The management of disruptive behavioral symptoms (DBS) in long-term care patients may occur in one of three approaches: non-pharmacologic, pharmacologic or a combination of the two. The Omnibus Budget Reconciliation Act (OBRA) requires careful usage, documentation and justification of the usage of pharmacologic agents for DBS in nursing home patients. In fact, most studies show little if any benefit to the use of drug; for DBS, especially the antipsychotics.
DBSs can be grouped as agitated behaviors and behaviors associated with psychotic symptoms of hallucinations, paranoia and delusional ideation. Agitated behaviors are more common in cognitively impaired patients, especially in patients with dementia of the Alzheimer's type (DAT). There are three groups of agitated behaviors: aggressive, physically nonaggressive and verbally agitated.
Aggressive behaviors, such as inappropriate grabbing, kicking, biting and scratching, tearing and hitting, or abusive verbal actions such as cursing, may be the most justified usage of pharmacologic agents, when non-pharmacologic methods do not adequately control the aggressive behavior.
Physically non-aggressive behaviors include wandering, pacing, inappropriate handling of objects or dressing/undressing, repetitive mannerisms or questions, and restlessness. This form of DBS should never be treated with pharmacologic agents.
Verbally agitated behaviors include repetitive complaining or requests for attention, repetitive negative assertions and yelling. These DBSs rarely respond to pharmacologic treatment. Only constant yelling or screaming has any justification for medication, under the OBRA guidelines.
Behaviors associated with psychotic symptoms that are persistent do respond to antipsychotics, in particular, but should be treated with the lowest possible dosage.
Non-Pharmacologic Approaches to DBS
The most important aspect to DBS management is to train the staff of the nursing home to understand the nature of the typical DBS episode. In the cognitively-intact person, the DBS usually is a means of communication. For example, I recently observed a stroke patient who began to scream for the first time. The reaction of the charge nurse was to call the attending physician for an order to sedate the patient. On further checking the patient's situation, however, we found that the patient simply wanted to be changed, as she was wet due to her incontinence.
This illustrated that, in the cognitively-impaired patient (e.g. DAT), the primitive instincts may be the only remaining reactive component to the patient's psyche. Staffers who handle the patient must recognize the perspective of the demented patient who exhibits physically aggressive behavior only when he or she is to be showered or moved or dressed. Gentle manipulation of the patient, especially when undressing or exposing to water, may lessen the likelihood of DBS.
The December 1992 issue of the journal Regimen emphasizes several non-drug alternative measures that call for creative interdisciplinary strategies to minimize DBS. These innovations include:
Multigenerational Approach - this involves the usage of full-time child care centers in nursing homes. The older person can offer special experiences, interests and skills, and can benefit from providing the special attention children need from adults who have both the time and patience to listen to them.
Pet Therapy is used to alleviate the sense of loneliness experienced by the elderly, and since many demented patients have intact memories of their early childhood days, pet therapy can give them a link with pleasant memories from their past.
Plant Therapy - by allowing a nursing home resident to care for a plant, a meaningful opportunity to create a more homelike atmosphere is afforded.
Art Therapy - gives a resident the chance to express themselves and their emotions even though they cannot verbalize.
Exercise and Dance Tharapy - can allow residents to improve mobility, circulation and self-esteem; also, confusion, loss of memory and depression can be improved with this form of alternative therapy.
Music Therapy - is one of the most popular alternative therapies, which allows patients with various levels of cognition to experience many happy memories.
An additional form of therapy is access to worship services, which give the resident a chance to express and experience their religious beliefs, regardless of the level of cognition.
Pharmacologic Approaches to DBS
The OBRA and COBRA legislation requires that nursing facility (NF, formerly SNF and ICF) patients be:
1. Free from unneccesary drugs OF ALL
TYPES (remember that most drugs
have a possibility to be psychoactive - see below) Unnecessary Drugs are defined as:
a. Excessive dose
b. Excessive duration
c. Excessive adverse consequences
d. Without adequate monitoring
e. Any combination of the above 2. Free from chemical restraints (what
are most commonly thought of as
psychotropic drugs to include
antipsychotics, antidepressants and
anxiolytic and hypnotic meds). If
antipsychotic drugs such as Haldol,
Mellaril or Navane, are to be used
they must be used appropriately.
Many times the drug regimen for the nursing facility patient includes medications that can affect cognition, mentation, alertness, and ability to perform activities of daily living (ADLs).
The table lists drugs -- an extremely wide variety of them -- that may be used, knowingly or not, as chemical restraints.
The patient receiving an antipsychotic must have an indication from the following choices: Schizophrenia or schizo-affective disorder; delusional disorders acute psychosis or mania with psychotic mood; brief reactive psychosis; atypical psychosis; Tourette's Syndrome; schizophreniform disorder; Huntington's chorea; short-term symptoms of nausea, vomiting, hiccups or itching; and dementia associated with psychotic or violent features that represent a danger to the patient or others.
As already mentioned, yelling may be considered to be an indication for medication, if t is constant and considered traumatizing to other residents. Of course the usage of an isolation room, in which all the "Yellers" or "Screamers" are placed, is preferable to sedation.
Antipsychotic drugs should NOT be used for the following:
Restlessness, fidgeting, or wandering; insomnia; depression; screaming or crying out; anxiety; memory impairment; uncooperativeness; agitation; sedation; calming; "inability to manage patient."
Reasons for the usage of antipsychotic drugs must be documented on the physician's orders or progress note and in the patient care plan.
Antipsychotic drugs MUST be used in the minimal dose necessary to control the above indications. This minimalization may be assured by: 1. Periodic tapering -- minimally, every
six months -- by at least 25% of
the daily dose in an attempt to discontinue
the drug if patient improvement
is noted; 2. Using staff intervention to find out
why the patient may have a behavioral
problem; 3. Monitoring and documenting the
HARMFUL patient target symptom
or behavior (e.g. biting, scratching,
kicking), and whether the target symptom
is actually affected on a month-to-month
basis by the antipsychotic; 4. Observing and documenting adverse
effects (e.g. sedation, falls, worsened
behavior or disorientation/confusion,
extrapyramidal symptoms and tardive
dyskinesia) on a monthly basis. The
latter two movement disorders (EPS
and TD) should be assessed at least
every 6 months using an AIMS or
similar scale. 5. The most common side effects of all
drugs n use in nursing home patients
must be made a permanent part of
A case evaluation illustrates the OBRA-required documentation of harmful behavior and drug effects:
CASE - L.L., an 83-year-old patient with advanced dementia, has engaged in kicking, biting and/or scratching over 21 episodes in the prior 3 months. She is placed on 0.5 mg haloperidol daily and has only 3 episodes of harmful behavior over the next 3 months. She has also fallen 3 times since being placed on the haloperidol. The Quality Assessment and Assurance Committee (QAAC), with consultant pharmacist input, recommends that the haloperidol be decreased to 0.25mg per day.
James W. Cooper, Pharm.PhD., FASCP, FASHP, is Professor and Assistant Dean at the University of Georgia College of Pharmacy, Athens, GA.
DRUGS USED AS PSYCHOACTIVE CHEMICAL RESTRAINTS (KNOWINGLY OR NOT)
Psychoactive Drugs Used in Nursing Homes
Antipsychotics - Mellaril, Serentil, Thorazine, Navane, Haldol,
Stelazine, Prolixin, Taractan, Moban, Loxitane, Trilafon(*) Antidepressants-Elvail/Endep(*) Aventy/Panelor, Vivactyl, Tofranil/
SK Pramine, Norpramin/Pertofrane, Sinequan/Adapin, Ascendin,
Ludiomil, Prozac, Wellbutrin, Surmontil, lithium, Clozaril,
Anmafranil. AVOID MAOI TYPE A ALTOGETHER Antiparkinsonism Agents- L-DOPA, Sinemet, Symmetrel, Cogentin,
Artane, Kemadrin, Benadryl, Atkineton, Parlodel, Permax, Eldepryl Antianxiety and Hypnotic Agents - Librium, Valium, Dalmane,
Miltown/Equanil, Tranxene, Paxipam, Centrax, Klonopin, Ativan,
ProSom, Doral, Serax, Xanax, Halcion, chloral hydrate, Doriden,
Noludar, Placidyl, Seconal, Nembutal, Amytal, Tuinal, Butisol,
phenobarbital Antihistamines (Combination, cold/hay fever products with
decongestants)-Chlor-trimeton (ornade, Isochlor), Dimetane
(Dimetapp), Benadryl, Tavist, Ambodryl, Clistin, Decapryn,
Polaramine, Forhistal, Actidil (Actifed), PBZ, Histadyl, Tacaryl,
Phenergan, Temaril, Atarax/Vistaril, Optimine, Periactin,
Seldane, Hismanal Antinauseants-Phenergan, Tigan, Compazine, Torecan, Reglan,
Trans-Scop, Antivert/Bonine, Marezine Antidiarrheals - Lomotil, Immodium, Donnagel, Parapectolin Antisecretory - Robinul, Donnatal, Levsin, Atropine, scopolamine,
Pamine, Quarzan, Tral, Darbid, Cantil, Banthine,
Pro-Banthine, Pathilon, Bentyl, Daricon, Ditropan, various
combination products Antiulcer Drugs - Tagamet, Zantac, Pepcid, Axid Analgesics - Darvocet/Wygesic, Talwin, Percodan, Percocet,
Lortabs, codeine, morphine, all narcotics Antihypertensives (with central nervous system effects)-Aldomet,
Wytensin, Tenex, Catapres, Ismelin, Hylorel, reserpine,
Inderal, Corgard, Tenormin, Blocadren, Lopressor, Visken,
Normodyne/Trandate, Sectral, Levatol, Cartol, Isoptin/Calan/
Verelan, Kerlone Antianginals - Isoptin/Calan, Cardizem, Procardia, Cardene,
Norvasc, DynaCirc, Vascor
Antiarrhythmics-quinidine, Pronestyl/Procan, Norpace, Tonocard,
Tambocor, Mexitil, Cardarone, Enkaid, Decabid Anticonvulsants - Dilantin, phenobarbital, Tegretol, Depakene/
Kepakote, Mysoline, Karontin, Klonopin
CNS Stimulants - theophylline products, caffeine, Trental, Ritalin, Cylert (*) Indicates that these drugs may also be available in combination products
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