Neuroleptic Use in Nursing Homes Introduction to Neuroleptics
Neuroleptics, also known as antipsychotic medications, are primarily used to treat psychiatric illnesses, including dementia, in nursing home residents. Dementia, particularly Alzheimer’s disease (AD), is a common diagnosis among nursing home populations, often serving as the main reason for placement (Stoudemire & Smith, 1996). Studies suggest that dementia, especially AD, may be present in over 70% of nursing home residents, with about 24% of these individuals exhibiting psychotic symptoms (Stoudemire & Smith).
The use of neuroleptics in nursing homes often addresses behavioral complications of dementia, such as agitation, aggression, and psychosis. However, the use of these medications is complicated by the need to balance the benefits against the risks, especially given the potential side effects and the delicate condition of elderly patients. Primary care providers, including advanced practice nurses (APNs), frequently manage these patients in environments constrained by fiscal limitations, staff shortages, and federal regulatory standards.
Division of Interventions
Treatment of psychiatric symptoms in nursing home residents, particularly those with dementia, can be divided into two primary categories: pharmacological and nonpharmacological interventions.
- Pharmacological Interventions: These primarily involve the use of psychotropic medications. A retrospective chart review by Lasser and Sunderland (1998) involving 298 residents across seven nursing homes found that 70% of the subjects were on at least one psychotropic medication, with 42% on neuroleptics and 32% taking benzodiazepines. Among residents with AD, 54% were using neuroleptics, 27% were on benzodiazepines, and 13% were on both.
Another study that performed a secondary analysis of a clinical trial involving 446 subjects across three nursing homes found that between 14% and 19% of the residents were on neuroleptics (Siegler et al., 1997). While neuroleptics are frequently used to manage disruptive or psychotic features of dementia, their use requires careful consideration due to the risk of anticholinergic and extrapyramidal side effects, which necessitates a thoughtful weighing of risks and benefits.
- Nonpharmacological Interventions: These methods focus on modifying behavior through environmental changes, structured activities, and therapeutic techniques without relying on medication. Nonpharmacological approaches are recommended as first-line treatments before considering psychotropics and should continue alongside medication use if necessary.
Use of Chemical Restraints
“Chemical restraints” refer to the excessive or inappropriate use of psychotropic medications, including sedatives and neuroleptics, in residents without psychiatric diagnoses or behavioral symptoms warranting their use (Siegler et al., 1997). This practice aims to limit a patient’s physical movement or manage behavior that might be inconvenient for the staff but does not pose a danger to the resident or others (Fletcher, 1996).
To address concerns about the overuse of psychotropics and their adverse effects, the U.S. federal government introduced legislation under the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987). The Health Care Financing Administration (HCFA) issued guidelines based on these regulations in 1990, establishing restrictions on the use of psychotropic medications in nursing homes (Gurvich & Cunningham, 2000).
Requirements for Treatment and Diagnosis
The OBRA 1987 guidelines stipulate that clinicians must first rule out any medical or environmental causes of problem behavior before diagnosing and treating a resident with psychotropic medications. This approach helps prevent misdiagnosis, such as confusing delirium with dementia, which would necessitate a different treatment plan targeting an underlying medical cause.
To justify using neuroleptics, the target behavior must be clearly diagnosed and documented. Residents diagnosed with delirium should be reevaluated at regular intervals, with the goal of reducing or eliminating the medication whenever possible. The guidelines emphasize using the smallest effective dose for the shortest duration necessary (Gurvich & Cunningham, 2000).
Behaviors that are merely inconvenient to staff but not dangerous to the resident or others do not justify neuroleptic use. However, residents diagnosed with psychosis or certain medical conditions are not subject to these restrictions. Additionally, short-acting benzodiazepines may be used to treat dementia-related agitation, but their use is also regulated to minimize adverse effects and long-term dependency.
Research by Siegler and colleagues (1997) indicated a decrease in neuroleptic use following the OBRA 1987 legislation. Further, a panel comprising the American Psychiatric Association and the American Association for Geriatric Psychiatry reported reduced psychotropic medication use in nursing facilities due to OBRA 1987 (Colenda et al., 1999). However, this panel also noted uncertain or negative outcomes related to the legislation, such as tensions between clinicians and state surveyors. It remains unclear whether these regulations have significantly affected the quality of life for nursing home residents (Colenda et al.).
Medical and Nursing Research
Research on neuroleptic use for treating agitation in dementia patients shows only modest improvement at best, but consensus statements continue to recommend their use (Bartels et al., 2002). Overall, evidence supporting the efficacy of psychoactive medications is inconclusive, and the potential for adverse effects like sedation and anticholinergic reactions poses significant risks for this frail population.
There is growing evidence that atypical neuroleptics may offer a lower side-effect profile compared to traditional neuroleptics. However, these medications still carry risks, including extrapyramidal side effects. Some studies, like those by Herrmann (2001), suggest that antidepressants and anticonvulsants can effectively reduce non-cognitive symptoms of dementia and might be better choices for certain patients, depending on their comorbidities.
Additionally, research suggests that nonpharmacological interventions can effectively reduce behavioral problems and should be prioritized over psychotropic medications whenever possible. Such interventions include light exercise, music therapy, and environmental modifications (Bartels et al., 2002). The National Guideline Clearinghouse also provides evidence-based practice guidelines for managing Alzheimer’s disease, including specific strategies to reduce wandering and address problem behaviors.
Practice Guidelines
The guidelines issued by the HCFA align with evidence-based practice recommendations. They advise clinicians to assess the cause of any problematic behavior and carefully weigh the risks and benefits of prescribing neuroleptics for individuals with dementia. Nonpharmacological interventions should be considered the first-line approach and may be used in conjunction with psychotropics if necessary.
Research Outcomes
A randomized controlled trial by Teri et al. (2000) compared psychotropic medications, behavioral management techniques, and a placebo for treating agitation in dementia patients. The study found no significant differences in efficacy among these methods. This finding suggests that future research should focus on comparing the effectiveness of combining pharmacological and nonpharmacological interventions.
Randomized controlled trials comparing anticonvulsants with neuroleptics in dementia patients could also provide valuable insights. As the population continues to age, APNs and other healthcare providers will increasingly encounter dementia patients, necessitating a deep understanding of the available treatment options and their efficacy across various practice settings.
Conclusion
The use of neuroleptics in nursing homes, particularly for managing dementia-related symptoms, involves a complex interplay of pharmacological and nonpharmacological interventions. While neuroleptics may provide some benefits in controlling agitation and psychotic symptoms, their use must be carefully considered due to potential side effects and regulatory restrictions. Nonpharmacological approaches are recommended as the first line of treatment, with neuroleptics reserved for more severe cases where benefits outweigh risks.
Research suggests that combining different types of interventions may offer the best outcomes, and further studies are needed to explore these combinations. Understanding these dynamics is essential for nursing professionals and caregivers, especially as the elderly population continues to grow and presents with increasingly complex health challenges.