Overuse of antipsychotics in nursing homes

JZ_RN · Apr 30, 2012

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.

hotflashion, BSN, RN · Apr 30, 2012

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?

ClearBlueOctoberSky · Apr 30, 2012

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.

brandy1017, ASN, RN · Apr 30, 2012

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!

WhiteScrubs · Apr 30, 2012

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...

CapeCodMermaid, RN · Apr 30, 2012

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.

JZ_RN · Apr 30, 2012

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.

CompleteUnknown · May 1, 2012

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.

JZ_RN · May 2, 2012

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)

Long Term Care Columnist / Guide · May 2, 2012

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. :)

ClearBlueOctoberSky · May 2, 2012

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.