Antipsychotic Drug Use in Older Patients with Dementia: Proceed with Caution
Back in the day, administering antipsychotic medications to older adults with dementia got a bad reputation because, in some cases, these drugs may have been given to control patient behavior rather than to treat psychiatric conditions. Now concern about the use of these drugs is centering on serious physical risks.
All medications have the potential to cause side effects. The most common side effects noted in patients on antipsychotic drug therapy include movement disorders, dry mouth, blurred vision, constipation, dizziness, and weight gain. In rare cases, antipsychotics can cause more serious side effects such as changes in blood glucose or blood lipid levels, neuroleptic malignant syndrome, and cardiac arrhythmias. Now there are even more serious concerns. Studies over the past decade have shown that antipsychotics can put elderly patients with dementia at risk for stroke and even death.
In 2005, the Food and Drug Administration (FDA) issued a “black box warning” stating that administering atypical antipsychotic medications to elderly patients with dementia to treat behavioral disorders is associated with increased mortality. The FDA cited “a small but well established increase in the risk of death and stroke.” In 2008, the warning was extended to include conventional antipsychotics.
In March 2012, the Centers for Medicare and Medicaid (CMS) reacted to concerns by initiating a partnership to improve dementia care in nursing homes and reduce antipsychotic drug usage by 15% by the end of 2013. At least 11 states have achieved or exceeded this goal. Overall, the use of antipsychotic drugs in nursing homes fell by 9.1% during the same time period, resulting in roughly 30,000 fewer nursing home patients being given antipsychotic medications compared to when the partnership began. The CMS aims to reduce the prevalence of administering antipsychotic medications to elderly patients with dementia through training for care providers, making drug use data available online, and emphasizing alternative strategies.
A Medical Dilemma
Deciding to prescribe antipsychotic medications to elderly patients is a complex medical issue—and it is never an easy decision. Care providers can find themselves between a rock and a hard place, potentially facing legal ramifications whether they administer these drugs or not. In some cases, particularly when a patient’s violent behavior puts the safety of the patient or nursing staff at risk, ordering antipsychotic medications is a reasonable action, but it puts the patient at increased risk for serious side effects. If they do administer these drugs, they may be doing so without FDA approval—either by administering the drug to treat a condition not approved by the FDA, administering an unapproved dosage, or using the drug in a patient population (such as the elderly) for which the drug was not originally approved. If they withhold these drugs, they may leave themselves open to charges of negligence.
The Nurse’s Role
So what are care providers to do? Although there’s no clear-cut answer, nurses can play a vital role in reducing and, in some cases, eliminating the need to use antipsychotic drugs in elderly patients with dementia. In two essential areas—gerontologic nursing knowledge and nonpharmacologic interventions to treat the behaviors associated with dementia—nurses can have a huge impact.
For nurses who want to increase their knowledge about caring for patients with dementia, online resources are available from The Hartford Institute for Geriatric Nursing and the American Nurses Association . Nonpharmacologic interventions that can be effective in dealing with the behaviors exhibited by older adults with dementia include minimizing noise levels, maintaining a calm environment, and assigning consistent care providers to keep escalations of behavior at bay. Music therapy and therapeutic recreational approaches also can be effective. If the patient’s behavior does begin to escalate, focusing on feelings and attempting to anticipate care needs can provide the best approach.
To learn more about managing psychiatric emergencies, look into Mosby’s eLearning course, “ENA: Handling Psychiatric Emergencies.”