Caring for older people with dementia who are living in nursing homes can sometimes be a challenging endeavor. One particular area of concern is the use of antipsychotic medications in treating older adults with Alzheimer’s and other forms of dementia when behaviors associated with those conditions become problematic.
Antipsychotics have a lot of uses for psychiatric and mental health disorders, and these powerful drugs can make an enormous difference in the quality of life of individuals who need them. However, they’re sometimes misused, and that’s a major area of concern, says Dr. Katherine Brownlowe, a neuropsychiatrist and assistant professor of neurology and psychiatry with the Ohio State University Wexner Medical Center.
Recent reports suggesting that these powerful drugs may be overused or abused in some nursing homes has many people concerned, but preserving the accessibility of these medications for those who truly need them is also a consideration. This all adds up to making the use of antipsychotics in nursing homes a “complicated, nuanced issue,” Brownlowe says
Why Antipsychotics Are Sometimes Used
For many folks, as they age they develop dementia, whether that’s Alzheimer’s disease or another type of dementia. No matter which type of dementia your loved one might be dealing with, memory is affected, but that’s not the only issue these neurodegenerative conditions can create.
“I think we commonly think of older folks as having memory impairment, that’s often their primary symptom. But we also see changes in people’s ability to control their impulses and their ability to make good decisions as they get older,” Brownlowe says.
All of these symptoms, along with memory loss, are progressive and get worse over time. This can lead to psychiatric symptoms. “As people’s dementia progresses, they can develop paranoia and become very suspicious,” Brownlowe explains. In some cases, people with advanced dementia may develop symptoms similar to those seen in schizophrenia.
Yet, “there’s no FDA-approved medication to treat these (psychiatric) symptoms,” says Elizabeth Galik, professor of organizational systems and adult health at the University of Maryland School of Nursing in Baltimore.
These symptoms cause distress for the patient, as well as the caregivers, and can greatly decrease quality of life. Thus, some doctors have resorted to prescribing antipsychotic medications to treat these symptoms to reduce these problematic behaviors, such as combativeness when trying to assist a patient, delusions or hallucinations and paranoia.
In some cases, antipsychotics might help. “There’s some evidence that antipsychotics can be effective in treating physically aggressive behaviors that put the individual and others at risk and/or psychotic symptoms that negatively impacts the individual’s safety and/or quality of life and cannot be adequately managed using other interventions,” Galik says.
But the first line of defense should be behavioral intervention and working with the patient.
For example, “if a patient has a persistent delusion (a fixed, false belief) that food and medications are poisoned, this puts the patient at risk for weight loss and increased instability of medical conditions. Non-pharmacological interventions such as providing favorite foods, opening containers and preparing medications so the patient can observe that this is being done safely, and providing reassurance from trusted family, staff and friends should be attempted first.”
Other interventions could include:
— Emotional reassurance.
— Active engagement in meaningful activity.
— Personal interactions that support an individual’s underlying capability.
But if these non-pharmacological interventions are ineffective, and the patient’s health and safety are at serious risk due to the paranoid delusions, “it may be appropriate to consider the use of an antipsychotic,” Galik says.
However, their use may not be so much about alleviating the patient’s suffering as the caregivers. “It’s inappropriate to use an antipsychotic if the behavioral symptom can be managed with non-pharmacological approaches, such as sensory stimulation,” Galik says. Antipsychotics shouldn’t be used to treat insomnia, or “if the potential risks, such as sedation, stiffness, falls, cardiovascular effects and a small increased risk of death from stroke and or pneumonia outweigh the potential benefits of the medication.”
Misuse of Antipsychotics in Dementia Patients
Recognizing that there has been an issue with the use of these medications in nursing homes across the U.S., in 2012, the Centers for Medicare & Medicaid Services established the National Partnership to Improve Dementia Care in Nursing Homes, a public-private coalition to improve the quality of care for individuals with dementia living in nursing homes.
“Unnecessary antipsychotic drug use is a significant challenge in ensuring appropriate dementia care,” the CMS stated, pointing to data that showed that in 2010, more than 17% of nursing home patients had received daily doses of these medications that exceeded recommended levels.
The mission of the partnership is to deliver person-centered, comprehensive and interdisciplinary health care that focuses on protecting residents form being prescribed antipsychotic medications “unless there is a valid clinical indication and a systematic process to evaluate each individual’s need,” the center reports. In 2014, the coalition set goals of reducing antipsychotic use in nursing homes by 25% by the end of 2015 and by 30% by the end of 2016.
Improved training, increased transparency and providing alternatives to these medications are all approaches the CMS has established to improve the situation. And there has been a drop in the use of these medications across the industry. Prevalence of antipsychotic use for long-stay nursing home residents has fallen by 40% between 2011 and 2019, CMS reports.
While there are certainly some circumstances where the use of antipsychotic medications is absolutely called for — and the CMS acknowledges that the use of these medications shouldn’t decrease to zero — there’s still an effort underway to avoid overmedicating seniors with these powerful drugs when they aren’t absolutely necessary.
“In my belief, there’s no medication that’s right or wrong. Medication is a tool,” Brownlowe adds. And how and when it’s deployed determines whether it’s being used well or not. “Medications need to be used responsibly.”
In terms of helping an elderly patient with dementia lessen symptoms, Brownlowe says there’s “a lot of articles about the superiority of behavioral techniques rather than using antipsychotics.” But these techniques take time, effort and the right training on the part of the caregiver who’s working directly with the patient.
“When you have a nursing home that’s under-resourced, you don’t have enough people to take the time to provide personal care for someone who’s easily agitated and takes twice as long to work with that person to get them showered and cleaned up.” These seemingly simple tasks can be made infinitely more difficult if the patient is confused, agitated or uncooperative, and thus the medical team may receive a request from the caregiving team for a medication that quells these problematic behaviors. “It’s not being done maliciously” in most cases, Brownlowe says.
The question for health care providers working with older adults with dementia who are exhibiting paranoia and other difficult behaviors is how best to ease their suffering without over-medicating them and using these drugs as a form of chemical restraint.
“It’s a tough balance to strike between providing necessary care to people who are ill without putting them at risk and without putting the care providers at risk,” Brownlowe says. If the resident is a danger to themselves or the caregiver, sometimes an antipsychotic is the right choice. Other times it’s not, and it can be difficult to know which instance is which.
“I want to be really clear that this is really variable from place to place, and I do believe that most nursing homes work really hard to provide the very best care that they can for their residents given the resources they have,” Brownlowe says.
What to Ask for Your Loved One
If your loved one has dementia and is currently being cared for in a nursing home, ask about medications and how they’re being used. Brownlowe recommends asking:
Why is this medication being used?
It’s important to note that if your elderly loved one has always had a psychiatric disorder, the use of antipsychotics could well be entirely necessary. As such, the conversation with the medical team will be quite different.
“That’s not the category of patients in nursing homes that we’re talking about here. Here, we’re talking about patients who’ve received a new prescription later in life” related to their dementia diagnosis, Brownlowe says.
What is the expectation of this medication?
What is it supposed to help? What are the benefits that we can expect from this medication?
What are the side effects?
“It’s important to ask questions when a new medication is prescribed for a resident,” Galik says, “and families should feel comfortable asking about the indication of use of the medication, as well as potential side effects. Both families and staff can help to monitor for potential side effects and report any concerns to the prescriber.”
What alternatives are there?
If this isn’t working or the side effects outweigh the benefits, can we use a different medication?
Who is making decisions about medications?
“I think it’s really important for families and patients to understand who’s making these medication decisions,” Brownlowe says, because in some systems, it’s not always clear who’s making those prescribing decision and why.
What else could it be?
Is there another condition that could be causing these issues aside from dementia? Brownlowe gives the example of a urinary tract infection.
“Older folks don’t always have the same symptoms” as younger adults when they get a urinary tract infection. “Some of the early symptoms in older adults might be changes in mental status, confusion, agitation and aggression.” So, if your loved one has exhibited a change in behavior, ask what else it could be — and for a comprehensive medical assessment, including blood work or a urine test — before jumping to an antipsychotic medication.
Is there an environmental trigger?
“Medical causes of behavioral symptoms, such as pain, constipation and infection should also be explored as potential causes, as they may present as agitated behaviors,” Galik says. Brownlowe notes that for some older adults with dementia, communicating the underlying issue that could be causing aggressive or difficult behavior can be very difficult, but the cause could be environmental rather than physical.
For example, “if the family member can identify, ‘mom’s always hated things that are red,’ and the medical team says, ‘we just changed to new red scrubs. Maybe we can make an adjustment,'” Brownlowe says. That’s a simple example, but the idea is to “take a look holistically at what’s happening before we jump into the antipsychotic medication bin.”
Galik adds that families can open this dialogue “during the care plan meeting. Families can share information with the nursing home staff about resident likes and dislikes, routines and meaningful activities that can be used to help prevent and manage behavioral symptoms of distress.”
Brownlowe encourages folks to “have as open a dialogue with the people who are caring for loved ones in facilities, and remembering that, for the most part, everybody is doing their very best to provide good care. Everybody wants the best for the patient.”
Lastly, Brownlowe adds that, “antipsychotics do have a place, but their use needs to be thoughtful and judicious.”
But these days, “non-pharmacologic interventions should be used as first-line treatment in the management of behavioral symptoms in the context of dementia,” Galik says
Galik encourages family members to get involved in the care of a loved one in a nursing home. “Managing behavioral symptoms associated with dementia is more likely to be successful when families and nursing home staff work together for the benefit of the patient.”
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