There have been a variety of public policy initiatives designed to reduce the use of psychotropic medications in skilled nursing facilities, the most well-known is the so-called Omnibus Budget Reconciliation Act of 1987 (e.g., OBRA-87), which sets comprehensive guidelines for training nursing home staff and guidelines for prescribing psychotropic medications in nursing homes.
OBRA-87 required a number of changes to prescribing habits in nursing homes, all in the name of reducing the use of powerful medications as “chemical restraints.” It required prescribers to carefully document medications to be used for specific problems (e.g., as opposed to prescribing a resident Haldol for “dementia” it had to be for a specific behavioral issue). It asked providers to consider the use of shorter-acting medications rather than longer-acting ones, and to avoid other troublesome medications in older adults, such as cholinergic medications. The law also recommended providers regularly institute dose-reduction trials to see whether patients could function on less medications.
It appears OBRA-87 has had an effect on prescribing habits in nursing homes. According to research by Borson and Doane, prescribing habits have changed substantially over the years (Borson and Doane looked at ’89-’92), presumably due to the pressure brought to bear by the federal government’s purse:
- Prescriptions for antipsychotics (e.g., Haldol, thorazine, etc.) in LTC fell by 34.8%.
- Prescriptions for long-acting benzodiazepines (anxiolytics) fell by 70.1%.
- Antihistamines, lithium, and psychostimulant prescriptions also fell significantly (40%, 24.1%, and 17.1%, respectively)
This all looks good. After all, antipsychotic use in the elderly, particularly the so-called “first generation” antipsychotics, poses particular dangers. Many, if not most of the older adults in nursing homes are prescribed antipsychotics for the purpose of controlling behavior issues secondary to dementia – I personally am very concerned about use of these agents with patients, given the issues related to tardive dyskinesia and how prone a demented older adult might be (particularly as their dementia advances in severity) to developing such issues. Avoiding long-acting benzodiazepines and antihistamines in older adults also seems like a good outcome, given the high risk of falls in the long-term care population. Lithium, while effective, tends to have a very narrow therapeutic window (it tends to be toxic, particularly to the kidneys – which also are often compromised in older adults).
However, certain drug classes began to be prescribed more, apparently – particularly short-acting anxiolytics like lorazepam and alprazolam (up by 7.9% and 11.5%, respectively) – and clonazepam prescriptions rose precipitously, up by 368%. While it’s an improvement over longer-acting benzodiazepine meds (like diazepam), in my opinion it’s never a good thing to be prescribing ‘benzos’ of any sort to patients who by their nature are prone to falls and mental confusion.
Prescriptions for buspirone, also known as Buspar, rose by a staggering 557.7%. Buspar is an interesting medication – typically when one wants to use medications to treat anxiety or agitation in anyone, older adult or no, a physician can use the benzodiazepine class of medications. While effective, these have the side effects of increasing confusion and fall risk (particularly in older adults, mentioned above) and of course, are also habit forming. In particularly difficult cases, one can use more powerful first or second-generation antipsychotic medications, but using those with older adults creates the risk of additional problems, such as metabolic side effects and even increased risk of death; this is why the FDA has issued one of it’s rare black box warnings for the entire class of drugs when used with older adult populations with dementia.
Buspar generated a lot of excitement when it was first released on the market in 1986 due to the fact it did not seem to lead to addiction or mental confusion in its users. However, anecdotally (just based on my experience) it doesn’t seem particularly effective, although to be fair it’s supposedly as effective as benzodiazepines for treating anxiety.
Finally, the antidepressant drugs doxepin and amitriptyline also dropped by 24.5 and 35.8 percent, respectively, presumably due to the fact that doxepin is contraindicated for use in people with so-called organic brain syndrome (of which most dementias would qualify). Amitriptyline isn’t recommended for older folks because of its anticholinergic effects (older adults tend to produce less acetylcholine anyways – so they are more prone to unpleasant side effects from drugs with this tendency).
There continue to be periodic initiatives from governmental and regulatory bodies regarding psychotropic use in long-term care facilities, often with a focus on dementia patients. The latest is a push that began in March of 2012 and ended in December of 2012, which aimed to reduce the use of antipsychotic medications in dementia patients by 15% in all nursing homes.
What’s the alternative to using medications in long-term care facilities to treat behavior issues in dementia patients? In one of my next posts I’ll take that on (the subject of behavior management) – there’s actually lot that can be done, but it’s not as straightforward as giving people a pill or a shot – which is probably why it’s not as easy to do.