Rational Use of Antipsychotics in Long Term/ Sub-Acute Care or Even Home Care Depends on Your Perspective

 -----By Anna Shepherd, Health & Personal Finance Professional, Facility Asst Administrator

In a Wall Street Journal Blog published this past week, the feds are admonished for not doing more to help the elderly who are receiving too many antipsychotic drugs, whether they are in the nursing home or not.  See WSJ Blog

This is such a complex topic, but I believe it is telling that observers (whether they are GAO or HHS or others) believe that they can summarize and opine on a subject that requires 100% individualization.  Each case is unique and must be considered in its complete context.  And certainly, these drugs must be used at the lowest possible doses, especially in the elderly.

That said, I have a few issues with this story. It is accusatory to imply that having 61% of those diagnosed with dementia—and dangerous behaviors--on an antipsychotic is a bad thing. Dementia is a neurologic disorder and can trigger irrational and violent behavior on the level of schizophrenia. It is also a broad umbrella term that encapsulates many separate disorders—Lewy body, Alzheimer’s, Parkinson’s etc. One need go no further than an internet search to find hundreds of stories of disturbing violence in nursing homes among residents. The company I work for even experienced one such gruesome event this last fall. This is not to say that the nursing homes didn’t do their best to treat—or even that they did anything wrong. And it isn’t to say that lurking in every person with dementia is a homicidal maniac. But it does need to be said that nursing homes need to be allowed to treat the person as well as to keep the peace (remember we live in a highly litigious society).  Until the medical community knows more about the disease process of dementia and related disorders and can create new drugs to treat them, we’re left with finding the best fit from what is available.

I work in a sub-acute nursing facility and we frequently receive patients from the hospital who are medically stable (sometimes barely so) but who are undergoing such mental stress due to illness and rapid, drastic, changes in their health and overall quality of life that by the time they get to the nursing home setting they, frankly, may be on the verge of a psychotic episode—dementia or no. Another subset of these people may even have prescribed pysch meds (particularly something like Ambien) at home but are not continued on them while in the hospital. They may show up at the hospital with little ability to give a medical history or primary physician—if they have one to begin with. Thus, while they are in a very weak condition during their hospital stay, there may not be a need for these meds, but by the time they are in the nursing home and on the mend with therapy, they begin to lapse into whatever underlying mental condition they were once being medicated for.  The nursing home clinician must rationally deal with this scenario, and doing so may show up as a negative statistic for the nursing home, weighing against it as a negative metric for elderly people taking these tranquilizers.

Furthermore, upon admission of a new patient, our nursing staff often have no health history other than what the hospital discharge notes list as diagnoses; if included in this list is something like a ‘mood disorder’ or history of bipolar, then the first reaction by staff is to document any and every behavior and request orders for mood stabilizing drugs to bridge the individual’s transition into their rehab stay or long term care. I’m not saying this is right, but having one nurse in charge of 20 people means that a facility can only handle so many behavioral disruptions!  In this sense, staff education is most certainly warranted.

However, it must be said that in my building, most of the people who are on antipsychotics shortly after admission are tapered off of them at some point during their stay. This is how our medical director prefers to treat—and at the risk of sounding like a broken record--I think this is ultimately just another example of how our new health care system removes provider discretion in favor of uniformity and agreeable performance metrics. 

The needs of the individual patient and the other residents who are forced to live around them are often lost in translation!