Ask the Medical Director: The appropriate use of antipsychotic medications in LTC

Within the nursing home population, antipsychotic medications are typically prescribed for the treatment of psychotic disorders, such as schizophrenia; psychotic symptoms, including delusions and hallucinations associated with other conditions, such as Alzheimer’s disease or delirium; and behavioral and psychological symptoms related to dementia (BPSD), when these symptoms present a risk of danger to the resident or others.

Last spring (May 2011), the Office of the Inspector General (OIG) published a report titled, Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents. The report placed emphasis on the off-label use of antipsychotics in nursing homes. The report went on to state that these medications carry significant risks and have not been very effective in patients suffering from dementia. Since then, the role of antipsychotics in the management of individuals with dementia in LTC facilities has continued to generate interest and remain under scrutiny.

Here is what medical directors, practicing in long-term care had to say about the appropriate prescribing of antipsychotic medications:

“Antipsychotic medications have to be used carefully when used for FDA indicated conditions such as schizophrenia and bipolar disorder, and much more carefully when used off-label as in dementia-related behaviors. In these cases conservative measures must fail first, and the patient must be regularly demonstrated to be enabled, and not disabled by the antipsychotic medication.” – Charles Crecelius, MD, PhD, FACP, CMD

"There is no doubt that antipsychotic medications are dangerous, and nobody thinks they are the answer to every problem. We all support the initiative to eliminate inappropriate use of these drugs.  But there are some situations where they are necessary, and where they are very helpful. The most important fact to remember is that when other measures have failed, we use these medications to treat a person's distress—not to sedate them or to make nurses' lives easier." – Karl E. Steinberg, MD, CMD

“I try to reserve the use of antipsychotic medications for true psychiatric disorders among frail older adults. However, there are occasional situations where antipsychotic medications can be very effective. This is especially true when treating serious behavioral problems among cognitively impaired residents that are unresponsive to non-medicinal interventions.”
–J. Kenneth Brubaker, MD. CMD

“We have a great opportunity to educate physicians, families and staff about the care of elders who are not always able to express their needs clearly. This may mean being creative and thinking ‘outside of the box.’ We know from other disease processes and attempts at symptom management, a pill is not always the immediate answer. AMDA is pleased to provide educational materials on the assessment of ‘behaviors’ in elders with dementia and treatment considerations, including when appropriate, the use of antipsychotics. (www.nhqualitycampaign.org). – Karyn P. Leible, RN, MD, CMD

AMDA-Dedicated to Long Term Care Medicine has established best practices for medical staff and has developed Clinical Practice Guidelines and tool kitson dementia, delirium and acute problematic behavior that are specific to long term care. Additionally, AMDA has recently published the Multidisciplinary Medication Management Manual, which provides practitioners in long-term care with information and tools to help them improve patient care, enhance medication management and reduce medication errors. These and other resources can be found at www.amda.com/resources.

Krista Das is the Director of Marketing & Communications at AMDA–Dedicated to Long Term Care Medicine. She can be reached at kdas@amda.com.  AMDA is the national professional association of medical directors, attending physicians and other professionals practicing in long-term care and is committed to the continuous improvement of patient care. AMDA provides education, advocacy, information  and professional development to enable its members to deliver quality long-term care.