Crisis in Long-Term Care Psychiatric Treatment?

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2016 is not a good time to be a psychiatrist or psychiatric clinical nurse specialist in long-term care. Long-term care mental care is in crisis. Overregulation, nursing home politics, and ineffective medications are making practicing in this environment difficult. Psychiatrists and psychiatric nurse prescribers are being told to cut medications of all classes secondary to regulations. Pharmacy consultants review charts and make dose reduction recommendations that the psychiatrist must accept or reject and provide documentation for every decision. The volume of paperwork this generates is significant. Behavior management team meetings are now common in most facilties where staff members from directors of nurses to social workers are suggesting dose reductions. While no one denies a multidisciplinary team approach in patient management and treatment is helpful, the psychiatrist can often feel under attack as he/she is the one who has ordered these medications. In addition primary care physicians and nurse practitioners are often are adding and eliminating medications without input from psychiatry. A common practice is for the primary physician to hear that a patient is depressed, start the patient on an antidepressant, and then order a psych consult eliminating the choice available to the psychiatrist. Recently a primary care physician came in and discontinued all anti-anxiety medications with no tapering. Another frequent example is a primary physician will request a psychiatric consultation but not agree with it, then a week later a new consult is put in for these same behaviors.

The black box warning on antipsychotics, while needed to protect patients with dementia from severe side effects, is impeding treatment of others. In the haste to reduce or cut antipsychotics, patients with schizophrenia are having their medications reduced, resulting in symptoms to be managed solely by behavioral interventions. Bipolar disorder in nursing homes is not listed as illness where antipsychotics are indicated. Using an antipsychotic for its mood-stabling property or to enhance the effect of an antidepressant is not allowed.

Patients with legitimate psychiatric symptoms such as hallucinations and delusions are denied treatment with antipsychotics even though the benefit will outweigh the risk. Medications such as trazodone are often used where an antipsychotic is indicated.

Denial of off label use is strictly enforced, often leading to conflict between patients and staff. Many patients are prescribed Seroquel for sleep in their community by their prescribing physician. This is often after failing other sleeping pill trials. They enter the nursing home where this drug is not allowed due to it being an antipsychotic. They then get disrupted sleep during a time when they might need it most – in rehab.

In addition to antipsychotic use being cut, regulations are now calling for dose reductions in other classes of medications. Antidepressants must have dose reduction trials twice a year even if the patient is stable. This often leads to decompensating and a kindling effect. Anti-anxiety medications can cause many issues as falls, disinhibition, and increased confusion, to name a few side effects. But there are cases where they may be needed or are tapered too fast to comply with reduction regulations.

Many families and attorneys assigned to represent patients now contest the request of a psychiatrist to use an antipsychotic medication when the psychiatrist in good faith feels it is needed. This delays treatment and often prevents it. Involuntary admissions for patients to gero-psych units are overutilized1 and patients often return back no better off because the medications and treatments used in these hospital settings are not allowed in long-term care (e.g., benzodiazepines, restraints, antipsychotics). A patient’s delusions may clear up in the hospital on an antipsychotic. As soon as he returns, suggestions start for a dose reduction.

Patients with dementia often voice depressive and suicidal statements. They rarely have the executive functioning ability to carry these out and often forget they may have said it. Many nursing homes respond to this by a “safety first protocol,” sending these patients to emergency departments and psych units unnecessarily. These are some of the problems facing psychiatry in the nursing home setting.

There are many others of course that all prescribers face as the prior authorizations, insurance denials, and staff politics.

Psychiatry consultants are often asked to document “resident-to-resident” altercations and other incidents that should be part of or routine patient management and at the time of the event. I am often asked to evaluate incidents that have happened days before and, in the case of patients with dementia already forgotten about. These notes are requested because we have to “notify the state.”

A final issue I will bring up is the perception (or reality) that the drugs available in the nursing home settings for patients who are elderly and with dementia are not all that effective.

Antipsychotics have the black box warning that they are not indicated for the treatment of psychotic symptoms in patients with dementia. Recent studies indicate antidepressant use is linked with increased atherosclerosis;2 a limited benefit in dementia patients;3 and increased risk for death, stroke in postmenopausal women4. Antidepressants may only be effective in treatment of the severest depression5, and citalopram linked to abnormal heart rhythm6. Is their use helpful or creating more medical problems for patients?

Cholinesterase inhibitors and Namenda have proven to provide little benefit in nursing home patients.7 Studies also indicate mood stabilizer effectiveness for the treatment of behavioral incidents in patients with dementia is limited and may be harmful.8 Other non-medication treatments as psychotherapy and counseling may have value in the patients without cognitive deficits, but patients with these deficits make up the majority of patients in many nursing homes.

I find working in long-term care mental health frustrating but rewarding. Changes are needed in the current policies that increases costs, take up time and, can destabilize patients. Hopefully, the future will bring new policies, treatments, and medications to further aid this challenging population.


References

  1. LaFerney M. In/Voluntary Admissions. ADVANCE for Nurses. 2006;6(8):35.
  2. Shively C, et al. Effects of long-term sertraline treatment and depression on coronary artery atherosclerosis in premenopausal female primates. Psychosomatic Medicine, April 2015 DOI: 10.1097/PSY.0000000000000
  3. Banerjee S, et al. Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial. The Lancet, 2011:378(9789),403-411.
  4. Medscape. Antidepressants linked to increased risk for death, stroke in postmenopausal women. http://www.medscape.org/viewarticle/714315 
  5. Fournier J, et al. Antidepressant drug effects and depression severity. JAMA, 2010;303(1):47-53. DOI:10.1001/jama.2009.1943
  6. FDA. FDA Drug Safety Communication: Abnormal heart rhythms associated with high doses of Celexa (citalopram hydrobromide). http://www.fda.gov/Drugs/DrugSafety/ucm269086.htm
  7. Laferney M. Testing and monitoring: Essential for cholinesterase inhibitors. http://www.reflectionsonnursingleadership.org/Pages/Vol37_2_Col_LaFerney_testing.aspx
  8. Xiao H, et al. A meta-analysis of mood stabilizers for Alzheimer’s disease. Journal of Huazhong University of Science and Technology. Medical Sciences 2010;30(5):652-658.
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