Using Antipsychotic Drugs Off Label In Nursing Homes To “Manage” Behavior
© January 8, 2008 by Imelda Maurer, cdp

Once again a research study has affirmed the obvious: nursing home residents who are treated with antipsychotic drugs as a result of exhibiting “behavioral problems” do better when they are taken off these drugs. The New York Times in its January 4, 2008 issue described the study, conducted in England, Wales and Australia and its findings. In part the article reads, “The study sharply challenges standard medical practice in mental health clinics and nursing homes in the United States and around the world.”

First, a simple glossary:
Antipsychotic drugs. refer to those medications that were originally developed to treat psychosis. A diagnosis of psychosis includes conditions such as schizophrenia, bipolar disorder, mania and delusional disorder. Medications to treat these psychoses include Haldol; Risperdal; Abilify; Clozaril; Zyprexa; Symbyax; Seroquel; Geodon

Behavioral Problems. Terms like this or adjectives such as “combative,” “aggressive”, “uncooperative”, “resists care” are seen in nurses’ notes of typical nursing homes. Such descriptions are subjective, reflecting a bias on the part of the one charting. Good care givers, professional health care providers, know to look for the meaning in any behavior. All behavior has meaning. It is the task of the caregiver to find that meaning and address the issue the resident is attempting to communicate. Mary Lucero, a nationally known expert on dementia and dementia care notes, “Resistance to care is a message of distress. It is evidence of frustration and anxiety pushed to the last resort.” A person with dementia cannot act with the reasoned intent to cause harm. Aggressive or combative behavior is that person’s means to protect, to remove an obstacle or to stop an action seen as harmful to him/her.

Off label use of a drug. When a drug has been developed and approved by the FDA for a certain disease or disorder, but a health care provider prescribes it for a condition other than that covered by the drug’s FDA approval, the practice is called off label use. Physicians attending nursing home residents in far too many cases prescribe any of these antipsychotic drugs as all-purpose tranquilizers

Typical nursing home. Whenever I use that term in my blog, it describes any nursing home that is institutional in culture, where staff convenience determines a resident’s daily routine, where regulations may be duly adhered to but in a mechanistic, impersonal way, and where activities are generic and repetitive. As a consequence, morale is low among staff and residents. Turnover, especially among front line staff, the direct care givers, is very high. Unfortunately, the residents can only escape through death.

Back to the study! An editorial in the journal Lancet, in which the full study was described, advises against using these antipsychotic drugs to address behavioral issues at all. “We know that behavioral treatments can work very well with many patients.” Johnny Matson, professor of psychology at LSU in Baton Rouge writes.

Hooray for the authors of the study who conclude that the routine prescription of the drugs for aggression “should no longer be regarded as a satisfactory form of care.” Physicians in typical nursing homes may practice their craft primarily by prescription. It occurs, for example, when the director of nurses tells the attending physician that Resident X has been shouting out during the night, or is “combative” and “uncooperative” with care. An all-purpose tranquilizer --- read antipsychotic drug being used off label--- is prescribed. The resident’s behavior changes. His/her body may become rigid; the resident may become untalkative, unable to feed him/herself any longer, is no longer oriented to those around him/her, shows signs of depression, and may be one of the “slumpers” typically found around the nurses’ station.

I am reminded of Steve Shield’s words about culture change here. Steve, CEO of Meadowlark Hills, Manhattan, Kansas says, as I wrote in an earlier blog, that when he and his staff were exposed to the philosophy of culture change they all saw it as holy. “It is holy,” Steve explained to me, “because it liberates the elderly and returns hope to them.”

True culture change – the kind that results in transformative environments for residents and for staff – will reflect medical personnel and licensed staff who look for the meaning in resident behaviors and who try, in as many ways as it takes, to address the issue the resident is trying to communicate.