Finding a Place for Antipsychotics in Nursing Homes
Why this physician supports the use of antipsychotics in palliative care.
The outcry over the use of antipsychotics has ranged far and wide. Governmental agencies and senior advocacy organizations have pointed out the abysmal data: Antipsychotics have a negative impact on morbidity and mortality. They say we are chemically restraining those who are too fragile to stick up for themselves. They say we are sedating patients instead of treating them.
And I disagree wholeheartedly.
I manage a large group of moderately to severely demented nursing home patients. They are agitated and delirious on a regular basis. Assessment for infections, pain, constipation, depression, or other inciting factors often come up empty. Their behavior is disruptive, dangerous, and heartbreaking for their loved ones.
The proper treatment of impeccable environmental control, one-to-one supervision, and extensive counseling for both patient and family is often not available or prohibitively expensive. And so, our choices become limited.
We have moved away from physical restraints in the skilled nursing facility environment because they are dangerous, inhumane, and oftentimes add to agitation. Sedatives (specifically the benzodiazepine class: lorazepam, alprazolam, clonazepam) can increase agitation and are frowned upon among geriatricians.
Leaving patients floridly delirious without treatment is not only unduly burdensome to the family and nursing staff, but it also pulls clinical support away from others who need help on the unit and leaves patients upset and suffering.
Antipsychotics are effective. They calm quickly with few physical adverse effects.
Using antipsychotics in a demented person suffering from delirium is a prime example of palliative care. They are prescribed for patients with moderate to severe dementia who have a low-quality existence.
This is what defines palliative care. We trade quality for quantity in patients who suffer deeply and who are often only minimally aware of their surroundings.
It's good for patients. It's good for families.
It's excellent palliative care.