Antipsychotic Medication in Elderly Demented Nursing Home Residents

http://www.senate.gov/fplayers/jw57/commMP4Player.cfm?fn=aging113011&st=1093&dur=0, a video of the United States Senate Special Committee on Aging hearing about overuse of antipsychotic use in nursing home residents

http://www.aging.senate.gov/hearings.cfm, the home page of the United States Senate Special Committee on Aging

One of my clinical pharmacists on the interdisciplinary team staffing the Medical-Psychiatry Unit alerted me to the recent AMA MorningRounds news announcement about the continuing overuse of antipsychotics to control agitated behavior in demented elderly persons in nursing homes. The link above takes you to the video of the United States Senate Special Committee on Aging hearing about the issue.

Be forewarned, the video is almost 2 hours long, It’s not similar in any way to the fun and comical music videos I generally attach to my posts. It’s a sobering and sometimes painful video document of the problems we have providing safe and high quality care for older persons in this country. It’s a call to action toward creating a sea change in the culture of how we care for the elderly. Sometimes the tenor of the testimony gave me the impression that the concern about overprescribing of antipsychotics for the management of problematic behaviors in the demented elderly is focused on just the economic burden imposed on our national and state economies.

But because I’m a blogger and pay a fair amount of attention to words, I gradually got a sense of one of the major issues in this crisis, which is that the “culture” of medical care contributes to the problem in a major way. You’ll notice that a number of physician leaders give testimony, among them geriatricians. No geriatric psychiatrist was asked to testify, and I’m not sure why–but by the end of the 114 minute video, I decided that the panel did an extraordinarily thorough job of describing the problem and outlining potential solutions.

And there was a very important reminder that the problem of trying to fix behavioral problems with drugs is often a mistake. Challenging behavior in elderly demented persons (substitute “grandfather”, “uncle”, “brother”, “sister” and so on) is frequently an attempt by them to communicate with us, when the skill of language is lost during the course of dementia. One common problem (among many) they might be trying to communicate with us about is untreated or inadequately treated pain. Research and clinical best practice guidance for years now have counseled health care professionals to try nonpharmacologic behavioral methods first–exhaustively before resorting to psychotropic medications of any kind, not just antipsychotics.

The panel rightly identified that the overprescribing of antipsychotics doesn’t just occur in nursing homes, but is common in hospitals and other types of long-term care facilities and assisted living facilities.

As a psychiatric consultant in the general hospital and co-attending staff physician on the Medical-Psychiatry Unit, my colleagues in medicine and surgery and I are faced with difficult decisions every day about how to cope with challenging and sometimes dangerous behaviors in patients who had cognitive impairment of various kinds including dementia (one of the main risk factors for delirium) who get delirious resulting from medical problems. My colleagues occasionally have an issue with my usual number one recommendation, couched in the usual terms: “Delirium is not a psychiatric problem per se, but a medical emergency; please try finding and resolving the inciting medical problems causing delirium first.” And again, some have an issue with my other oft-expressed opinion, “Haldol is not the treatment for delirium; the treatment for delirium is diagnosing and treating the underlying medical causes.”

Sadly, when behavioral management methods don’t work to control dangerous behavior, we’re compelled to use antipsychotics to maintain safety for patients and caregivers. It’s imperative, though, to have a careful informed consent discussion with families about the risks and benefits of a drug-assisted management approach that will hopefully be temporary. This is the “off label” prescribing mentioned in the video, which physicians legally can and sometimes must do. What is illegal is the “off label marketing” of antipsychotics done by pharmaceutical companies who have settled multimillion dollar lawsuits over this practice. What families need to know is that research repeatedly shows that there are many risks for harm from antipsychotics (including increased risk for death) and little to no benefit when used in an effort to manage challenging behaviors that are not dangerous but which may interfere with providing care.

By far, though, the preferred way to manage challenging behaviors in the demented elderly is through non-pharmacologic interventions. I learned from a recent newsletter from the Mayo Clinic about what Dr. Glenn E. Smith, PhD, LP and colleagues at Mayo Clinic are doing to help caregivers managed disruptive behavior using the Dementia-Behavioral Assessment and Response Team (D-BART, see link at http://mayoresearch.mayo.edu/mayo/research/alzheimers_center/d-bart.cfm) [1]. The D-BART intervention has been helping professional care providers and family members since 1995 and the method reduces the frequency and severity of negative behaviors and improves quality of life and mood for patients with dementia. D-BART can include a licensed neuropsychologist, a psychiatrist, and a dementia education specialist. The patient-centered and team-based approach follows the notion that aggression and agitation are influenced by medical, environmental, psychological, and social factors. The view is what is explicitly commented on in the video, which is that behavior is a form of communication. According to Dr. Smith, “Behavior is a form of communication. As caregivers, it’s our job to detect what the behavior is trying to say and work from that knowledge.” The D-BART approach helps caregivers recognize and capitalize on the understanding that they can adapt a lot easier than the demented person.

D-BART can offer virtual access to those in need by virtual consultations using Skype (for explanation of what Skype is and how it works, see link http://en.wikipedia.org/wiki/Skype). The team provides a laptop or downloadable survey software to facilities that use Skype technology. They review teh survey and the patients electronic medical record prior to the interview of the patient. A group session amongst the team and caregivers results in practical recommendations. A study in 2010 showed D-BART outcomes following consultation indicating that 79% of caregivers reported improvement in the patient’s target behaviors, although it’s not perfect as 7% showed worsening behaviors and 14% showed no change. And the idea is to teach caregivers how to help one patient and they can share what they learn with others–an inductive teaching model which can help spread knowledge and skills faster.

The way to change the course of this crisis in health care treatment of the demented elderly will involve education in nonpharmacologic behavior management techniques, new and stiffer penalties, closer oversight by regulatory agencies, and an increased emphasis on collaboration amongst many stakeholders in our system. The last involves cultivating greater awareness of how the culture of care can create both crises and opportunities.

1. Mayo Clinic PsychUpdate, Psychiatry and Psychology News From Mayo Clinic, Vol. 3, No. 2, 2011.

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