Neuroleptic Use in Nursing Homes

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.