pain management/narc abuse in the geriatric population

[mmc51264, BSN, MSN, RN]

Can anyone point me in the direction of some articles about the issue of narcotics, etc in the older population? I work in a rehab unit in a LTC facility and am amazed at the amount of pts that take a HUGE amount of meds for anxiety, insomnia, and of course, pain. I know that pain is what the pt says it is, but it is no wonder that they fall down so much!

For example, I have a pt right now: came in 2 months ago for a hip fx. Already on 20mg oxycodone, 10 mg ambien and 0.5 xanax prn TID. a family member insisted that pt had been on this for a while. pt compliant in rehab, gets better-enough to go home with said family member. ONE week later, I come in from a day off and pt is back! Fell and broke humerus near shoulder. Is angry b/c the doctor is trying to reduce meds b/c he thinks they are contributing to falls (duh). Pt got percocet 5/325 changed back to 20mg oxy. has ambien and xanax BID. Here's where I have trouble. Pt goes to ortho, gets HIM to change order for xanax to TID!!!!! I work 3-22, so I have let the supervisor know and they are going to contact facility doctor to clarify whose orders to follow. Now pt is non-compliant with PT instructions and has become VERY depressed. Are the elderly WAY too over-medicated, or is it just me?

I am amazed at how many family members seem to push HARD for the most medication. I don't know why they cannot see the correlation between the falls and altered mental status and the medications. Very frustrating.

[CapeCodMermaid, RN]

There is a correlation between falls and over medication. But....most elderly people are UNDER medicated.

You just do the best you can and try to educate the patient and use non-chemical means to decrease pain. You will always have a few people who take as much medication as they can.

[BrandonLPN, LPN]

I think they're overmedicated when it comes to all the freaking vitamins, fish oil, coenzyme, etc. I mean, why don't we just piclke them so they live forever? I *don't* think they are overmedicated when it comes to pain meds. Nor with meds like Ativan, depakote, seroquel, etc. If I ever get to the point where I'm totally demented and playing with my own feces, I hope some kind nurse "snows" me, too.

[morte, LPN, LVN]

But that isnt the sort of patient the OP is talking about. I think we are seeing the women from the fifties who medicated themselves into not caring about the strictures in their lives. ....

I think they're overmedicated when it comes to all the freaking vitamins, fish oil, coenzyme, etc. I mean, why don't we just piclke them so they live forever? I *don't* think they are overmedicated when it comes to pain meds. Nor with meds like Ativan, depakote, seroquel, etc. If I ever get to the point where I'm totally demented and playing with my own feces, I hope some kind nurse "snows" me, too.

[Mandalpn30]

I work in a sub acute rehab center also..and I feel that most of our residents don't receive ENOUGH pain medication. Many family members are scared to allow their parents to receive pain medication for their pain due to beliefs of "overdose" or "addiction". As nurses pain is supposed to be the sixth vital sign and it is what the pt says that it is! So many nurses are undereducated on accurate pain management!! I hope that when I am put in that situation that I have an understanding and well educated nurse!!

[WhiteScrubs]

Agree that undermedication is by far the greater problem than overmedication. There will always be the resident here or there who will take anything and everything a doc will give them. This usually doesn't have anything to do with their age and has been an ongoing issue with them. They have also likely built up more of a tolerance to the meds d/t taking them for extended period of time so doses/frequency won't mean the same to them as they would to opioid naive patients.

Way more common are the residents/patients who don't even want to take tylenol or tramadol for fear of becoming dependent. It is up to the nurse to always assess the pain, believe the patient, educate if needed, and treat with whatever intervention is most appropriate.

[LTCNS, LPN]

I am a big advocate for pain management in the elderly and often see long term care patients with severe arthritis, for example, not even have Tylenol ordered for pain when they are obviously experiencing at least moderate pain. I have no problem with giving an elderly person in pain as much pain medication as he/she needs. As a chronic pain sufferer, I can only hope someone would make sure I get the pain management I need if I ever have to go to a LTC home.

I do have to agree with Brandon about all the vitamins and supplements. I do understand certain meds. are needed to promote wound healing but what is the purpose behind a MVI w/Fe, a MVI, Fish Oil, Zinc, Vit. E, etc...all for one patient? Wouldn't the MVI cover most of what the patient needs?

Another thing I don't understand is what is the rationale behind keeping a patient with advanced alzheimer's on Namenda, Exelon, Razadyne or Aricept? Personally I have seen the s/e of Namenda and Aricept cause more falls than narcotic pain meds. and psych meds.

[NurseCard, ADN]

I hear about controversy re: over use of psych medication in nursing homes... and THAT is contributing to the under-use of meds to help these poor people calm down and get some sleep every now and then.

The controversy, at least here in my state, is that nursing homes overuse psych meds in order to "snow" residents so that facilities require fewer staff to monitor them. Therefore, during the last state survey, social workers were pressuring MD's at my facility to discontinue a lot of the residents' psych meds.

The PROBLEM is that now, we have a lot of residents who holler all night and can't sleep! They aren't necessarily trying to get up, falling, etc... some of them are just lying in bed yelling! I feel terribly SORRY for them, but the MD's won't give them the psych meds that they need so that they can get proper rest.

[morte, LPN, LVN]

I was told, years ago, by a NP that NURSING has to step up and do excellent documentation that the psych meds are NOT snowing these folks, but allowing to maximize the capacity to live. Not exactly in those words, but they will do. This requires in summary/weekly note, whatever, the the use of these meds be addressed. Then the doc has back up when some orifice comes after them with this request.

I hear about controversy re: over use of psych medication in nursing homes... and THAT is contributing to the under-use of meds to help these poor people calm down and get some sleep every now and then.

The controversy, at least here in my state, is that nursing homes overuse psych meds in order to "snow" residents so that facilities require fewer staff to monitor them. Therefore, during the last state survey, social workers were pressuring MD's at my facility to discontinue a lot of the residents' psych meds.

The PROBLEM is that now, we have a lot of residents who holler all night and can't sleep! They aren't necessarily trying to get up, falling, etc... some of them are just lying in bed yelling! I feel terribly SORRY for them, but the MD's won't give them the psych meds that they need so that they can get proper rest.

[CapeCodMermaid, RN]

The problem started when hundreds of thousands of people with dementia were put on antipsychotics for behavior management. Not everyone with dementia needs an antipsychotic. They need a quiet safe environment with room to wander around.There are, however, elderly people who ARE psychotic and benefit greatly from these medications.CMS reacts with a broad brush to try to solve problems that took years to create. So, those people who can truly benefit from some seroquel or risperdal will most likely be denied the drugs and their last years on the planet will be torture.