Antipsychotics – Entry 1

Dear Diary:

Yesterday, Hattie’s daughter Carol stopped by my office, concerned about her mother’s behavior. She says Hattie seems confused. She keeps asking for her husband (Hattie’s a widow), and doesn’t seem to know what day it is. Anna (RN) and Sherry (NA) have also noticed that Hattie seems lethargic, dozes frequently, and has trouble feeding herself at dinner time.

This is atypical behavior for Hattie and may be a result of all that has happened since she broke her hip, and could be delirium. It’s not uncommon for elderly patients to become confused, agitated, or lethargic in the hospital, even if they were sharp as a tack before they went in. The behavior change could have many causes, such as anesthesia, pain meds, changes in electrolytes, or even infection. People are often prescribed an antipsychotic to calm them and reduce agitation rather than treating the underlying cause.

I feel certain that this is the case with Hattie. However, my nursing staff thinks she’s showing signs of dementia, and wants to add medication to treat the confusion and agitation. I reminded them that delirium is not the same as dementia. Delirium usually comes on suddenly, often following surgery, hospitalization, or an infection, while dementia is the result of a progressive decline in memory and thinking skills. A quick look at Hattie’s chart revealed what I suspected –she was prescribed Olanzapine: 0.25 mg po TID during her hospital stay. Since she’s no longer in crisis, we need to wean her off this drug and monitor changes in her behavior.

Nursing homes across the country are charged with reducing unnecessary antipsychotic medications for residents. We need to help Hattie get back to her baseline. I’m going to ask Anna to check in with the pharmacist, and then call Hattie’s physician to determine if a taper of the Olanzapine is appropriate.

I’m getting some resistance from my nursing staff, because they are worried that without this medication, Hattie’s going to get more agitated, more confused, and maybe even fall again. The effects of the Olanzapine were likely a contributing factor to her first fall which resulted in a broken hip. I’m sure they’re also reluctant because they’re stretched so as it is, and tapering the medication would mean they would have to closely monitor Hattie’s behavior, checking on her regularly during the taper.

How can I help them understand the importance of decreasing or eliminating the use of antipsychotic medications for residents who don’t have a diagnosis of a mental illness? How do I get them to take the time to figure out the underlying cause for Hattie’s agitation, rather than relying on dangerous medications?

Signed, Donna

8 Comments

  • We have actually discovered that decreasing some medication has decreased the behavior for some of our residents. I am a frontline worker, and I was surprised by this information. I think we need to educate educate educate! The more the staff realize the benefits of decreasing the medication, the more comfortable they will be for the next resident. I also think that giving them some non pharmaceticul approaches beforehand would help them with any behaviors that would come up.

  • I think families need guidance and understanding of the psychotropic meds also. We have families who are reluctant to have their loved ones being taken off of psychotropics. They fear that that behaviors and or past issues will return.

    • Agreed! To help address family fears, let them know antipsychotic medications present a risk for their loved one and the thinking about the use of these medications has changed. One resource to help with this family discussion is the Long Term Care Community Coalition “Get the Facts about Antipsychotic Drugs and Dementia Care”.

      Let them know you will work with them and the resident to find ways to keep the resident from experiencing distress while trialing a dose reduction. Discuss your nonpharmocological interventions, how dose reduction works, and the monitoring you will do. Engaging the family and resident in the process will increase likelihood of success.

  • Non-pharmacologic interventions are key. Once staff learn the importance of approach in dementia care the medication reduction flows easily. 3 years ago the Alzheimer’s association with MN and ND began a dementia care certificate program consiting of 8 webinars and 3 workshops. We are currently 15 strong. This training is fabulous. Care givers are pulling away from the tasking of showers and weights and respecting that biting, screaming and scratching mean, “No.”

  • We are reviewing antipsychotics at our monthly QAPI meeting with our Medical Director in attendance. Our Consultant Pharmacist is working with Fairview Pharmacy to provide a trifold brochure to our Physicians. We continue to listen to webinars that are offered on Antipsychotics and residents with Dx of Dementia.

    • We would be very interested in seeing the brochure when it is complete. We are every day looking at psychotropic meds and how we can educate staff, families and yes even physicians.

  • I started digging into the records of one resident who has diagnoses of “hallucinations and delusions”. I do see the specific charting regarding these issues over the past year. But I also saw that several times during the year she has been prescribed mulitple psych meds and/or had dose increases simultaneously. These orders came from our house psychiatrist. I realize she is an expert at psych issues but I can’t help question her rationale for loading this lady with Seroquel, Remeron and Trazodone all at the same visit. How can we possibly know what is or is not effective? My plan is to arrange a meeting in January (when the psychiatrist visits) and respectfully question some of her orders. I will not make any move during the holidays because my little resident has been somewhat weepy with all the goings on of Christmas but when it’s over I believe she is the one resident I can focus on to reduce or possibly eliminate the Seroquel as well as some of her other meds.

  • Education is always a big part of getting staff on board in reducing or discontinuing anti psychotic medications. Having inservices on the effects of these drugs on the elderly is a great idea and finding out from the family what the patient was like prior to the hospitalization. Find out what the patient enjoys to do and their history really does help.

Share your nursing home perspective on this quality improvement issue.