Last week's symposium on Toxic Medicine was so informative, I thought I would take the opportunity to post a few blogs capturing the laws and regulations governing the use of psychoactive medication in California Nursing Homes.
1. What is a psychoactive medication?
This type of medication includes anti-depressants (e.g. Zoloft, Prozac), anti-anxiety medications (i.e. Ativan, Valium), hypnotics (e.g. Halcion, Restoril), and anti-psychotics (i.e. Haldol, Seroquel, Zyprexa, Risperdal). The most controversial psychoactive medication is the anti-psychotic. As the name implies, this class of medication was designed to treat serious mental illness - i.e. psychosis like schizophrenia. They are not approved by the FDA for treatment of dementia related psychosis. In fact, the FDA has issued its strongest warning, a "black box" warning, guarding against the use of anti-psychotic medications for treatment of elderly patients, experiencing dementia-related psychosis, and cautioning that the use of this class of medication increases the "risk of death" in elderly patients.
2. Why are these medications used in a nursing home setting?
Typically, a psychoactive medication will be used to "manage behavior", such as restlessness, agitation, resisting care, or being combative toward staff. Oftentimes, they are used as a first response to the behavior, though the law requires the medication be used to treat a specific medical condition and be used only after alternative therapies have failed. Too often, they are prescribed within hours of admission, when a nursing home patient is confused, disoriented, likely in pain, in fear or anxious.
3. Under what circumstances can a psychoactive medication be used in a nursing home?
Two basic requirements should be met before administration of a psychoactive medication. First, psychoactive medications are to be used as a last resort for treating behavioral symptoms only after non-drug alternatives have been tried and failed. To do this, however, requires adequate numbers of well-trained staff to respond quickly to the physical needs of residents, such as help with toileting, getting in and out of bed, bathing, hunger, or thirst. If staffing is not adequate, and resident needs go unmet, it is more likely the resident will suffer from anxiety and agitation and act out. Second, if medications are ordered, the physician must obtain informed consent and the nursing home must document that the physician obtained informed consent to administer the medication either from the resident (if competent) or their responsible party.
More information regarding informed consent will follow in the next post.
