Authors: Harkirat S Bal.
In the United States, despite the Black Box Warning issued by the Food and Drug Administration (FDA), antipsychotic agents are commonly used among the geriatric psychiatric patient population. Cardiometabolic, Cerebrovascular, Drugs-Induced Parkinsonism (DIP), Tardive Dyskinesia (TD), and Neuroleptic Malignant Syndrome (NMS) are just a few of the more serious adverse effects of typical and atypical antipsychotic agents. Residents in nursing homes deserve to receive optimum psychiatric care with regard to their mental health. Fortunately, almost all of the nursing homes have abandoned the use of restraints. Unfortunately, psychotropic agents (i.e., anxiolytic, antidepressant, and antipsychotic agents) are often needed in nursing homes to manage acute psychosis or disruptive behaviors, such as agitation, aggression, restlessness, screaming, fidgeting, scratching, spitting, hitting, biting, pacing, wandering, refusing care and medications, etcetera.
Nursing homes are subject to meticulous oversight by the Centers for Medicare and Medicaid Services (CMS) and are assessed using a five-star rating system. To adhere to rigorous state and federal regulations and to avoid issues during the survey window, many facilities have strict policies of discontinuing almost all psychotropic agents as soon as a resident is admitted to a nursing home, putting clients at risk of harming self or others.
In general, nonpharmacological interventions should be implemented first, followed by psychotropic agents as adjunct therapy only. However, pressure from residents’ families to “do something” and clinicians’ internal urges to help residents suffering with psychopharmacological agents, especially during acute agitation, necessitate creative and holistic protocol and policy revisions to manage these residents with disruptive behaviors. We owe this vulnerable population a dignified and suitable environment (Milieu) in nursing homes.