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The Use of Antipsychotic Medication In Long Term Care

The Use of Antipsychotic Medication In long Term Care . Gary Epstein-Lubow, MD, and Andrew Rosenzweig, MD, MPH. This brief review frames the historical routine monitoring for side effects; consid- In Massachusetts, the Department of context surrounding Antipsychotic medi- eration of concurrent behavioral treatment; Public Health has convened an Antipsy- cation for patients in nursing homes and and, at least one attempt every six months chotic Task Force to raise awareness about other long -term care settings. The infor- to reduce the dose of Antipsychotic (or docu- Antipsychotic use, including possible educa- mation is meant to describe, concisely, the mentation of a rationale for no dose reduc- tion campaigns and direct interaction with evidence for and against the use of antip- tion).

372 MEDICINE & HEALTH/RHODE ISLAND The Use of Antipsychotic Medication In Long Term Care Gary Epstein-Lubow, MD, and Andrew Rosenzweig, MD, MPH This brief review frames the historical

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Transcription of The Use of Antipsychotic Medication In Long Term Care

1 The Use of Antipsychotic Medication In long Term Care . Gary Epstein-Lubow, MD, and Andrew Rosenzweig, MD, MPH. This brief review frames the historical routine monitoring for side effects; consid- In Massachusetts, the Department of context surrounding Antipsychotic medi- eration of concurrent behavioral treatment; Public Health has convened an Antipsy- cation for patients in nursing homes and and, at least one attempt every six months chotic Task Force to raise awareness about other long -term care settings. The infor- to reduce the dose of Antipsychotic (or docu- Antipsychotic use, including possible educa- mation is meant to describe, concisely, the mentation of a rationale for no dose reduc- tion campaigns and direct interaction with evidence for and against the use of antip- tion).

2 3 nursing home clinicians and administrators. sychotic treatment. Every patient's expe- Soon after OBRA, serial introduction long -term care facilities are likely to welcome rience is distinctive, and each treatment- of second generation antipsychotics started. such activities because the new GDR guide- decision has potential benefits and risks. Early interest in these medications may have lines carry devastating penalties for non-com- The first Antipsychotic Medication led to increased use in nursing The pliance. For example, F-Tags are regulations approved for use in the United States was original interest in the second generation within the state operations manual; they are chlorpromazine.

3 In the 1950s, the use of antipsychotics for use in the elderly may have written by the Centers for Medicare and chlorpromazine allowed for been driven by beliefs regarding reduced Medicaid Services. The F-Tags set guidelines deinstitutionalization of millions of resi- risk for parkinsonism, though most of these for prescribing clinicians, pharmacists, nurs- dents from psychiatric hospitals. In the medications can impair gait and mobility. ing homes and state surveyors. F-Tag 329. ensuing five decades, antipsychotics in the An estimated 25% of nursing home resi- applies to unnecessary psychotropic medi- first generation with chlorpromazine dents in the United States receive at least one cations.

4 The goals of F-Tag 329 are to en- and the second generation, beginning Antipsychotic Medication in a given sure that 1) medications are clinically re- with clozapine, have been in and out of Though much of this use is for off-label in- quired to treat a condition; 2) behavioral or favor for patients in long -term care. dications, the vast majority of Antipsychotic other non- Medication measures are used; 3). treatment is for evidence-based Medication use is in an effort to promote the Antipsychotic Medication AND Nevertheless, the Antipsychotic prescribing highest well-being; 4) actual or potential NURSING HOME REFORM rate in nursing homes5 and the relationship negative outcomes are avoided; and,5) all In 1987, the Omnibus Budget Rec- between the use of antipsychotics and mor- negative outcomes are promptly identified onciliation Act (OBRA) incorporated tality8 remain concerns.

5 And treated. If GDRs are not conducted nursing home reforms. OBRA required according to the rules, the nursing home all nursing home residents to participate REGIONAL ATTENTION TO THE USE must undergo a cumbersome follow-up: a in a national database originally defined OF ANTIPSYCHOTICS IN long level 4 deficiency (immediate jeopardy) re- by the Resident Assessment Instrument, TERM CARE sults if there is failure to monitor or reduce today known as the Minimum Data Set The January 2007 iteration of OBRA the dose of an Antipsychotic in the presence (MDS). The Resident Assessment Instru- recommends Gradual Dose Reduction of a side effect such as worsening gait and ment led to significant improvement in (GDR) of all Antipsychotic medications in mobility due to parkinsonism, or if there is a care plan documentation, greater use of nursing homes.

6 For patients newly admit- failure to do a non-contraindicated GDR in advanced directives and better behavioral ted and receiving an Antipsychotic medica- the context of a significant negative drug ef- treatments for problem such as bowel in- tion, or established patients who begin an fect such as tardive dyskinesia. continence, while reducing problematic Antipsychotic Medication , during the first practices such as physical restraints and in- year of treatment staff must document at SAFETY AND EFFICACY OF. dwelling urinary least two attempts to reduce the medica- Antipsychotic Medication USE. OBRA led to increased monitoring of tion, with at least one month between the FOR ELDERLY INDIVIDUALS.

7 Antipsychotic Medication in nursing homes, attempts. If the Antipsychotic Medication The OBRA legislation occurred 15. but it is not clear whether overall usage de- continues beyond the first year, staff must years before the US Food and Drug Ad- clined2 or remained stable1 during the early attempt one GDR every year unless clini- ministration (FDA) began generalized 1990s. For patients receiving Antipsychotic cally contraindicated. Documentation that warnings regarding elderly patients' use of Medication , the OBRA regulations man- a GDR is clinically contraindicated must Antipsychotic Medication . In the years date that all nursing homes report the fol- include 1) notation that target symptoms following OBRA, use of first generation lowing: an appropriate diagnosis for use of worsened during the most-recent GDR antipsychotics declined; by 2004, prescrip- an Antipsychotic Medication , including spe- attempt in the current facility along with tions for second generation Antipsychotic cific target symptoms along with change 2) the physician's current medical opinion medications in nursing homes outnum- in these symptoms over time.

8 Administra- as to why additional attempts at GDR are bered first generation use 10 to A con- tion of the Medication within a recom- likely to impair the patient's functioning or siderable portion of this Antipsychotic mended 24-hour dosage limit along with worsen the target symptoms. treatment is for behavioral disturbances 372. MEDICINE & HEALTH /RHODE ISLAND. associated with dementia.; there has been label use, Antipsychotic Medication is rea- moderate empirical support for this prac- The January 2007 sonable for psychotic symptoms that occur tice since the early 1990s9 with declining iteration of OBRA in isolation (such as in delusional disorder). interest regarding these medications in the or in the context of other conditions such context of documented adverse events.

9 Recommends as delirium, Parkinson's disease, psychotic As Antipsychotic Medication prescrib- Gradual Dose depression and dementia. Regarding de- ing continued, pharmaceutical companies mentia, in addition to the treatment of psy- invested in clinical trials directed at gain- Reduction (GDR) chotic symptoms such as hallucinations and ing an FDA indication for the use of of all Antipsychotic delusions, Antipsychotic Medication has antipsychotics in the treatment of behav- been used as treatment of other target ioral aspects of dementia. In addition to medications in symptoms such as irritability, aggression and continued evidence for efficacy, informa- nursing homes. disinhibition, as noted above.

10 Tion became available regarding risks for Once a target symptom(s) has been medical adverse events ( , stroke, dia- established, the clinician should ask several betes and death) related to use of second CONSIDERATIONS WHEN STARTING questions before starting a new trial with generation antipsychotics in elderly indi- OR CONTINUING Antipsychotic an Antipsychotic . First, is there a current viduals. The first reports of these concerns Medication TREATMENT IN THE behavioral emergency, or a high likelihood appeared in 2003: a study of risperidone NURSING HOME that intense target symptoms will recur soon showed a non-statistically significant in- Residents in long term care continue and interfere with the patient's or others'.


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