September/October 2012

Making the Case
for Antipsychotics Use

By Jessica Girdwain
Aging Well
Vol. 5 No. 5 P. 32

The use of antipsychotic medications in long term care (LTC) settings has come under increasing scrutiny. Opponents suggest these drugs are often used as a quick fix for elder behavioral disturbances rather than having caregivers take the time to work with difficult patients. Others argue that families frequently aren’t consulted before antipsychotics are administered. But some physicians support the use of antipsychotics in older adults’ LTC treatment as long as the medications are used safely and conscientiously.

“It’s important to consider that the over-85 demographic is the most rapidly expanding group in society. Therefore, the incidence of dementia is enormous. The condition of dementia coupled with agitation is becoming an emerging public health issue of great significance,” says David Harnett, MD, chairman in the division of psychiatry at Lawrence Memorial Hospital in Medford, Massachusetts.

“Indeed, among nursing home residents, as many as two-thirds have dementia,” explains James Ellison, MD, MPH, clinical director of the geriatric psychiatry program at McLean Hospital in Belmont, Massachusetts. “Of those, 80% or more will experience agitation. If these patients lash out, they may inadvertently or purposely injure a staff member or fellow resident, a problem made worse by the resident’s frailty. There might be significant consequences.”

Proceed With Caution
While scrutiny has increased related to the use of medications to control agitation or violence that can occur in dementia patients, Harnett and Ellison say misconceptions about antipsychotics and their use are greatly impacting elder care. “One common error is the idea that antipsychotic medications do no good whatever and are so toxic they injure or kill all who take them,” Ellison says.

Experts acknowledge that antipsychotics warrant careful regulation because of the medications’ many possible adverse effects. But when they’re used in the right patients at the lowest effective dose for the shortest period of time and these patients are carefully monitored, antipsychotics can be a relatively safe and helpful component of a more comprehensive treatment, Ellison says.

In the initial approach, it is important for a physician to examine a patient for any covert medical causes of dementia-related agitation, such as infection or pain, Harnett notes. Then when addressing the psychological aspect of agitation, the first course of action physicians should consider is behavioral treatments, which help many elders. However, some patients have difficult syndromes and can become explicitly violent, Harnett notes. “Behavioral treatments should always be considered, but it’s naïve to believe that you can stop every problem with them,” he says.

A patient who may be a good candidate for antipsychotic medications generally has significant dementia along with psychotic symptoms and/or behavioral disturbances, Ellison says. If an antipsychotic is considered, the physician needs to determine whether the medication’s use can be justified on the basis of an FDA-approved indication, such as schizophrenia or bipolar disorder. “There are a number of nursing home residents with these disorders in addition to dementia,” Ellison notes. If the physician is prescribing for an off-label indication (eg, treating psychosis caused by dementia and not bipolar disorder or schizophrenia), consider that studies show these medications have a limited—although not zero—effect.

Next, physicians should ask themselves whether they have adequately considered the patient’s safety profile. For example, does the patient have diabetes? (Antipsychotic medications can affect symptoms of this condition.) Is the patient taking other medications that could interact adversely with an antipsychotic?

Implementing Care Strategies
Harnett broaches a larger issue that often figures into LTC facilities admission and care strategies. Without the availability of antipsychotics as an option for a course of treatment, fewer nursing homes would be willing to accept difficult patients, so what happens to dementia patients who desperately need facility care? It’s important to recognize that antipsychotic medications have an appropriate use. “If we demonize these medications and say that the elder facilities using them are bad, then they won’t want to take in these patients,” Harnett explains. “We should be supporting them, not condemning them.”

Often overlooked are family members who provide care to patients with dementia-related behavior management concerns. “The unsung heroes are families. They give up a lot to care for someone who is suffering from dementia. A number of families swear by antipsychotic medications, and they appreciate a physician who prescribes these cautiously and then monitors the patient closely afterward,” Harnett says.

Physicians should be open with the families of patients displaying agitated or violent behaviors and explain that antipsychotics are prescribed only in cases where the physician believes it’s an absolute necessity. It’s important to explain to the family both the benefits and the potential detriments. And if family members want to try to avoid such medications, providers should work with them to find another course of treatment.

Physicians deciding whether or not to prescribe an antipsychotic medication should look at the whole picture with consideration of the severity of a patient’s symptoms, Harnett advises. If not terribly severe, symptoms may be reasonably managed without using these drugs. “But if you have a patient who is suffering terribly and having paranoid delusions about caretakers and families, then it’s time to evaluate the risks and benefits of antipsychotics,” he says.

Shared Decisions
It’s important for healthcare professionals to work collaboratively with family members to educate them about a patient’s disease and the recommended medications to make sure that families are comfortable with the course of treatment. “They’re the decision makers and need to give informed consent,” Harnett says.

Physicians should make time to speak to families during a patient’s initial evaluation. “This is time well spent. It builds a nice alliance between the physician and the family—they really appreciate the gesture, and it’s better than waiting down the line to speak up when symptoms worsen,” he says.

It can also be beneficial for physicians to suggest appointing one family member as the contact person to ask questions and relay answers to the other family members. When a clinician receives multiple calls from different family members about the same patient’s treatment, confidentiality may be jeopardized, and miscommunication becomes more likely.

Whatever the course, Ellison says, “I think the most important thing is that we align our expectations with the actual effects of these drugs and other treatments. We can’t expect that any treatment will help everybody or that they will be without side effects. But when used correctly and monitored, many different interventions have value.”

— Jessica Girdwain is a Chicago-based freelance writer who has contributed health-related articles to several national magazines.