By Molinari, Victor; Branch, Laurence G.
Aging Today , Vol. 32, No. 6
Mrs. M. is an 82-year-old Florida widow with two married children living in other states. A petite woman who has always had a pleasant, outgoing personality, she likes walking to keep fit. For the past five years, though, she has resided in assisted living and exercises less. She has had three chronic conditions, including Parkinson's disease, for many years, and is being treated with medications prescribed by a specialist.
Recently, Mrs. M. developed a moderate case of bacterial pneumonia and was hospitalized. She was put on antibiotics, sleeping pills and an increased L-Dopa dosage for Parkinson's. In the last five days of her two-week stay, she was prescribed antipsychotic medication to ameliorate her declining mental status and to control hallucinations she had begun experiencing. When discharged to a nursing home, Mrs. M. had deteriorating mental status and recently prescribed antipsychotic medication-but no psychiatric evaluation or behavioral health diagnosis.
Nearly every month, reports appear documenting the untoward side effects of psychotropic medication, especially in elders in nursing homes. Particularly troubling are medications dispensed to treat behavioral problems among residents with dementia. In 2005, the FDA issued "black-box" warnings on medication bottles designating both atypical antipsychotic medication (which refers to medications with fewer side effects, such as extrapyramidal symptoms or tardive dyskinesia); in 2008, FDA warnings appeared on traditional anti-psychotic medications.
These cautions followed years of research that questioned antipsychotic medications' effectiveness and documented their deleterious consequences-including morbidity and mortality. The Sedating elders
issue of overuse of antidepressants and sedatives in elders also has been raised.
Nursing home residents are often admitted without a long-term history of either psychiatric diagnoses or treatment. However, research conducted in 2010 at the University of South Florida has demonstrated that within three months of admission, 70 percent or more of nursing home residents are on at least one medication with psychoactive properties, and 15 to 20 percent are on four or more. We note in an "in press" article, "Reasons for Psychiatric Prescription for New Nursing Home Residents," in Aging fir Mental Health, that while there is often adequate justification and monitoring of psychoactive medications, the use of non-psychopharmacological approaches to address behavioral problems and psychiatric symptoms lags behind psychoactive medication use.
Computerized warning systems should red-flag residents found to be on improper prescription regimens.
And there is a well-documented high prevalence of mental health problems in nursing homes. Barry Rovner and colleagues, in International Psychogeriatrics (2:1, 1990), suggested that nursing homes can be viewed as de facto psychiatric institutions. There are three main categories of residents with psychiatric problems: those with serious mental illness (schizophrenia, bipolar disorder, schizoaffective disorder), those with dementia and behavioral problems and those who are anxious or depressed because of reduced functioning caused by medical problems and difficulties adjusting to nursing home life.
A Multi-Layered Issue
Researchers, educators and advocates must recognize the complexity of the problem. Contrary to what is often portrayed, many nursing home administrators are sensitive to the mental health needs of their residents, and strive to ensure adequate care, as we concluded in Agingb Mental Health (13:3, 2009).
"Over-medicating" nursing home residents could be considered a rational response of administrators trying, with limited resources, to help residents with multiple mental health symptoms. It also could reflect the society-wide trend of increased psychiatric medication use.
Another factor is that despite mandatory nursing home staff training in mental health care in some states, there is woeful inattention to such matters in state nursing home regulatory statutes, other than federally legislated screening for those with serious mental illness, according to Debra Street and colleague's 2006 Nursing Home Residency and Serious Mental Illness: State Experiences report to the state of Florida. …