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*Last Updated January 1, 1997*
Developed jointly by the Board of
Directors of the American Association for Geriatric Psychiatry (James
Greene, MD, representative), the Clinical Practice Committee of
the American Geriatrics Society (AGS) (James Fanale, MD, representative),
and the Council on Aging and Committee on Long-Term Care (Ira Katz,
MD, chair), American Psychiatric Association. A similar document
has been approved as an official position statement of the APA.
Approved by the Executive Committee of the AGS, April 1992.
It is the position of the American
Association for Geriatric Psychiatry (AAGP) and the American Geriatrics
Society (AGS) that nursing home residents with psychiatric disorders
are entitled to the full benefits of treatment with the broad spectrum
of therapeutic options available to clinicians responsible for their
care. Recent controversy in this area has resulted from inadequate
attention to the distinction between the appropriate medical use
of these medications for the treatment of psychiatric disorders
and the misuse of these agents. Review of the recent literature
in this field indicates two distinct trends. On one hand, there
is considerable evidence that these medications have frequently
been overused and misused in the nursing home, often without attention
to psychiatric diagnosis, evaluation of the causes of behavioral
disturbances, trials of alternative treatments, or assessment of
the benefits and the risks of treatment. On the other hand, research
demonstrates that there is a high prevalence of psychiatric illnesses
that can respond to psychotherapeutic medication and that these
disorders have been underdiagnosed and undertreated. These divergent
findings emphasize the importance of distinguishing between the
appropriate use of psychoactive medications and their misuse.
There has been little controlled
clinical research on the safety and effectiveness of psychotherapeutic
medications in nursing home residents. Concerns about the misuse
of psychoactive medications have led to the formulation of federal
guidelines regarding the use of certain psychotherapeutic medications.
The current situation is marked by a press for reform in the absence
of complete knowledge about what constitutes optimal care. The clinical
needs of nursing home residents cannot, however, be deferred. In
this context, groups representing providers with expertise in this
area must take responsibility for developing and disseminating a
statement of the clinical principles that define appropriate treatment
with psychotherapeutic medications.
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 care 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 II: 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 of 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 lability, hallucinations, delusions, anxiety, agitation,
motor restlessness, and sleep disturbances.
In cognitively 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 psychiatric disorders and consideration
of mental health issues in the design of the environment and the
delivery of basic services to all residents.
Position III: The basic 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 rather, 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 nonpharmacological 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 effects 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 IV: 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
lability, 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 and
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.
1. 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.
2. 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.
3. 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 therpeutic
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 resients
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 V: Functional psychiatric
disorders such as depression are common in nursing home residents
and require treatment. These disorders frequently co-exist 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
underrecognition and undertreatment of a disorder that can contribute
to distress, disability, inadequate nutrition, and mortality. Major
depression can go undiagnosed because subjective complaints may
be dismissed as 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.
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