Use of Psychopharmacological Medications for Behavior Control
Psychopharmacological Medication Review
As we reported last month, CMS has issued six new quality measures including:
- Percentage of long-stay residents who received an antianxiety or hypnotic medication (MDS-based)
Psychopharmacological medications are defined as “any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders”. These medications may include antipsychotics (i.e., Risperdal), antidepressants (i.e., Lexapro), anxiolytics (i.e., Ativan), sedative-hypnotics (i.e., Restoril), anticonvulsants (i.e., Depakote), antimanic (i.e., lithium), and cognitive enhancers (i.e., Aricept).
These medications are typically indicated to treat a medical condition (i.e., seizures) or a psychiatric condition (i.e., bipolar disorder, depression). Indication for use must be documented in the medical record and monitoring must be in place for both efficacy and side effects. If any of these medications are used to control behavior, other causes for the behavior must be considered and non-drug interventions must be documented to not have been effective.
Psychiatric disorders or distressed behavior – As with all symptoms, it is important to seek the underlying cause of distressed behavior, either before or while treating the symptom. Examples of potential causes include:
- Delirium (medications, infection, electrolyte imbalance, metabolic disorders)
- Chronic psychiatric illness such as schizophrenia or schizoaffective disorder;
- Acute psychotic illness such as brief reactive psychosis;
- Substance intoxication or withdrawal;
- Environmental stressors (e.g., excessive heat, noise, overcrowding);
- Psychological stressors (e.g., disruption of the resident’s customary daily routine, grief over nursing home admission or health status, abuse, taunting, intimidation);
- Neurological illnesses such as Huntington’s disease or Tourette’s syndrome; or
- Medical illnesses such as Alzheimer’s disease, Lewy body disease, vascular dementia, or frontotemporal dementia.
When a resident is experiencing an acute medical problem or psychiatric emergency (e.g., the resident’s behavior poses an immediate risk to the resident or others), medications may be required. In these situations, it is important to identify and address the underlying causes of the problem or symptoms. Once the acute phase has stabilized, the staff and prescriber consider whether medications are still relevant. Subsequently, the medication is reduced or discontinued as soon as possible or the clinical rationale for continuing the medication is documented.
When psychopharmacological medications are used as an emergency measure, adjunctive approaches, such as behavioral interventions and techniques should be considered and implemented as appropriate. Longer term management options should be discussed with the resident and/or representative(s).
References: From the Revised Surveyor Guidance for Unnecessary Medications (F329) 9-15-06
This article was originally published in our monthly issue of From the Front Lines – a monthly publication that shares best practices and medication-related challenges faced by “front line” staff in long-term care and post-acute (LTCPAC) facilities.