Anti-psychotics and geriatrics

systoly · Mar 1, 2009

Its classified as a chemical restraint. We need to be sure that we dont use them for staff convienance. They can have toxic effects on some people and cause a decline in function. If someone is nonambulatory I dont think they can cause much damage to themselves or others even though it can present a problem when trying to provide direct care. Res. that are combative and resisitive to care are a challenge.

That is a good point, but it can go both ways. I've seen too many residents decline after a change in Rx regimen based on statistics. Personal care can certainly present a challenge, but with some creativity and a team approach it's usually quite managable. Nutrition, hydration and weight loss also present a challenge. As staff, we understand these challenges and continously look for better ways to address them. However, the biggest challenge is to preserve the relationship beetween the resident and family and friends. A change in regimen can take away more of the precious little time the resident and family can share. I'm all for a reduction in medication (overall), but I disagree with the shotgun approach.

RochesterRN-BSN, BSN, RN · Mar 1, 2009

I see haldol used for ACUTE behavior problems along with Ativan......both in very low doses. Like Ativan 0.5mg or 0.25mg and Haldol 2.5mg or 1.25mg. I see a change in being less apt to reach for an anti-psychotic for behavioral problems that are NOT related directly to actual psychosis. Doing things like decreasing stimulation, etc. It is hard when we have limitations. I am in the psych ER now and not inpatient so I see more of the term control of behaviors as opossed to when I was inpatient on a unit with a lot of geri's....I know it's harder dealing with the day in and day out, bed time....etc. It's hard when your hands are tied with med limitations. Hopefully with all of these limits being put out there we will see some new meds put out there for these patients.

Cause like another poster said a mentally ill person doesn't stop being ill just cause they get old! And unfortunatly then you sometimes have to deal with the various causes of dementia on top of the original mental illness. The difficulty is that many want to treat the agitation that is caused strictly by Alzheimers the same way they do mental illness when really that is a medical disease that happens to often have a behavioral aspect....not really a real mental illness. So it really needs to be approached differently by docs as well as by nurses.

achot chavi · Mar 2, 2009

Legally speaking I wouldn't take it on myself the responsibility for what the doc orders or not, i would pass on (in writing) the pharmacists message to my DON, med director and unit physician . I would rather the pharmacist pass it on him or herself.

On a personal note, we give Seroquel etc to geriatric pts who need it as the benefits outweigh the risks, we monitor blood tests, EKG's etc. report all changes to the doc etc.

While it is always a goal to reduce the number of meds (psych and otherwise) that our pts are taking (polypharmacy is rampant in nsg homes) we cant d/c a med that is benefiting the pt.

In any event, the doc makes the call, I don't dictate to my docs what to give or not- I do recommend d/cing something if I feel that it is unnecessary- but it is his or her call (and responsibility).

CapeCodMermaid, RN · Mar 2, 2009

The nurse who accepts the order and the nurse who gives the patient the medication shares responsibility if it is a 'bad' order. We no longer free ourselves of responsibility by saying "The doctor ordered it". If you as the licensed person feel the dose is too high or the drug is wrong it is YOUR responsibility to speak up. I've had to tell docs that I would NOT give 50 mg of Coumadin (doc ordered it...looked to me like he was drunk...no one else spoke up because he was the chief cardiologist..I refused to give such a high dose. Read 3 weeks later his license had been pulled for ETOH) and I had to refuse an order for FLOMAX for a woman. The doctor screamed at me saying he knew what he was doing. I reminded him that Flomax was for BPH, the patient was a woman so she didn't have a P that could get H'd B or otherwise. (I've found humor often diffuses a tense situation). He stopped finally and said "What the heck DO I want then??" Perhaps", I offered, "You meant to order FLOVENT?" Right he said and honestly was glad that I stopped him from making a mistake. WE are all responsible.

achot chavi · Mar 2, 2009

The nurse who accepts the order and the nurse who gives the patient the medication shares responsibility if it is a 'bad' order. We no longer free ourselves of responsibility by saying "The doctor ordered it". If you as the licensed person feel the dose is too high or the drug is wrong it is YOUR responsibility to speak up. I've had to tell docs that I would NOT give 50 mg of Coumadin (doc ordered it...looked to me like he was drunk...no one else spoke up because he was the chief cardiologist..I refused to give such a high dose. Read 3 weeks later his license had been pulled for ETOH) and I had to refuse an order for FLOMAX for a woman. The doctor screamed at me saying he knew what he was doing. I reminded him that Flomax was for BPH, the patient was a woman so she didn't have a P that could get H'd B or otherwise. (I've found humor often diffuses a tense situation). He stopped finally and said "What the heck DO I want then??" Perhaps", I offered, "You meant to order FLOVENT?" Right he said and honestly was glad that I stopped him from making a mistake. WE are all responsible.

I agree, there are many recorded court decisions where the nurse was helld responsible for mistakes in the doctors orders and giving Seroquel 2000 mg to a geriatric patient would be wrong.

But we are talking about giving psych meds according to a Psychiatrists recommendation and Drs order in an appropriate dosage . Yes it has to be done with caution but what other option do we have?

Can you recommend a better option? This is what this thread is looking for.

PsychNurseWannaBe, BSN, RN · Mar 3, 2009

I don't know what other options exist. I do not see anything wrong with using antipsychotics judicisouly...keeping into account the patient's age and other comorbidities and medications. Giving an antipsychotic and equating that as a restraint is an old way of thinking, no thanks the State. If it helps to improve the persons function by controlling the psychosis, then the medication is given as directed for the right reasons. Why keep a person in mental angst just because the State says it is a restraint or facility policy is so vague on the issue, it leaves you hangning? If someone is bipolar at 20...they will more than likely be bipolar at 80... We can not take away their meds and leave them high and dry and watch them decomensate.

As far as being above the national average... are you in an area where mental health issues are more prevelant? How do they think the average is created? Many people on a lot... many people on a little and there's the average. They need to take into account the bell curve. To take away someones mental health medication is cruel. The powers at be need to understand how crappy it must be for these people to live out their lives in a mind that isn't playing by the rules. How fun is it for the person to be scared, psychotic, fearful, untrusting of others?

Whenever I see these pharmacy reviews, I put in my two sense worth and pass it on. I am the nurse... I am their advocate and to take away meds for the sake of numbers is no different than neglect.

I am sorry I don't have any answers, but I don't believe there needs to be an answer other than, the medical and nursing communities (actually probably more like administrative communities) need to understand that these medications are needed.

Do your AIMS tests, keep behavioral logs, utilize interventions geared towards therapuetic communication.

I wish you luck!

~Psych

achot chavi · Mar 4, 2009

Discussed this with our Psychiatrist, His claim is that if a person is a long term user of Risperidal or Seroquel or the like they may safely continue using the anti psychotic. For a geriatric pt with dementia starting antipsychotics as a new drug can be problematic and should be avoided. Having said that, there is no current replacement.

RochesterRN-BSN, BSN, RN · Mar 4, 2009

Discussed this with our Psychiatrist, His claim is that if a person is a long term user of Risperidal or Seroquel or the like they may safely continue using the anti psychotic. For a geriatric pt with dementia starting antipsychotics as a new drug can be problematic and should be avoided. Having said that, there is no current replacement.

This makes sense as the new behaviors likely are r/t the dementia and not mental illness. It is really not a commmon thing --if even at all possible to have an 80 YO suddenly develop schizophrenia......this desn't happen. If they are suddenly behaving differently, even showing signs of "psychosis" such as paranoia or the common visual hallucinations-- it is almost always organic--medical in nature, in my experience. Most common, of course, the infamous UTI or any infection really, some meds--I have seen IV Avalox do crazy things to a geri patient! lol, brain or liver CA.....etc. So treating these things with an anti-psychotic is really not appropriate-- you have to treat the cause of the behavior/psych s/s. So this info from the doc totally makes sense to me.

achot chavi · Mar 4, 2009

This makes sense as the new behaviors likely are r/t the dementia and not mental illness. It is really not a commmon thing --if even at all possible to have an 80 YO suddenly develop schizophrenia......this desn't happen. If they are suddenly behaving differently, even showing signs of "psychosis" such as paranoia or the common visual hallucinations-- it is almost always organic--medical in nature, in my experience. Most common, of course, the infamous UTI or any infection really, some meds--I have seen IV Avalox do crazy things to a geri patient! lol, brain or liver CA.....etc. So treating these things with an anti-psychotic is really not appropriate-- you have to treat the cause of the behavior/psych s/s. So this info from the doc totally makes sense to me.

Exactly- well put!

ksangel · Mar 5, 2009

just a thought: has anyone else noted that when geriatrics start having behavior and demntia issues..... some simple lab like electrolytes and u/a can be the answer. its so suprising when dr says confusion is not sign of uti.... but with increased incontinence and strong urine.,..... it is. seen the uti and electrolyte imbalances can really mess up the thinking process in the elderly...... find the source before starting a new med..... nursing 101

achot chavi · Mar 6, 2009

Not just that, it could be side effects of meds like morphine, it could be an undetected infection, or B12 deficiency etc.

Sometimes a new admit will have behavior problems till they settle in and if you overmedicate- they will be a zombie for no reason. We had a recent new admit who became agitated at night (hello- new environment, and staff, etc.) nurse (on her own) injected Halidol 5 mg. the guy was out of it for 4 days!!! (nurse was called on the carpet, explained that the doc said give it and she forgot to ask for a faxed order... doc confirmed...still...)

any other sources of behavior changes...

pielęgniarka, RN · Mar 6, 2009

DEPAKOTE is utilized as a mood stablizer and often with good results in our geriatric behavioral psych unit... following a taper of seroquel or some other antipsychotic meds. We start out at 125 mg BID for one week and increase to 250mg BID. In the sprinkle form it is easier for some residents to consume as well.