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Antipsychotic Medications in Nursing Homes

CME credit available from Massachusetts Medical Society through May 2017.

Published Materials

Preventing over use of antipsychotic drugs in nursing home care: Safer alternatives

The primary goal of this educational program is to help nursing home clinicians better manage the behavioral and psychological symptoms of dementia and reduce the reliance on antipsychotic medications. The program synthesizes the evidence on the risk-benefit relationship of antipsychotic medication, most notably the elevated risk of mortality, when used in this population. It encourages nursing home staff to firstly rule out any reversible clinical, psychological and environmental triggers of behavioral problems and presents advice on non–pharmacological approaches to be tried. Behavioral and psychological symptoms of dementia (BPSD) can manifest as yelling, physical aggression, apathy, hostility, sexual disinhibition, defiance, wandering, psychotic symptoms, emotional lability and paranoid behaviors.1-2 BPSD are common, with up to 90% of patients with dementia experiencing such symptoms at some stage during their illness.2-6

Antipsychotic drug risks and side effects in patients with dementia

While APMs are FDA-approved for the treatment of major psychiatric disorders, such as schizophrenia and bipolar disorder, they are NOT approved to treat BPSD. In this population, the risks often outweigh the benefits.

In a meta-analysis of 15 randomized trials, patients given an atypical antipsychotic drug had higher rates of death than patients given placebo7

Strategies for managing behavioral and psychological symptoms of dementia (BPSD)

Identifying the difference between acute and non-acute BPSD can assist prescribers in managing patients with BPSD appropriately, and determine if APMs are necessary.

An algorithm for managing behavioral problems in older patients with dementia6-8

When patients present with BPSD, the first course of action should be to perform a comprehensive assessment of the symptom(s), considering the ‘ABCs’:

  • Antecedents: What are the triggers for the behavior(s)?
  • Behavior: Which behavior, or behaviors, are appropriate targets for intervention?
  • Consequences: What are the consequences of the behavior(s) for the patient and others?

Many of these ‘triggers’, when removed, alleviated or modified, reduce symptoms in patients. Always be sure to address a patient’s unmet needs, especially pain or discomfort.

Clinical, psychological, and environmental causes of BPSD are often reversible

Non-pharmacologic management strategies

Solid evidence exists that staff training can improve behavioral symptoms and reduce the need for antipsychotic medication in patients with dementia. Programs, such as the Massachusetts Senior Care Foundation OASIS program (www.maseniorcarefoundation.org/OASIS.aspx), target staff as a way to reduce off-label use of APMs.

Effective environmental modification 8


Information current at time of publication, May 2014.

The content of this website is educational in nature and includes general recommendations only; specific clinical decisions should only be made by a treating physician based on the individual patient’s clinical condition.


References
  1. Kales, H.C., et al., Risk of mortality among individual antipsychotics in patients with dementia. Am J Psychiatry, 2012. 169(1): p. 71-9.
  2. Huybrechts, K.F., et al., Risk of death and hospital admission for major medical events after initiation of psychotropic medications in older adults admitted to nursing homes. CMAJ, 2011. 183(7): p. E411-9.
  3. Lonergan, E., J. Luxenberg, and J. Colford, Haloperidol for agitation in dementia. Cochrane Database Syst Rev, 2002(2): p. CD002852.
  4. Carson, S., M.S. McDonagh, and K. Peterson, A systematic review of the efficacy and safety of atypical antipsychotics in patients with psychological and behavioral symptoms of dementia. J Am Geriatr Soc, 2006. 54(2): p. 354-61.
  5. Ahmed, U., H. Jones, and C.E. Adams, Chlorpromazine for psychosis induced aggression or agitation. Cochrane Database Syst Rev, 2010(4): p. CD007445.
  6. Mohamed, S., et al., Effect of second-generation antipsychotics on caregiver burden in Alzheimer’s disease. J Clin Psychiatry, 2012. 73(1): p. 121-8.
  7. Schneider, L.S., K.S. Dagerman, and P. Insel, Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA, 2005. 294(15): p. 1934-43.
  8. Wehry, Susan. OASIS 1.3. Training Manual for Trainers 2012. Statewide Initiative to Safely Reduce the Off-Label Use of Antipsychotics. Mass Senior Care Foundation; 2013.