Nursing Homes and Neuroleptic Use
Whats are Neuroleptic, Division of Interventions,Use of Chemical Restrains ,Requirement for Treatment and Diagnose,Medical and Nursing Research,Practice Guidelines,Research Outcomes.
Whats are Neuroleptic
Psychiatric illnesses, particularly dementia, are common diagnoses
in nursing home residents. Often, they are the main reason for nursing home
placement (Stoudemire & Smith, 1996).
It has been reported that dementia,
mostly Alzheimer’s disease (AD), may be present in over 70% of residents in
nursing homes and 24% of those residents may exhibit psychotic features
(Stoudemire & Smith).
Primary care providers, including advance practice
nurses (APNs), are treating a growing population of older adults with dementia
and many cases will be complicated with behavioral problems such as agitation.
In addition to the complexities of the illness the clinician must frequently
practice in an environment of fiscal constraints, staff shortages, and concerns
about meeting federal standards.
Division of Interventions
Treatment can be divided into pharmacological and
nonpharmacological interventions. Psychotropic medications are the main stay of
pharmacological treatment. Lasser and Sunderland (1998) did a retrospective
chart review involving 298 residents in seven nursing homes.
They found that
70% of the subjects took at least one psychotropic, 32% were taking
benzodiazepines, and 42% were on neuroleptics. Within the AD group 54% were
taking neuroleptics, 27% were taking benzodiazepines, and 13% took both.
Another study involving a secondary analysis of a clinical trial with 446
subjects in three nursing homes yielded lower but still significant results.
Between 14% and 19% of the subjects were taking neuroleptics in the three
groups studied (Siegler et al., 1997). Although neuroleptics are commonly used
to treat disruptive or psychotic features of dementia, the potential for
anticholinergic and extrapyramidal side effects requires careful weighing of
risks and benefits.
Use of Chemical Restrains
“Chemical restraints” is a term used to describe the excessive or
inappropriate use of psychotropic medications, particularly sedatives and
neuroleptics, in residents who do not have a psychiatric diagnosis or
behavioral symptoms that justify their use (Siegler et al., 1997).
Another
description is a drug that is used to limit the physical movement of the
patient (Fletcher, 1996). In an effort to protect the residents of nursing
homes from over reliance on psychotropics and their adverse reactions, the
federal government passed legislation restricting their use.
This legislation
was part of the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987). In 1990,
the Health Care Financing Administration (HCFA) issued guidelines based on OBRA
1987 regulations (Gurvich & Cunningham, 2000).
Requirement for Treatment and Diagnose
The first step in the guidelines requires clinicians to rule out
medical or environmental causes of a problem behavior. This is essential in
avoiding the misdiagnosis of delirium, which would dictate a different course
of treatment possibly targeting an underlying medical cause.
To justify the use
of a neuroleptic the target behavior must be diagnosed and documented. The
resident with delirium must be reevaluated at set intervals with a goal of
reducing or eliminating the medication. Ideally the smallest effective dose
will be used for the shortest period necessary (Gurvich & Cunningham,
2000).
Behaviors that may be inconvenient to the staff but not dangerous to the
resident or others are not considered appropriate for neuroleptic use.
Residents diagnosed as having psychosis or certain medical conditions are not
included in these restrictions. Short acting benzodiazepines may also be used
to treat dementia with agitation. They also have restrictions that seek to
limit adverse reactions and long-term use.
Research done by Siegler and colleagues (1997) indicated a decrease
in use of neuroleptics after the OBRA 87 legislation.
In 1998, a panel
consisting of the American Psychiatric Association and the American Association
for Geriatric Psychiatry reported that there had been decreased use of
psychotropic medications in nursing facilities in response to OBRA ‘87 (Colenda,
Streim, Greene, Meyers, Beckwith, & Rabins, 1999).
The panel also reported
that there might be uncertain or negative outcomes related to OBRA 87. The
focus on eliminating “chemical restraints” from nursing homes may have led to a
tense atmosphere between clinicians who feel they are making sound clinical
decisions and state surveyors (Colenda et al.).
It is uncertain whether these
regulations have affected quality of life for the nursing home residents
(Colenda et al.).
Medical and Nursing Research
Research involving neuroleptics for treatment of agitation shows
modest improvement at best; however, consensus statements recommend their use
(Bartels et al., 2002). Overall, evidence that psychoactive medications are
effective was inconclusive.
The adverse reactions such as sedation and
anticholinergic effects are known to be a risk for this frail population. The
atypical neuroleptics may offer a lower side-effect profile, but still carry
risks such as extrapyramidal side effects.
Herrmann (2001) reported that there
is emerging evidence that antidepressants and anticonvulsants are effective in
reducing non- cognitive symptoms of dementia. These classes of medications may
be better choices for some patients depending on comorbidities present.
According
to Bartels and colleagues (2002), research suggested that nonpharmacological
interventions have been effective in reducing behavioral problems, and
evidence- based practice recommends their use. They should be instituted before
psychotropic medications, when possible, and continued after medications are
prescribed.
Some of the interventions for behavioral symptoms include light
exercise, music, and environmental modifications (Bartels et al.). The National
Guideline Clearinghouse has similar evidence based practice guidelines for AD,
including specific interventions to reduce wandering and to treat problem
behaviors.
Practice Guidelines
The guidelines issued by HCFA seem to concur with evidence-based
practice guidelines. The clinician is expected to assess the cause of a problem
behavior and weigh the risks and benefits of prescribing a neuroleptic to a
person with dementia. Nonpharmacologic interventions should be considered first
line and may be used in conjunction with psychotropics.
Research Outcomes
One randomized controlled trial comparing psychotropics, behavior
management techniques, and a placebo found no significant differences in
efficacy for treatment of agitation (Teri et al., 2000). Future research should
be directed at comparing the effectiveness of combining pharmacological and
non- pharmacological interventions.
Randomized control studies comparing
anticonvulsants with neuroleptics in subjects with dementia may also be of
benefit. As the population continues to age, APNs will be providing care for a
growing number of patients with dementia. Knowledge of the treatment options
and their effectiveness is essential and will apply to all practice settings
that encounter older adults.