22/04/2024
When Medications Harm Seniors In Institutional Settings
When Medications Harm Seniors in Institutional Settings
I have been a nurse caring for seniors my entire career, which has lasted over 25 years. Caring for seniors is both rewarding and challenging. It becomes even more challenging when there is a diagnosis of dementia or Alzheimer’s. Anyone who has cared for someone with dementia and Alzheimer’s knows no two people ever present the same way.
This is affected by genetics, personalities, and the area of the brain that is primarily affected. For example, based on my experience as a nurse, those with frontal temporal affect tend to have no filters and are significantly more impulsive. Those with vascular dementia tend to be more physically aggressive. While those with Alzheimer’s tend to lose speech but retain the ability to sing.
There is also a correlation between increasing behaviors and what is termed Sundowning. The term Sundowning is a misnomer; in fact, the behaviors can be observed at any time of day, but primarily in the early afternoons and evenings. Sundowning is identified by agitation, anxiety, tearfulness, aggression, and more. For more information on sundowning, please see this link:
https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/expert-answers/sundowning/faq-20058511 #:~:text=The%20term%20%22sundowning%22%20refers%20to,Sundowning%20isn't%20a%20disease.
Behaviors related to dementia and Alzheimer’s can often be related, however, to other conditions. One of the most common reasons for increased behaviors with dementia is bladder infections; other issues can be pain, hunger, and uncomfortable clothes (this is especially true for people with texture issues). My biggest rant as a nurse, however, is the use of anti-psychotic medications being used to treat these behaviors.
As a Director of Nursing, I would frequently see seniors with dementia who were prescribed Seroquel or Zoloft for behaviors such as attempting to get out of bed or calling out. These medications were often started in the hospital and continued into the Assisted Living Facility, Nursing Home, or Skilled Nursing Facility. Often, these medications were prescribed for people with no previous diagnosis of Psychosis. These medications also often have “Black Box” warnings, specifically for seniors related to death, falls, significant weight loss, etc.
Unlike hospitals that can chemically restrain individuals, nursing homes or skilled nursing facilities are mandated under the Center for Medicaid and Medicare to reduce the number of antipsychotic medications for seniors due to the risk of physical and mental harm. But why aren’t hospitals and assisted living facilities under the same mandate?
The use of antipsychotic medications in the management of behavioral and psychological symptoms of dementia (BPSD) remains a contentious issue. While these medications may offer short-term relief for symptoms such as aggression and psychosis, their off-label use—meaning for conditions outside the drugs' approved indications—raises significant ethical, legal, and health concerns.
The Over-Prescription Problem
A recent study highlighted in a thorough review of antipsychotic use in dementia care has brought to light the alarming frequency with which these drugs are prescribed off-label. Despite the known risks, including an increased chance of stroke and even death, antipsychotic drugs are routinely administered to manage BPSD. This not only poses significant risks to patients' health but also places a legal onus on prescribers and care facilities, suggesting an urgent need for regulatory oversight.
Legal and Ethical Concerns
The review underscores a disturbing practice: the prescription of these potent drugs often occurs without adequate consultation with caregivers or clear communication about the potential side effects. This lack of informed consent violates basic ethical principles in medical practice. Moreover, the legal framework currently allows for this practice without sufficient checks, leaving patients vulnerable to harm without clear avenues for redress.
Advocating for Regulatory Reform
The article calls for stringent regulatory interventions to manage the off-label use of antipsychotic medications. Such measures could include better tracking of prescription practices and outcomes, stricter guidelines for off-label use, and more robust training for healthcare providers on the risks associated with these drugs.
Non-Pharmacological Alternatives
Crucially, the review advocates for non-pharmacological interventions, which are often overlooked in the rush to 'manage' difficult behaviors pharmacologically. Non-drug approaches, such as tailored care plans that address the specific environmental triggers or health issues causing distress, are not only safer but often more effective in the long term. Techniques such as music therapy, cognitive-behavioral strategies, and structured daily activities can significantly improve quality of life without the severe risks posed by antipsychotics.
The Way Forward
The challenge now is to shift the paradigm of care from one that prioritizes convenience and quick fixes to a more humane, thoughtful approach that truly considers the best interests of those with dementia. Families and caregivers must be part of the conversation, armed with all the information they need to make informed decisions about their loved ones' care.
For too long, the quick prescription of antipsychotic medication has been a Band-Aid solution to a complex issue. It's time for a change, focusing on comprehensive care strategies that respect the dignity and health of dementia patients. Let us advocate for a future where every individual with dementia receives care that is as safe as it is effective.
Reference:
https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/expert-answers/sundowning/faq-20058511 #:~:text=The%20term%20%22sundowning%22%20refers%20to,Sundowning%20isn't%20a%20disease.
