AAGP Position Statement: Psychotherapeutic Medication in the Nursing Home
Adopted by AAGP Board of Directors, March 1997
Position 1: Optimizing the use of psychotherapeutic medications will require additional support for both clinical training and research.
Rationale: The attention given to psychoactive medications in 1987 OBRA legislation and subsequent regulations demonstrates the central importance of the appropriate diagnosis and treatment of psychiatric disorders in the nursing home. Bringing the care of the greatest number of nursing home residents up to the level of the current state of the art will require further educational support for the development of professionals trained in geriatric psychiatry and medicine and for additional training of other physicians in the appropriate use of psychotherapeutic medications in the nursing home.
Regulations governing the use of psychoactive drugs in the nursing home are being developed at a time when there are major gaps in the scientific knowledge that is available from randomized clinical trials or from systematic clinical observations of the effects of drug treatment specifically in this setting. Substantive improvements in the case of nursing home residents will require targeting support to facilitate research in this area, both basic clinical research on the diagnosis, clinical course, and treatment of psychiatric disorders among nursing home residents and health services research on the delivery of care to these patients.
Both federal regulations and this statement of principles must at this time be considered provisional. Both should evolve as additional knowledge becomes available.
Position 2: Appropriate use of psychotherapeutic medications for the treatment of patients with diagnosed psychiatric disorders is an important component of the medical and mental health care of nursing home residents.
Rationale: At least half of all nursing home residents suffer from a dementing illness, most commonly Alzheimer's disease or vascular dementia. For residents with dementia, the appropriate use psychotherapeutic medications is for treatment of the affective, psychotic, and behavioral symptoms that are likely to occur during the course of their illness. These symptoms include depression, mania, affective liability, hallucinations, delusions, anxiety, agitation, motor restlessness, and sleep disturbances.
In cognitive intact, medically stable residents, appropriate use is for the treatment of psychiatric syndromes rather than symptoms and is for therapy of the affective, psychotic, and anxiety disorders of late life. In the nursing home, the most common of these is depression, occurring with a prevalence of at least 20%-25% among cognitively intact residents. In these residents, it is associated with increased medical morbidity, disability, and mortality.
As in other settings, the availability of physicians with expertise in the use of psychotherapeutic medications is necessary but not sufficient to meet the mental health needs of nursing home residents. Other important components of mental health care include the use of psychosocial and behavioral treatments for residents with diagnosed disorders and consideration of mental health issues in the design of the environment and the delivery of basic services to all residents.
Position 3: The basis principles underlying the treatment of psychiatric disorders and behavioral problems in the nursing home are identical to those for the treatment of geriatric patients in other settings.
Rationale: Nursing home residents are entitled to access to all effective and safe treatments for their illnesses and symptoms. The nature of the site does not alter the responsibility of the physician and the facility to provide for appropriate treatment, including treatment with psychotherapeutic medications. Evolving federal guidelines governing the use of psychoactive medications have been designed primarily to limit their inappropriate use. However, if these regulations are applied without regard to the appropriate clinical circumstances, they could have a negative effect on the delivery of appropriate treatment.
The use of psychotherapeutic medications in the nursing home is a component of medical therapeutics that should be governed by the same principle as other medical treatments; this involves the application of scientific knowledge and clinical judgment for the benefit of the individual resident.
A) The most important use of psychopharmacological treatment is for the alleviation of the resident's distress and the reduction of disability resulting from psychiatric symptoms. Although certain psychotherapeutic medications are useful for treating agitation and destructive behaviors that cause danger to the resident or others, these indications constitute only a part of medical psychotherapeutics. Psychiatric disorders that occur in cognitively intact residents and psychotic, affective, and behavioral symptoms that occur as components of dementia can be treatable causes of excess disability. Depression, for example, can be a barrier to rehabilitation or recovery and is associated with increased functional impairment in a number of chronic diseases. As a result, treatment of depression in long-term-care residents has the potential to enhance functional performances as well as to reduce distressing symptoms.
B) The initial step in the evaluation of any psychiatric disorder or behavioral symptom must be to consider the possibility that the symptoms result from a medical illness, previously diagnosed or undiagnosed. Delirium resulting from disturbances in cerebral activity is common among patients with symptoms of acute onset. When agitation or behavioral symptoms interfere with the medical evaluation of such patients, use of psychotherapeutic medications on an acute, short-term basis may be necessary to allow medical examinations and laboratory tests to proceed. The primary goal of treatment in such cases is not reduction of the behavioral symptoms as an end in itself, but as a necessary step in evaluating the patient for potentially serious medical disorders. Residents with persistent behavioral disturbances also require comprehensive diagnostic evaluations that include consideration of medical causes and medical factors affecting treatment. Such evaluations can, however, be approached on a less urgent basis.
C) In the nursing home, as in other psychiatric treatment settings, comprehensive treatment planning must consider both pharmacological and non-pharmacological interventions. The latter may include modifications in the delivery of basic nursing care, changes in activities, environmental manipulations, behavioral approaches, and psychotherapy. Psychosocial treatments should be evaluated as both alternatives and adjuncts to pharmacotherapy.
D) Physicians planning treatment with psychotherapeutic medications for nursing home residents must consider the manner in which aging affects the actions of drugs being prescribed as well as the potential for drug-disease and drug-drug interactions. Nursing home residents are vulnerable to adverse drug effects as a result of their multiple chronic diseases, use of multiple concomitant medications, and the pharmacokinetic and pharmacodynamic changes that accompany aging. Treatment planning must consider the altered metabolism of many drugs in the elderly, the increased sensitivity of target organs, and the potential for drug-drug interactions occurring at both the level of drug metabolism and at target organs. Preventing drug-disease interactions requires a review of the resident's medical status before new medications are prescribed.
E) The physician's responsibilities for administering treatment with psychotherapeutic medications include the need to monitor therapeutic benefits and the adverse effects of medications, with ongoing modifications in the treatment as needed. In general, this modification requires baseline assessment of the resident's symptoms and level of functioning and repeated reevaluations during treatment. In addition, the resident should be observed and monitored for early signs of adverse effects specific to the agent being prescribed.
F) The physician has the responsibility of providing information about all medications, including psychotherapeutic medications, to patients or, when necessary, their health care proxies. However, medications necessary on an emergency basis to facilitate the evaluation of potentially serious medical disorders or to treat dangerous behavior should not be withheld from patients in need.
Position 4: Nursing home residents with Alzheimer's disease and other dementias should be evaluated to determine whether they are experiencing affective, psychotic, and behavioral symptoms; when such symptoms are present, they should be treated.
Rationale: Alzheimer's disease and the other dementias of late life occur in over one-half of nursing home residents and account for the majority of their psychiatric diagnoses. The dementias are manifest by cognitive deficits and by more variable and more treatable behavioral disturbances including depressions, psychoses, and other psychiatric syndromes. The cognitive signs of dementia include amnesia, apraxia, aphasia, agnosia, and impaired judgment that may not only cause disability but also make residents more vulnerable to environmental stresses. These symptoms do not respond to treatment with currently available psychotherapeutic agents, but should be managed by closely supervising the resident within a structured and supportive environment. In contrast, residents with symptoms of major depression, mania, hallucinations, delusions, and anxiety are likely to require and respond to treatment with psychotherapeutic medications. Other symptoms such as affective liability, impulsivity, apathy, and dysregulation of sleep may also respond to drug treatment.
A) Psychiatric symptoms and behavioral disturbances in residents with dementia should be treated when they are distressing to the resident, when they cause impairments in self care, social interactions and participation in activities, and when they are a source of danger to the patient or others. When symptoms are dangerous, the safety of the resident and others often requires the initiation of psychopharmacological treatment on an urgent basis. In other cases, the timing of pharmacological an psychosocial treatments must reflect the needs of the individual resident.
B) The choice of medications for the management of psychiatric and behavioral symptoms in residents with dementia must depend primarily on the nature of the resident's symptoms.
- When symptoms and history suggest that the resident has an affective, psychotic, or anxiety syndrome as a component of the dementia, treatment should be initiated with agents known to be effective for these symptoms.
- Neuroleptic medications can be effective for the treatment of less specific symptoms of agitation, but there are also suggestions from small-scale studies or case reports that carbamazepine, trazadone, short-acting benzodiazepines, and other agents may be of benefit.
- All treatments with psychotherapeutic medications must be considered to be therapeutic trials. If, within a reasonable period of time, a treatment has not been effective in improving target symptoms, if it is accompanied by significant or proportional adverse effects, or if it has led to a deterioration in the resident's level of functioning, then it should be modified or discontinued. When evaluating outcomes, it is important to monitor the resident's social interactions, participation in activities, and self care, as well as the frequency and intensity of behavioral symptoms.
C) When an antipsychotic medication is used for the treatment of agitation and related behavioral disturbances, the process of dose adjustment, rather than the final dose, is a rational measure of the quality of treatment. Residents with agitation secondary to dementia, in general, respond to doses that are low relative to those used in younger adults for the treatment of schizophrenia, but there is significant interindividual variability in the rates of drug metabolism and sensitivity to drug effects. Treatments for all residents should start at low doses, with dose increments made as needed after careful observation of the resident for both therapeutic response and adverse effects. PRN medications can have an important role during the upward or downward titration of dosage. They also can be of benefit when prodromal symptoms are observed in residents with infrequent recurrent episodic disturbances.
D) Neither the natural history of behavioral disturbances in residents with dementia nor the long-term effects of psychotherapeutic medications have been adequately studied. Therefore, the appropriate duration of such treatment must be established on an individual basis. When residents have been stabilized on medications that appear to be effective, trials of dose reduction or discontinuation are desirable to determine the necessity for continuing maintenance treatment.
Position 5: Functional psychiatric disorders such as depression are common in nursing home residents and require treatment. These disorders frequently coexist with and complicate the disabling chronic medical and neurological disorders that make long-term care necessary.
Rationale: Major depression occurs in approximately 20%-25% of cognitively intact nursing home residents, most frequently in association with chronic mental illness. The primary problem in this area is not overuse of medications, but under-recognition and under treatment of a disorder that can contribute to distress, disability, inadequate nutrition, and mortality. Major depression can go undiagnosed because subjective complaints may be dismissed and understandable reactions to chronic illness and nursing home placement or because neurovegetative and behavioral symptoms may be attributed to physical illness. Systematic approaches to screening residents are necessary to ensure that residents with significant symptoms are identified and referred for diagnostic evaluations.
When treatment with antidepressant medications is initiated, regularly scheduled follow-up is necessary to monitor therapeutic response and potential side effects and to make dose adjustments. Although, in general, it is necessary to start treatment in elderly residents at low doses, it is also necessary to ensure that residents with persistent symptoms receive adequate treatment.