Psychotropic Medication Use
This is a preliminary rather than a completed best practice framework.
The DADS Quality Assurance and Improvement vision for psychotropic drug use in LTC is
Using psychoactive medications only for appropriate clinical indications and with proper monitoring.
Definitions and Scope
Although the term psychotropics has a variety of meanings made explicit in state and federal statutes, the term here is used more narrowly to refer to three classes of agents: antipsychotics, anxiolytics and sedative/hypnotic drugs. Drug classes such as antidepressants, anticonvulsants, anti-parkinsonian agents and others used in the management of other psychiatric and neurological conditions are addressed in illness-specific frameworks. The general principles of appropriate psychotropic drug use are discussed in this page while more specific information is presented in medication topic pages.
Behavioral and psychological symptoms are common among nursing home residents, with a prevalence as high as 82% among those with cognitive impairment. Many nursing home residents also experience sleep disturbances. In Texas LTC facilities, nonpsychotic behavioral symptoms and sleep disturbances are often managed inappropriately with psychotropic medications. These agents cause a greater incidence of adverse events in the elderly. Successful non-drug therapy for these symptoms can decrease adverse drug effects, improve resident outcomes, and reduce health care costs.
A 2003 DADS review of the medication administration records of Texas nursing facility residents 65 years and older found that 28.9% of residents had taken an antipsychotic in the preceding week, 18.7% had taken an anti-anxiety medication, and 8.5% had taken a sedative/hypnotic. Texas residents were prescribed these medications at rates 1.2, 1.7 and 3.0 times greater than the corresponding national averages. Among residents taking antipsychotic medications, 37.5% had no clinical indication that met widely accepted criteria (e.g., OBRA-87) for appropriate use. In the absence of persuasive evidence that Texas nursing facility residents have greater needs for psychotropic medications than LTC residents elsewhere in the United States, there is reason for concern regarding the appropriateness of psychotropic medication use in Texas LTC.
Evaluation prior to the reduction or discontinuation of psychotropic medication should include the following:
Clear Identification and Understanding of the Clinical Problems, Goals, and Risks
Residents on more than one psychotropic drug, residents whose
symptoms have been controlled for 30 days or more, and those who experience
side effects are candidates for medication reduction or discontinuation.
For these residents, ask the following questions (these apply to all
antipsychotic, anti-anxiety, and sedative/hynotic drugs):
- Why were psychotropic drugs prescribed?
- Was a specific clinical condition diagnosed and documented in the clinical record?
- Were relevant non-pharmacological interventions initiated prior to prescribing a psychotropic agent?
- Is psychotropic therapy appropriate for this condition?
Has informed consent been obtained from the resident and/or family? Make
sure the informed consent includes the following required information:
- Specific condition to be treated;
- Beneficial effects on that condition expected from the medication?
- Probable clinically significant side effects (common side effects/adverse reactions) and risks associated with the medication, as reported in widely available pharmacy databases or the manufacturer's package insert; and
- Proposed course of the medication.
- What are the measurable goals of the prescribed therapy? (For example, "The resident will wash his hands no more than ten times a day. There will be healing of cracked, bleeding hand lesions.")
- Are those goals being monitored? Has therapy been titrated in response to therapeutic monitoring?
- Are side effects being monitored? Has therapy been titrated or changed in response to side effect monitoring?
Trial and Evaluation of Reduction or Discontinuation of Therapy
Identifying a mood or behavioral symptom should not lead directly to the prescribing of psychotropic medications without a trial of non-pharmacological management. The exceptions to this statement are situations in which most clinical evidence shows that psychotropic therapy is necessary to manage the disorder (e.g., schizophrenia and related psychoses). Similarly, to proceed directly from identifying residents taking psychotropic medications to the discontinuation of those medications is not best practice. In general, stepwise medication reduction at certain time intervals (e.g., every seven days) is recommended. Residents should be carefully evaluated at each interval for the emergence of side effects or new symptoms unresponsive to non-pharmacological therapy, which should be implemented during, as well as after, psychotropic drug reduction or discontinuation.
If dose reduction is ended due to an adverse event (e.g., the reemergence of symptoms that cannot be controlled without medication), this should be documented in the resident's chart. It is important to note that research has repeatedly demonstrated that the discontinuation of antipsychotics [4,5,6,7,8] and benzodiazepines [4,8] in nursing home residents is often successful. Discontinuation of pharmacological therapy is not necessarily associated with an increase in behavioral symptoms [5,6,8] or an increased use of physical restraints.[5,7]
Not every resident who is on psychotropic therapy will be a candidate for
reduction or discontinuation of psychotropic therapy. Use the following DADS
Quality Monitoring structured resident assessments to assess the appropriateness
of psychotropic drug use and to identify residents who are candidates for
withdrawal of the following psychotropic drugs classes:
Validated tools for illness screening and symptom rating are also available.
These scales are supplements to rather than substitutes for resident assessment
and a detailed recording of symptoms. Use scales that are specific to the
For care planning strategies, refer to each specific topic.
- Use of Antipsychotic Medications
- Use of Anti-Anxiety Medications
- Use of Sedative/Hypnotic Medications
Key Components for Successful Psychotropic Drug Reduction Programs
Successful psychotropic drug reduction initiatives requires cooperation from
staff and family
members.[4,5,6,7,12] Include the following structural
and process elements in your initiatives (these apply to all
of antipsychotic, anti-anxiety, and sedative and hypnotic drugs unless
- Psychotropic drug reduction training for all staff members.
- Geriatric psychopharmacology training for medical staff.
- Psychotropic drug reduction education for family members.
- Frequent reevaluation of all residents who remain on psychotropic drug therapy.
Part I. Education
- Assess the factors that influence the prescribing of psychotropic drugs in your facility.
- Use DADS Joint Training and QMWeb resources to provide staff and family education on psychotropic drug reduction.
- Educate staff and family members on the use of non-pharmacological alternatives for behavioral symptoms, sleep complaints and situational anxiety.
- Provide periodic training in strategies to manage behavioral symptoms in residents with dementia.
- Develop a facility plan for reducing the use of psychotropic medications, and present it to staff, family and resident council.
- Work with DADS Pharmacist Quality Monitors to pilot, evaluate and refine your psychotropic drug reduction program.
Part II. Discontinue Unnecessary Psychotropic
- Begin with your facility's Quality Indicator report to identify residents who are taking antipsychotics in the absence of a psychotic disorder (QI-19) and residents who are taking anti-anxiety and/or hypnotic medications (QI-20).
- Review all medication administration records in order to identify additional residents on antipsychotics, hypnotics and anti-anxiety medications not yet noted in MDS assessments.
- Use a structured assessment instrument to evaluate each of these residents for the appropriateness of psychotropic drug use. Leave the completed assessment(s) on the chart for future reference.
- Schedule periodic psychotropic drug use reassessment for every resident who continues on treatment.
For residents in whom psychotropic medications were begun without a trial
of non-pharmacological interventions or begun for particular symptoms, address
- What is the psychiatric diagnosis? Does it meet DSM-IV criteria?
- Do the symptoms represent a danger to the resident or others?
- Are there environmental triggers for these symptoms?
- Are there treatable medical causes such as pain for these symptoms?
- Have the symptoms worsened when the medication was tapered or discontinued?
Implement a psychotropic drug reduction plan.
- Involve the resident's family in the design of the plan.
- Provide family education on the risks of psychotropic drug use, the expected negative effects of continued psychotropic drug use, and the anticipated benefits of psychotropic drug reduction.
- Closely monitor the resident for adverse effects of dose reduction.
- Adjust the pace of dose tapering to minimize adverse effects.
- Carefully document the changes in the symptoms of residents in whom psychotropic drug reduction or discontinuation is not successful.
- Review each chart to identify instances in which care plans and actual care giving are not congruent.
Part III. Prevent the Unnecessary Initiation of
- Require the use of structured assessment for psychotropic drug use before these medications can be ordered.
- Utilize a formal facility process to care plan, implement and evaluate the use of behavioral interventions and environmental modifications for symptoms that may respond to non-pharmacological therapy.
- Use a formal review process to develop care plan alternatives when structured assessment shows that psychotropic drug use is not necessary.
Part IV. Monitor Therapy for Benefits and Side
Use a process of on-going structured assessment to ensure all of the following:
- That there is monitoring for the known side effects of the psychotropic medication(s).
- That there is monitoring of each psychotropic medication's effects regarding the therapeutic goals. For example, monitoring of the sleeping patterns of residents taking hypnotics.
- That psychotropic medications are considered as possible causes of unexpected adverse events
- That the family and prescribing physician are notified of significant changes in the resident's condition that may be related to psychotropic medications.
- That the physician responds to notifications concerning adverse events potentially related to psychotropic medications.
The following deficiencies may be cited for failure to use psychotropic medications appropriately. Tags that might be cited as evidence that necessary services were not provided to a resident with psychiatric symptoms are also listed. The deficiency list is representative rather than exhaustive.
|Program||Licensure Tags (State)||Certification Tags (Federal)|
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