A recent article in the Wall Street Journal ("Nursing Homes Struggle To Kick Drug Habit", December 20, 2007) discussed alternatives to using anti-psychotic medications to control the behaviors of older adults with dementia. If your unfamiliar with why these drugs are administered at all, then here is a bit of background.
As dementia's progresses the confusion that accompanies the disease process can result in perceptions of danger and situations that make the afflicted individual fearful and distrustful, often mis-perceiving their environment and the intentions of those around them. Because these symptoms are associated with an altered state perception the resulting behaviors are often characterized as a psychosis.
There has been much concern and debate about the use of anti-psychotic medications in older adults to treat behavioral symptoms.
The extreme of this argument on the Con side has been that anti-psychotics are chemical restraints and should be banned from use altogether. The opponents rightly understand that in many cases these uncomfortable symptoms are a response to environmental stimuli and can be controlled or reduced by proper attention to the environment in which people with dementia are cared for (and the behavior of their caregivers).
Proponents for the use of anti-psychotics in persons with dementia are often the mental health practitioners who are called by physicians and nurses in skilled nursing facilities or family members begging for some relief, both for the confused patient who seems to be in emotionally painful distress, as well as for those around them.
There is some evidence for concern about the use of these drugs in older adults. The Food and Drug Administration has issued a "black box" warning labels that these drugs can increase the risk of death for elderly dementia sufferers.
The WSJ article describes alternative practices for treating persons with dementia that have helped reduce or eliminate the need for psychotropic medications. These are common sense solutions such as: creating an environment that reduces fear and anxiety, insuring consistency in caregivers (reduced turnover), allow time for the caregivers to get to know the individual older adult (their needs and preferences) and a focus on staff training on the special needs of the cognitively impaired. Sounds simple no? Then why isn't every nursing home and mental health professional in the country weaning all elders with dementia off the stuff?
Because there is no panacea and this issue like so many in long term care is complex. Changing the culture of long term care is slow and changing the environment of existing facilities is expensive. Retaining quality caregivers requires both money and a management's determination to value its staff and provide both monetary and non-monetary incentives for staying in a tough work environment. If all nursing homes were run by non-profits would things be better? That would depend on how non-profits decided to (or were required to) spend their money. Both Shareholder's of for-profit facilities and Board Member's of non-profits need to make the decision if they are going to divert some of their revenue to accommodate the need for High Touch (rather than high tech).
And, as the article points out, the alternative methods do not always reduce confusion, fear, anxiety, or the undesired behaviors. However, there is no question that these alternatives work and should be the rule, rather than the exception.
Your thoughts?
