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When physicians in a nursing home prescribe a medication for a resident, they intend to improve the resident’s quality of life by curing a disease, eliminating or minimizing the symptoms of a disease, slowing or halting the progress of a disease, or preventing a resident from developing a disease or symptoms of a disease. Therefore, federal law (OBRA) requires that physicians apply a benefit-risk analysis in each decision to prescribe a medication. The doctor must decide whether the medication will benefit the particular resident enough to warrant the risks the medication may pose to the particular resident. [1]  Thus, dosages must be tailored carefully to allow for particular patient characteristics taking into consideration the possibility that the drug may interact with that patient’s other medications or disease processes.

Because psychotropic medications pose such a threat to the safety of the elderly, federal law strictly regulates the use of psychotropic medications in nursing homes. In order to assist facilities in their compliance with the law, guidelines have been established for the use of psychotropic medications. All of these medications are subject to the “unnecessary drug” restrictions of OBRA. Under these restrictions, medications that are duplicative, excessive in dose or duration, or used in the presence of adverse effects or without adequate monitoring or indication are defined as “unnecessary drugs” that may not be used. [2]

 Inappropriate Uses of Psychotropic Drugs

Under these legally binding OBRA guidelines, the following are inappropriate reasons for use of psychotropic drugs in nursing homes:

·        Wandering

·        Poor self-care

·        Restlessness

·        Impaired memory

·        Anxiety

·        Depression

·        Insomnia

·        Unsociability

·        Indifference to surroundings

·        Fidgeting

·        Nervousness

·        Uncooperativeness

·        Unspecified agitation or agitated behaviors that do not pose a threat to the resident or to others  [3]

 Appropriate Uses of Psychotropic Drugs

The following are appropriate reasons for use of psychotropic medications:

·        Schizophrenia

·        Schizoaffective disorder or delusional disorder

·        Psychotic mood disorder

·        Acute psychotic episodes

·        Brief reactive psychosis

·        Atypical psychosis

·        Tourette’s syndrome

·        Huntington’s disease

·        Organic mental syndromes, including dementia, that have associated psychotic and/or agitated features [4] including specific behaviors such as kicking, biting, or scratching that are quantitatively documented by the facility, cause the resident to present a danger to self or others, or actually interfere with the facility’s ability to provide care; as well as continuous crying out, screaming, yelling, or pacing if those behaviors cause an impairment in functional capacity and are quantitatively documented

Federal Regulations for Prescribing Psychotropic Medications

To comply with federal law when prescribing a psychotropic drug, a nursing home must do all of the following:

1.      Quantitatively and objectively document the behaviors showing:

·        all methods that the facility has tried in order to protect the resident from harming either herself or a third party without using drugs

·        that the facility has observed the resident and concluded that the behavioral symptom requires some form of intervention

·        that the staff has investigated to determine whether the behavior is caused by other events in the resident’s life (e.g., a death in the family)

2.  Demonstrate that the behaviors are persistent or permanent rather than transitory

3.  Demonstrate that the behaviors are not caused by preventable reasons such as:

·        environmental factors (i.e., excessive heat, noise, and overcrowding)

·        a change in the resident’s customary daily routine

·        a change in the resident’s medical condition such as constipation, fever, infection, or medication reactions    

4.  Demonstrate that the behaviors are causing the resident to:     

·        Present a danger to herself or to others     

·        Continuously scream, yell, or pace if these specific behaviors cause an impairment in functional capacity

·        Experience psychotic symptoms (hallucinations, paranoia, delusions) not exhibited as dangerous behaviors or as screaming, yelling, or pacing but that cause the resident distress or impairment in functional capacity [5]

5.  Document diagnoses and specific target symptoms or behaviors identified by a physician. This is because treatment with psychotropic medications is indicated only to maintain or improve functional status.

6.  Monitor the effectiveness of drug therapy

7.   Observe dosage limits, typically half of a normal adult dosage or less. Because the elderly have reduced kidney function and since most psychotropic medications are excreted through the kidneys, this means the elderly are most at risk if given psychotropics

8.      Attempt periodic dosage reductions or drug discontinuations

9.      Monitor side effects, particularly those of antipsychotics