Overuse of antipsychotics in nursing homes

  1. This story was big news in the Boston Globe this weekend. I hope never to encounter the overuse of antipsychotic medications in the patients I care for. It is one of the big fears when I think of what kind of patient-care horror show I hope never to be exposed to.

    Unfortunately, the two part story is not easily available online; you have to register or be a member of the Boston Globe. Part 1 is provided on the Boston.com website; not sure when Part 2 will be available there.

    Through the Boston Globe website you can check a nationwide listing of nursing homes to see how heavy their use of antipsychotics is:


    For each nursing home listed, the table indicates:

    • Percentage of residents without psychosis or related condition who received antipsychotics
    • Residents with Medicaid coverage
    • Residents with behavioral problems
    • Nurse minutes per resident per day

    Here's a little article that explains How the Data Were Analyzed.
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    About hotflashion, BSN, RN

    Joined: Oct '09; Posts: 282; Likes: 174
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    Specialty: 3 year(s) of experience in Foot care


  3. by   JZ_RN
    If anything at my job I think they're underused. I have some patients who could really use a depakote, seroquel, ativan, and haldol smoothie quite often. I do agree that drugging people rather than dealing with their issues is not the way to go, but with dementia patients with extreme behaviors and no other interventions that help at all, I thank the inventors of the antipsychotics.
  4. by   hotflashion
    JZ_RN, do you work at a nursing home? If so, does your facility appear on the nationwide listing? If so, what are the numbers?

    I think the "other interventions" are skilled-personnel intensive. That frequently means that the care is more expensive, though spending more money doesn't automatically mean the actual care delivered will be better.

    In what way do you think your patients "could really use" a cocktail such as you describe?
  5. by   ClearBlueOctoberSky
    I work on a secured unit, and we have a lot of patients that are on Depakote, Seroquel or Zyprexa. Those three are our big ones.

    In our case, I don't think it is a overuse issue, though, as our docs are good about decreasing or d/cing the medications when they think the behaviors are under control or when they or staff thinks that the medication is no longer needed. I do have one patient that I told the PA that we could probably use a prn Zanax or Ativan for due to her particular behavior, and was told that the State doesn't really like to see that, so they are trialing her on Seroquel.

    For us, it is a no-win situation. Most of our patients have some form of violent behavior. Some may think that it is just a staffing issue, but it isn't. We have to keep our residents safe, and sometimes that amounts to trying to control the majority of behavior with medication and using non-pharm interventions for the outbursts.
  6. by   brandy1017
    I believe that antipsychotics need to be given to some patients, particularly those who are violent whether it is because of dementia or because they were that way their whole life is irrelevant. For the safety of fellow patients and caregivers I think patients should be given medication so they are not attacking others. This is necessary if they are a danger to themselves or to others!
  7. by   WhiteScrubs
    It is entirely unrealistic to expect antipsychotics to only be prescribed for a diagnosis of psychosis. I see antipsychotics frequently used for patients/residents with dementia with agitation. It is not a first line treatment, but can be very effective, and can improve the quality of life of the resident. Certainly, any medication can be overused or used improperly, but I don't think there is any need to fear their usage. The real horror show would be not medicating these residents properly and safely.

    I hope never to encounter the overuse of antipsychotic medications in the patients I care for. It is one of the big fears when I think of what kind of patient-care horror show I hope never to be exposed to.
    I work in LTC, on a secure unit for residents with dementia. I checked the list, and my facility is included -- we are significantly below the national median for antipsychotic usage, HOWEVER, that is because it includes my entire SNF facility. Many of those residents that are there for short term rehab stays, and therefore won't be on antipsychotics (unless previously in use prior to admission...).

    If they were to just look at the percentage for my floor, our percentage would be much higher. Not 100%, but well over 50%, and I don't think any of those cases are unnecessary. I see a lot of scheduled Seroquel, Risperdal, and Zyprexa, along with scheduled and PRN Ativan. Our psych docs are very involved in the care of our residents. If we observe significant agitation/agression, we can request an evaluation, but the docs aren't likely to change meds/add antipsychotics unless we have a well documented pattern in the nurses notes.

    Granted, I only looked at the listing and not the accompanying article, but I don't believe those percentages provide much info without additional data about the type of patient population that the facility serves. Just my thoughts...
  8. by   CapeCodMermaid
    The Globe??? Really??? It's better to read a scholarly article than something in a non-medically oriented newspaper.
    We use antipsychotics appropriately. Many of these people are tormented with psychotic thoughts and the meds are the only things that give them any chance of good quality of life.
  9. by   JZ_RN
    I can't find the numbers, but I have 50 patients to myself and only about 5 are on antipsychotics, though there are a few with PRN ativan, but it's mostly for seizures. Mind you that this is an alzheimer's/dementia unit. Many more of them than 5 have what I would consider "psychiatric" problems. (hallucinations, delusions, etc.)

    I have many patients who are abusive, physically and verbally, and who have very disruptive behaviors, screaming, hitting, spitting, crying, etc. They have dementia and are nonverbal or barely verbal and you can't really reason with them. And forget about having more staff so someone can sit with them, they don't even want to pay another nurse so I don't have 50 residents alone. 3 aides, sometimes 2. It's ridiculous.
  10. by   CompleteUnknown
    Sometimes it really is a staffing issue (either not enough staff or staff who simply don't know (and don't care to learn) how to work with residents with severe behavioural issues), but sometimes no amount of increased staffing or non pharmaceutical interventions would do any good at all.

    Some of these people are living in absolute misery every single hour of every single day and are so very distressed that the risks of medication are less than the risks of no medication.

    Of course these medications shouldn't be overused but sometimes there is no other choice. Numbers and percentages don't always tell the story, some facilities may have low numbers but are actually overusing these drugs, and others may relatively have high numbers but are using them appropriately.
  11. by   JZ_RN
    I have patients with morbid and horribly distressing hallucinations and delusions. But god forbid I give them some antipsychotics?

    I have never medicated someone for convenience. Only for their comfort and safety or for the safety of others. (residents who strike out at everyone)
  12. by   VivaLasViejas
    I don't medicate residents---or ask their PCPs to order medications---if they're only driving me crazy. I do it if they're driving THEMSELVES crazy! Worry, anxiety, irritability, agitation, confusion, fear.......none of that is comfortable for the person experiencing it. Add dementia into the mix, and you've got the potential for all sorts of unpredictable outcomes.

    Far better than allowing residents to stew in their own juices, so to speak, is to administer medications that defuse the emotionality while encouraging the body to rest. That's not to say we don't try other, non-drug interventions first when someone gets wound up: often all they need is to have their basic needs met (toileting, food, fluids etc.). Sometimes they need a little one-on-one time---a willing ear to listen to old stories, a couple of Scriptural passages read to them, even just a hug and reassurance that everything will to be OK.

    But when nothing else works, antipsychotics and anxiolytics can make the unbearable, bearable for everyone. I know that if one of my loved ones or I were demented and needed calming, it would be much more dignified to be given a pill than allowed to scream for hours on end, strike out at people, throw feces around the room, or cower under the bed.

    Just saying.
  13. by   ClearBlueOctoberSky
    I just wanted to clarify, Viva, that I don't routinely ask for this or that medication to be prescribed. Our doctors, PA's and NP's are really good about asking us our opinion on the patients and how they are doing, especially in regard to behaviors.

    In the particular behavior this resident has, when she gets to the point of being unable to redirect, most staff would medicate with the only prn she had, a pain medication. When the PA asked about her and the behaviors, I expressed my concerns. As a result, she decided on the Seroquel.

    On the other hand, just before I was hired, the facility Medical Director stated that he didn't want UA's done on the residents, because all of them would come back positive. What is supposed to happen is that we ask for empirical antibiotics if we suspect the resident has a UA. Have I done that? No. I am not comfortable doing that. I have called for change of condition on one resident in the last two weeks, suspecting a UTI. What did the on-calls do? Order UA's. I'm more comfortable stating my observation and letting them do the ordering, be it an abx or a lab.
    Last edit by ClearBlueOctoberSky on May 2, '12 : Reason: Yes, I made a mistake.
  14. by   CompleteUnknown
    This thread has been on my mind a bit lately. I'm one of the biggest proponents of trying everything possible before considering the possibility of anti-psychotics for people with dementia and extreme behaviours or seemingly intractable agitation or aggression. So often there really is an unmet need there and it can take a huge amount of work and trial and error to tease it out and trial various interventions and then decide whether or not it's working. It's very labour and time intensive but it's my experience that staff who are passionate about dementia care will put that effort in.

    Sometimes none of that works though and the judicious use of medication makes all the difference. It can mean that a resident who previously paced up and down the hallway from dawn to dusk can now sit still long enough to eat a meal. It can mean that a resident who previously believed everyone was going to hurt them and therefore tried to attack anyone who came near them is now able to start forming some relationships with the staff. It can mean that someone who previously screamed for long periods of time is now able to enjoy listening to music or smile at the staff when they say something funny or enjoy sitting in the garden for half an hour. All of those things are a huge improvement in someone's daily life.

    I hate the way the use of these medications is often reported in the media - as though using an anti-pyschotic equates to 'drugging' or sedating a resident. It's been my experience that if a medication is having a sedating effect, it is very quickly ceased, plus or minus a trial of another drug, because otherwise all the problems are still there but they're just masked and you've added more potential issues into the mix (increased falls risk for one).

    The thought of facilities being out there where residents are 'drugged' so they are easier to manage or for staff convenience or because the staff really don't have the skills to do it another way is very upsetting to me. I'm sure they do exist, I'm just very glad I have never worked in one.