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