When Are Antipsychotic Medications Necessary?

The issue addressed in this article from the journal, Caring for theAges, carries important information in two areas of interest to anyone serving elders in a retirement setting: 1) the appropriate place of antipsychotic medications for elders who have no diagnosis of a mental disorder and 2) the role of  the family member, the medical power or attorney or the "decision maker" if the resident is not capable of making her own decisions. I will refer to these individuals by one common term, "advocate."

The issue of excessive, inappropriate prescribing of antipsychotic drugs -- in violation of state and federal regulations -- for persons living with dementia in nursing homes has been mainstream news for more than two years now. Luxenberg states clearly and simply what the State and Federal guidelines are in this regard.

The author goes on to state the standard of care when he names all those engaged with the resident in assuring appropriate planning and implementation of treatment for elders iu a nursing home. He says: the "prescriber", the facility (sic) and the family work together and communicate with one another in setting care goals. Gone are the days when "the doctor ordered" suffices to stifle all questions. Gone are the days when family members are viewed as intruders rather than the strongest allies in achieving the best outcomes for the resident physically, mentally and psychosocially.

Acknowledging the role of these advocates, Luxenberg poses four questions that the resident, or the person acting on her behalf should ask the physician when medications are prescribed.  Note: this article applies to antipsychotic medications, but the same questions should be asked and answered to the satisfaction of the resident or advocate for any medication or plan of treatment. If these conditions are not satisfied, "informed consent" for treatment has not been provided. No one of us, resident of a nursing home or not, should ever submit to treatment (medication, diet, surgery, therapy, psychological counseling) without giving our informed consent. Answers to the four questions posed will provide sufficient information to provide informed consent.

For advocates ( including medical power of attorney)  of nursing home residents who cannot speak for themselves, the responsibility the advocates bear in this role is to seek adequate information about any proposed plan of care so that he or she, the advocate, can give informed consent for the suggested course, or can deny that treatment according to the wishes of the resident as put forward in his or her advance directives.

Here is the article in its entirety

When Are Antipsychotic Medications Necessary?

In this first of a two-part series on dementia-related behaviors, Dr. Jay Luxenberg, chief medical officer at On Lok Lifeways in San Francisco, talks about antipsychotic medications (Caring for the Ages. August, 2012.  Vol. 13, No. 8.  Page 18)

Antipsychotic medications are Food and Drug Administration (FDA) approved and used mostly for psychotic illnesses such as schizophrenia and bipo¬lar disorder. While none of these drugs has been formally approved by the FDA to treat dementia-related behaviors, they sometimes can be helpful for this purpose. By talking with your physician, you can learn more about when these drugs can help and when other treatments are better choices.

Antipsychotic medications are Food and Drug Administration (FDA) approved and used mostly for psychotic illnesses such as schizophrenia and bipolar disorder. While none of these drugs has been formally approved by the FDA to treat dementia-related behaviors, they sometimes can be helpful for this purpose. By talking with your physician, you can learn more about when these drugs can help and when other treatments are better choices.

Federal nursing home regulations state that antipsychotics should be used for dementia patients only when the behaviors pose a risk to self or others or symptoms are bad enough to cause great and prolonged distress for the person or seriously hurt his or her ability to function. The regulations also say that these drugs can’t be used for behaviors that don’t put the person or others in danger or at risk of physical injury. These include wandering, crying out or yelling, poor self-care, memory problems, mild anxiety, insomnia, and nervousness.

In general, antipsychotics should only be used after trying other means of managing the problem behavior, only in the lowest dose needed, and only for the shortest possible time. The physician will work with the resident and his or her family, as well as facility caregivers and staff, to figure out what is causing the problem behavior and what nondrug treatments might help. When it is decided that an antipsychotic may be needed, risks, benefits, and treatment options should be discussed with the resident and his or her family to be sure they understand them (except in some emergency situations).

The prescriber and facility staff also will work with the resident and family to set care goals. For example, if the drugs are used to help a man who is delusional and is terrified of people he sees under his bed, the care goal might be to get his delusions under control so that he can relax, sleep well, and have a better quality of life. Facility staff will work with the physician to track the person’s progress and to watch for possible adverse drug reactions or other drug-related problems.

4 Questions to Ask Your Physician:
• What are the pros and cons of this medication in this situation?
• What if I don’t want antipsychotic drugs to be used? What are some drug and nondrug options?
• How long will this medication be used?
• How do we decide treatment/care goals?

4 What You Can Do:
• Make sure the physician and facility staff know as much as possible about your or your family member’s personality, background, likes and dislikes, favorite things, fears and phobias, hobbies, habits, and so on.
• Let the physician know if you or your family member has a history of mental illness.

For More Information:
• Antipsychotics in the Elderly: www.amda. com/consumers/antipsychotics.cfm

What's Wrong with this Picture?

One of my e-subscriptions is to a quarterly newsletter published by the Missouri Department of Health and Human Services. In their current issue, there is an article with the title, “Missouri Nursing Homes Have Happy Clients, MU Researchers Say”. I have been unable to successfully access the URL listed for the entire article, so I can’t critique the research as such. But so many red flags waved brazenly as I read the article. But my first response when I read the title of the article was WHAT?!!
The whole system of traditional long-term care is sick, dysfunctional and “lethal to both resident and staff” (quote is from Steve Shields, culture change leader). Those deficits are reflected in the newsletter article.

1. Who of us wants to be seen or to be considered a “client” if we are living in a nursing home? Do any of us consider those with whom we live “clients”?
2. The survey may well have been valid and reliable for what it tested, but consider these facts:

a. Residents and family members are usually extremely uninformed about the minimum standards of care in a nursing home. So if the resident sits at the table for 45 minutes before a meal is served, does she or the family even know to complain? If the resident is awakened each morning and prepared for bed each evening at the convenience of the staff, rather than at the time she chooses, does she know her rights are being violated? I could go on and on.

b. For the most part, family members can sense the good will among caregivers. Perhaps that is why they and the resident think life can’t be any better in a nursing home. That’s where hopelessness seeps in.

c. I can’t think of a single family member who would say, “I intentionally put my mom in a third-rate nursing home.” Rather, we so often hear, “Mom’s nursing home is the best one in town.”

d. Jude Rabig, Ph.D. did a fascinating study that I regret has not received more recognition. Rabig interviewed residents of a “good”, traditional nursing home about their perception of their quality of life. The residents rated the nursing home highly. This nursing home undertook new construction, providing the same number of beds but with the architectural environment of households. (Household model, public space and private space – person-directed – transformative culture change – global workers – etc.). Six months after these same residents had moved into the household nursing home, Rabig interviewed them again about their quality of life. It is not surprising that they rated their quality of life as very high. It is quite revealing, however, that from their new home (not homelike, folks, HOME!) they looked back on their life in the “good” traditional nursing home as a very negative experience. “Incarceration” was one term used to describe life in a “good” nursing home before culture change.

So for 90% of Missourians to say that things are good, may well reflect that there is no concept that life can be better in a nursing home. (Oh, how I’d love to talk to the 10% dissident population! Perhaps they are the dreamers who won’t accept the overhead call system, the restraint alarms going off constantly, the deadened “activity” schedule, the uncertainty of never knowing who your caregiver will be today.)

3. Roughly 95 – 97% of the nursing homes in the United States are still run by a schedule that reflects task-first, person-wherever-she-fits-in philosophy. This reality, as horrendous as it is, does not exist because caregivers are selfish or unfeeling. It exists because this is the “system” in which they were trained. It is this lethal system that is responsible for the extremely high turnover in nursing homes, especially among direct-care staff.

One of the researchers is quoted in the article: “Nursing home administrators have worked diligently throughout the past decade to improve the quality of care delivered to residents and to make care settings more homelike.” Undoubtedly, that is true. But two points:

1. As long as the work is to improve a system that is dysfunctional and lethal to all who are touched by it, the energy is misplaced. The system must be turned on its head! Everything must be seen through eyes focused on person-directed values. Every practice and policy must be evaluated in light of the analysis of, ‘how do we do this at home?’

2. The touchstone of life in a nursing home is NOT the care. I wish I could remember the source of this statement that I read during the past week: “How is it that even when the care is superb, nobody wants to go to a nursing home?” Of course clinical standards must be met. But it must be provided through the prism of person-first, not task-first.

The touchstone of life in a nursing home is honoring the individual, being there in service. There’s a world of difference between “caring for” and being “in service”. How do most of us respond if someone says, “I’m going to take care of you.” We don’t want to be taken care of. If we need services, we want those services provided in a dependable, compassionate and competent manner. But “taking care of” reflects a lot of things that are the topic of another post on this blog.

To read the entire article, visit: http://munews.missouri.edu/expert-comment