded efforts to fight poverty.
“He and the first lady are returning to Georgia to talk about getting America back on track,” Karine Jean-Pierre, the principal deputy press secretary, told reporters as they traveled to the state.
First, though, Mr. Biden took a detour to Plains, Ga., where Mr. Carter lives with his wife, Rosalynn Carter. Mr. Carter, the longest-living former president, is 96 years old and a cancer survivor. He has remained largely out of the public view during the coronavirus pandemic, although he appeared at a parade in October for his birthday. He did not attend Mr. Biden’s inauguration in January, and the president had promised to visit him.
“This is a longstanding friendship,” Ms. Jean-Pierre said. “They said that they were going to try to see each other after inauguration.”
Mr. Biden was the first senator to endorse Mr. Carter’s presidential bid in 1976, when Mr. Carter was the Georgia governor and not considered the favorite for the Democratic nomination. Mr. Biden recalled that endorsement as part of a brief video message he taped this month for the film crew behind “Carterland,” a documentary on the Carter administration.
“Some of my colleagues in the Senate thought it was youthful exuberance,” Mr. Biden said in the video. “Well, I was exuberant, but as I said then, ‘Jimmy’s not just a bright smile. He can win, and he can appeal to more segments of the population than any other person.’”
In the message, the president hailed Mr. Carter’s work in office and after his defeat to Ronald Reagan in 1980, praising Mr. Carter for working to eradicate disease and house the poor while still finding time to teach Sunday school. Mr. Biden said Mr. Carter had called him the night before his inauguration to wish him well and say he would be there in spirit.
“Simply put,” Mr. Biden told Mr. Carter and Mrs. Carter at the end of the video, “we love you, and God bless you both.”
The visit between the two families on Thursday lasted less than an hour. Mr. Biden’s motorcade arrived at the Carters’ home from Jimmy Carter Regional Airport at 2:30 p.m. A pool reporter glimpsed Mrs. Carter, in a white top and using a walker, on the front porch. There was no sign of Mr. Carter.
The Turkish public will see it as evidence of American double standards, and anti-Western forces in Turkey will use it to incite fury, he said.
Both opposition and pro-government leaders attacked the expected designation.
“This is an improper, unfair stance,” said Kemal Kilicdaroglu, the leader of the largest opposition party, the Republican People’s Party.
Dogu Perincek, the leader of the ultranationalist Patriotic Party, in an open letter to Mr. Biden, questioned his authority to issue such a declaration. “As is known, the genocide against the Jews was adjudicated at an authorized court,” he wrote, “but regarding the 1915 incidents, there is no judicial ruling.”
The killings of Armenians occurred at the end of World War I during the collapse of the Ottoman Empire, the predecessor of modern Turkey. Worried that the Christian Armenian population would align with Russia, a primary enemy of the Ottoman Turks, officials ordered mass deportations in what many historians consider the first genocide of the 20th century: Nearly 1.5 million Armenians were killed, some in massacres by soldiers and the police, others in forced exoduses to the Syrian desert that left them starved to death.
Turkey has acknowledged that widespread atrocities occurred during that period, but its leaders have adamantly denied that the killings were genocide.
In the days leading up to Mr. Biden’s announcement, Armenians and human rights activists in Turkey expressed caution, partly because of years of political seesawing over the issue.
“Personally, it is not going to make me excited,” Yetvart Danzikyan, the editor in chief of Agos, an Armenian-Turkish weekly newspaper in Istanbul, said, pointing to a statement President Ronald Reagan issued in 1981 about the Holocaust that mentioned the “genocide of the Armenians” in passing.
At the risk of infuriating Turkey, President Biden is set to formally announce on Saturday that the United States regards the killing of 1.5 million Armenians by Turks more than a century ago to be a genocide — the most monstrous of crimes.
Mr. Biden would be the first American president to make such an announcement, breaking with predecessors who did not wish to antagonize Turkey, a NATO ally and a strategically pivotal country straddling Europe and the Middle East.
The expected announcement, which Mr. Biden had signaled when he was a candidate last year, has been welcomed by Armenians and human rights advocates. It carries enormous symbolic weight, equating the anti-Armenian violence with atrocities on the scale of those committed in Nazi-occupied Europe, Cambodia and Rwanda.
Use of the term is a moral slap at President Tayyip Recep Erdogan of Turkey, a fervent denier of the genocide. He has fulminated at other leaders, including Pope Francis, for describing the Armenian killings that way.
a crime under international law.
Cambodia, the 1994 genocide in Rwanda, and atrocities including genocide in the former Yugoslavia.
The International Criminal Court, which was created in 2002 in part to prosecute such crimes, has only one pending genocide case — Omar Hassan Ahmad al-Bashir, former president of Sudan, who is wanted on two warrants for crimes including genocide in the Darfur region between 2003 and 2008. The court cannot prosecute crimes committed before its inception.
The International Court of Justice, the highest court of the United Nations, ruled in January 2020 that Myanmar must take action to protect Rohingya Muslims, who have been killed and driven from their homes in what the country’s accusers have called a campaign of genocide. The ruling, which has no enforcement power, was the outcome of a lawsuit filed on behalf of Muslim countries that wanted the court to condemn Myanmar for violating the genocide treaty.
What was the Armenian genocide?
The violence against Armenians began during the breakup of the Ottoman Empire, the predecessor of modern Turkey, which included an area that is now Armenia, a landlocked country ringed by Turkey, Georgia, Azerbaijan and Iran.
Starting in 1915, the Ottomans, aligned with Germany in World War I, sought to prevent Armenians from collaborating with Russia and ordered mass deportations. As many as 1.5 million ethnic Armenians died from starvation, killings by Ottoman Turk soldiers and the police, and forced exoduses south into what is now Syria and elsewhere in the Middle East.
denial of genocide is ingrained into Turkish society. Writers who have dared to use the term have been prosecuted under Section 301 of Turkey’s penal code, which bans “denigrating Turkishness.” The denial is taught at an early age, with school textbooks calling the genocide a lie, describing the Armenians of that period as traitors and declaring the actions by the Ottoman Turks as “necessary measures” against Armenian separatism.
Why have U.S. presidents refrained from calling the Armenian killings a genocide?
Some have come close. President Ronald Reagan tangentially referred to the “genocide of the Armenians” in an April 22, 1981, statement commemorating the liberation of the Nazi death camps.
But American presidents have generally avoided describing the killings this way to avoid any backlash from Turkey that would endanger its cooperation in regional conflicts or diplomacy.
What has changed?
As a presidential candidate, Mr. Biden signaled his intentions a year ago in a speech on April 24, Armenia’s official day of remembrance of the genocide. He used the term “Armenian genocide” and asserted that “we must never forget or remain silent about this horrific and systematic campaign of extermination.” And in recent years, bipartisan anger toward Mr. Erdogan has grown. In 2019, the House and Senate passed resolutions calling the Armenian killings a genocide.
As vice president in the Obama administration, Mr. Biden never enjoyed an easy relationship with Mr. Erdogan, an autocratic leader who gave him an icy reception in August 2016. The two met a month after the failed coup in Turkey that Mr. Erdogan blamed on a Turkish cleric living in exile in the United States.
said last month that he believed Mr. Biden would make the genocide declaration despite knowing that a reset of U.S.-Turkey relations would then become “much harder.”
Mr. Erdogan’s aides have signaled that Mr. Biden’s declaration would face a hostile reaction in Turkey. The foreign minister, Mevlut Cavusoglu, said in a Turkish media interview this week that “if the United States wants to worsen ties, the decision is theirs.”
How many countries recognize the Armenian genocide?
According to a tally by the Armenian National Institute, a Washington-based group, at least 30 countries have done so.
The answer is more complicated concerning the United Nations, which played a central role in the treaty that made genocide a crime but has not taken a position on what happened in 1915 — 30 years before the global body was created. The website of its Office on Genocide Prevention and the Responsibility to Protect, in describing the origin of the term genocide, does not mention Armenia. António Guterres, the secretary-general, has skirted the issue.
Asked on Thursday about Mr. Guterres’s view, his spokesman, Stéphane Dujarric, said: “We have no comment, as a general rule, on events that took place before the founding of the U.N.” Genocide, Mr. Dujarric said, “needs to be determined by an appropriate judicial body, as far as the U.N. is concerned.”
PRAGUE — Russia’s unraveling relations with the West took a dramatic turn for the worse on Thursday when the Czech Republic, furious over what it said were Moscow’s fingerprints on a military-style sabotage attack on a Czech weapons warehouse in 2014, ordered the expulsion of as many as 60 Russian diplomats.
The Czech move, announced a day after President Vladimir V. Putin of Russia warned that the West risked a “fast and tough” response if it interfered with his country, escalated not only a diplomatic crisis between Prague and Moscow but a wider showdown between Russia and NATO, of which the Czech Republic is a member.
With Russian troops massing near the border with Ukraine and President Biden taking a tough stand against the Kremlin, Mr. Putin on Wednesday bluntly warned the West not to test Russia’s resolve in defending its interests, telling it not to cross unspecified “red lines” that he said would be defined by Russia.
The slashing of staff at Moscow’s embassy in Prague does not directly challenge Russian security. But it will severely damage intelligence operations, something that Mr. Putin, a K.G.B. officer in Eastern Europe during the Cold War, views as vitally important.
ordered out 20 Czech diplomats. Russia, which has used its Prague embassy as a center of espionage across the region, according to intelligence experts, previously had far more diplomats in the city than the Czech Republic had in Moscow.
Sergei V. Skripal, in the English town of Salisbury.
Two Russians identified by Britain as the main culprits in the Salisbury attack, both members of a military intelligence sabotage and assassination squad known as Unit 29155, turned out to be the same men Czech investigators had long suspected of involvement in the ammunition warehouse blasts but had not been able to identify.
Both men arrived in the Czech Republic under false names several days before the blasts and traveled to the site of the warehouse in Vrbetice, leaving on the day of the first explosion on Oct. 16, 2014.
Miroslav Mares, an expert on security policy at Masaryk University in the Czech city of Brno, said the Czech Republic wanted to “demonstrate its self-confidence and capability for resilience toward Russian aggressive behavior.” But he added that “the final effect strongly depends on support from Czech allies in the European Union and NATO.”