Antipsychotic medication in nursing homes

Federal regulations have a lot to say about antipsychotic medication use in nursing homes. In fact, such medications should be used only when absolutely necessary and reviewed at regular intervals for efficacy. This week on the podcast, we welcome Dr. Nancy M. Birtley, DNP to discuss how and when antipsychotic medications may be prescribed to nursing home residents.

Schenk: Hey out there. Welcome back to the podcast. My name is Rob.

Smith: And I’m Schenk Firm.

Schenk: And we are going to be your hosts for this episode. We are going to be talking today all about psychotropic drugs, but not just psychotropic drugs – a subcategory of psychotropic drugs called antipsychotics, what they are used for, their dangers and federal regulations surrounding them. We’re not doing that alone. We’re going to have Dr. Birtley on.

But before we talk about Dr. Birtley, a quick call to action for you, our dear listener. Please, if you are enjoying the content of these episodes, please like and subscribe wherever you get your podcasts from. Check out our YouTube channel. We have at this point now over 100 hours of videos regarding nursing home regulations, nursing home safety and nursing homes in general. So if you do go to that YouTube channel, please hit the notification bell so that you’ll be alerted for new videos and subscribe there. If you have a suggestion for content, please let us know. Shoot us an email or comment somehow, flag us down when we’re out and about on the town.

So this episode, folks, we are talking about antipsychotic medications and what they are used for in nursing homes, and as I said, we’re not doing that alone. We have a real expert with us today – Dr. Birtley. Will, can you tell us a little bit more about Dr. Birtley?

Smith: All right, well Dr. Nancy Birtley is an assistant teaching professor and an area coordinator of the Psychiatric Mental Health Nurse Practitioner Graduate Nursing Program at the University of Missouri Sinclair School of Nursing, which is also where she got her degree and her doctorate. In addition to her teaching position, Dr. Birtley is certified as a psychiatric mental health clinical nurse specialist and psychiatric mental health nurse practitioner. She’s got over 30 years of psychiatric nursing experience. She’s worked in different roles including staff RN, nurse manager, psychiatric nurse liaison and for the past 27 years as advanced practice nurse. She’s the owner of Nancy M. Birtley LLC Psychiatric Consultation Services, where she provides psychiatric consultation services to residents in over 20 long-term care and retirement communities in the St. Louis metropolitan area. She specializes in geriatric psychiatry and long-term care and she has expertise in dementia treatment and reducing unnecessary psychotropic medications, which is why she’s our guest today.

Schenk: Awesome. So in other words, highly qualified.

Smith: Highly qualified.

Schenk: Awesome. Well Dr. Birtley, welcome to the show.

Birtley: Good morning, thank you so much for inviting me.

Schenk: No problem. We are excited to have you on because you are definitely an expert on this subject and I don’t believe on this podcast after however many hundred some odd, seventy some odd episodes that we’ve had an entire episode dedicated to antipsychotic or even psychotropic drugs in general. So we’re super happy that you’re here to educate our audience on the basics of what these drugs do and why the industry should be monitoring them and their usage in nursing homes. So as an opening question, just in general, Dr. Birtley, what is a psychotropic drug and specifically what is an antipsychotic drug?

What are antipsychotic medications?

Birtley: Of course. So a psychotropic drug is a general term that describes any medications that are used to treat a psychiatric illness. That may include antidepressants, anti-anxiety drugs, mood stabilizers, etc. There is a class called antipsychotics that are a type of psychotropic drug, and that type of drug is typically used to treat psychotic symptoms like hallucinations where people see things, hear things, taste things, smell things or feel things that are not real or delusions, which are commonly false beliefs which most people would think of that as paranoia, fear that someone’s out to get them or someone’s talking about them or against them. Those symptoms are caused by a chemical in the brain called dopamine, and when there’s too much dopamine, it stimulates our sensory neurons to see things and hear things and believe things that aren’t real. And what these drugs do, they block the neurons from being stimulated by dopamine, and therefore they don’t stimulate those neurons to fire to make us see things and hear things and believe things that aren’t real.

Schenk: So if I understand correctly then, these types of drugs are used to treat the symptom of someone having a hallucination. Or so I guess how does it work – I don’t know, I’m not a doctor or anything so I’m just using layman’s terms like does it stop the chemical and it stops the hallucination? Or does it make the hallucination go away? Does it make it less? How does that work?

What are antipsychotic medications typically used to treat?

Birtley: What these drugs do is they will stop the hallucination. They will stop the delusion by blocking that chemical in the brain from stimulating the neurons to think that there’s something there that isn’t really there. These drugs are typically used for schizophrenia, and most people know schizophrenia – many people think schizophrenia is multiple personalities, but in reality, schizophrenia is someone who has hallucinations and delusions, false beliefs and they see things and hear things, etc., that aren’t real.

Schenk: And to your knowledge, are these drugs I guess more highly regulated in nursing homes than other drugs? And if so, why?

What are guidelines governing use of antipsychotic medication in nursing homes? 

Birtley: Absolutely, these drugs are more highly regulated. And the reason why is there has been a large amount of research and very rigorous research that have shown these drugs have very adverse side effects, especially in elderly people with dementia. These research studies actually indicate increased association with death – 60 to 80 percent increase in death in people who have dementia and take these drugs compared to those who have dementia and don’t take these drugs. And that death is typically caused by strokes and heart attacks but may also be caused by other things like falls.

Schenk: What about the idea that these drugs kind of make the individuals have behavior that is more beneficial to the staff and that’s a possibility of why these things are being prescribed when they’re maybe not supposed to be being prescribed? I understand the concept – it’s dangerous because it makes the risk of stroke or heart attack higher, but can you speak to the behavioral component to these prescriptions?

Birtley: Yes, and these drugs are very commonly used first line – they’re very commonly prescribed first line for that very reason, to reduce behaviors quickly and make it easier for caregivers to provide any care that these residents need. These drugs take five to seven days in most cases, but in some cases 10 to 14 days to even have an antipsychotic effect, so they’re not using these drugs to treat a true psychosis. They’re using these drugs to sedate, to give quick and easy response, and that’s historically why they’ve been used as a first line agent, not so much to treat psychosis, because in elderly people with dementia, it’s not a true psychosis caused by that chemical in the brain. It is confusion, not delusion, confusion, not hallucinations. And these drugs are simply being used to sedate and not to treat a true psychosis. They do work quickly and that’s why they like to use them first line because they work quickly. Within a half hour, the person is usually calm.

Smith: And that is what we tend to see is that places that are short of staff, when you have somebody who is problematic for the staff who doesn’t want to cooperate because they don’t know what’s going on because their reality is different, it’s easier to have that person chemically compliant than it is to find alternatives. So it seems like it’s often misused.

Birtley: I agree. It is often misused in that way and it’s something that I have dedicated my career to is educating the staff on how to intervene other than using psychotropic medications and ways that may like it takes more time for the staff to intervene but in reality, it’s much effective, and in the long run, takes less time to intervene based on that particular resident.

There are other classes of psychotropic medications that are safer and just as effective and less sedating that might relieve some of those symptoms if the staff’s non-pharmacological interventions are unsuccessful or not sufficient to reduce the behavior. So it’s a huge – it’s not black and white. It’s a very complicated situation because, yes, they are many times understaffed. The staff is oftentimes not trained to deal with these individuals. So yes, the drugs are often used inappropriately for that reason.

Schenk: And I think it speaks volumes to the power of these medications that in federal regulations governing nursing homes, which in a lot of way don’t have any teeth, these regulations revolving around psychotropic drugs, it’s essentially the default position is not to prescribe them unless absolutely necessary. And then if somehow you prescribe them as needed, the as needed only lasts for two weeks, and I think that to me shows how dangerous these things can be because there are other things I don’t feel like there should be higher regulations on and there aren’t, like pressure injuries or reducing the hazards from falls and the regulations don’t really touch on those too much, but with these drugs, they do.

So let’s kind of – you mentioned interventions and interventions apart from prescribing these medications, so can you talk a little bit about the assessment process with the resident that has behavioral issues that might need these medications, and then what interventions do you see in your research, in your experience, that maybe are better or at least an alternative to using these drugs?

Why are assessments so important for prescribing antipsychotic medications in nursing homes? 

Birtley: Yes. So as we assess individuals who are having behaviors, the first thing to evaluate is are they a danger to themselves or others, because that’s one of the caveats that the federal regulations give as a reason to use antipsychotics first. If that individual is severely combative, picking up furniture, throwing furniture, putting other residents in danger, that is one of the rare situations that an antipsychotic is considered appropriate by the Centers for Medicare and Medicaid.

Certainly that needs to be documented extensively and certainly that can be prevented 90 percent of the time if we intervene quickly. So if staff can be in-tuned to very subtle changes in the resident’s behavior – are they starting to become more restless? Are they starting to pace? Are they looking for their mother or father who are long deceased but they don’t remember that?

And for staff to sit down with them and one of the most effective means, non-pharmacological means of dealing with this is validation. You validate their reality rather than imposing your own reality on these individuals. So if this resident is looking for Mom and Dad who are deceased, you’re not going to help matters by saying, “Oh, your mom and dad have been gone for 50 years,” or “Gee, what is your birthday? How old are you? Oh, you’re 90? What makes you think your parents would still be alive if you’re 90? What sense does that make?” That is not the appropriate way. That’s called reality orientation.

The appropriate way is to ask, “Tell me about your mom and dad. What were they like? What kind of work did they do?” Really get them to engage and reminisce about their parents, validate that they believe their parents are alive and validate as if their parents are alive and really engage in a caring, empathic conversation with that resident about their parents. That takes a little time, and in the long run, you will start to settle them down a little bit and at that point, you can move into distraction and move into more recent conversations or more recent discussions.

Of course exercise, walking with them, helping them “look for their parents” or helping them explore their environment, music therapy, and that’s using music from their time, and that’s going to change as each generation comes into the facilities. It used to be we played a lot of Big Bang music and classical music, and now we’re starting to see baby boomers coming into the nursing homes. So maybe we’re going to move into rock and roll or rap or some of the music that that generation started to see, but music that they’re familiar with can also help calm them.

So they’re using more aromatherapy where they have certain types of essential oils that they might rub on the skin that helps calm people and scents like cooking cookies, the smell of Tollhouse cookies that are baking. So different types of aromatherapy are all excellent, non-pharmacological interventions. But the key is to intervene quickly and be able to recognize this. And staff that care for these residents day after day start to get a real sense of, “Oh, Mrs. Smith, she’s really starting to get upset. We’re going to start intervening and talk with her and walk with her and help her be calm before she gets to the point of being agitated and upset.”

Schenk: I like what you said about starting with validation and trying to understand the perspective of that individual resident and what they’re going through, asking the questions, and going for a walk with them and participating in that activity while validating. And we had an episode, at least a couple years back, on elopement, and Will, I don’t know, I can’t remember the guy’s name, he had a military background, but he started an organization for awareness of elopement and wandering, and he referred to it as going on a mission, that if the individual is trying to walk out there, it’s because he’s going to work or they’re going to visit their mom because they’re home from college. So part of that validation process is understanding possibly, if you accept that you can, what that mission is, and then you help them on that mission or you do the sidetracking thing, but never like, “You haven’t worked since 1962.” You validate. That’s kind of what he was saying as well.

Birtley: Indeed. And I have had nursing homes with some of the best validation. We had a resident who was a maintenance man and every day, he would sundown. Sundowning is a term we would use to describe as the day progresses, they get more confused when they have dementia. And he would try to tear things apart in the unit. He would try to break down the desk or he would try to break down the drinking fountain or what have you because that was his job as a maintenance worker. So they started giving him safe jobs to do when he would start looking for a job to do, and at one point he would come up and they’d say, “Oh, I need you to work on this transistor radio,” and he was wise to this and said, “Well I can’t do that without a work order.” So then the nursing staff started creating a work order and they did this validation of this man’s reality and it just went swimmingly. That whole shift, he was calm. He was relaxed. He was feeling like he was in his own real world and not being belittled. And a lot of the point of validation is saving face, helping them save face and maintain their integrity and their self-esteem rather than belittling them and making them feel stupid because they don’t remember that their parents are deceased or that they no longer work or whatever their reality happens to be.

Schenk: I see. Will, were you going to say something?

Smith: Well I was just going to say, and I’m not sure whether or not this is advisable psychiatrically, but I used to work in a nursing home and being the one male or one of the few males in a very female-dominated area, I would always be confused by the residents as somebody’s long-lost son or somebody’s husband all the time. And again, I’m not sure if this is the right thing to do, but I would always go along with it because I just didn’t see the point in saying, “Your husband died in World War II,” or “Your son doesn’t come here anymore,” or anything like that. And it seemed to be that that’s all they wanted to know.

Birtley: I think that’s very appropriate. Your point is to create moments of joy, not cause distress and suffering and grief. And just going with the flow – unless it leads to something more inappropriate – but for the most part, you’re validating them and you’re creating moments of joy and there’s nothing wrong with that. I had a lot of staff that are afraid because they think they’re lying and they’ve always been taught not to lie, and I always tell them, I did a seminar and there were a bunch of sisters from the various convents in the area, and I even turned to the sisters and I said, “Sisters, is it okay to have a little white lie to help these people with dementia have a better life?” and they said, “Absolutely.” So that kind of absolves these people who are afraid of lying to these residents because it’s all about creating joy, creating wellbeing and maintaining integrity and self-esteem of these residents.

Schenk: Dr. Birtley, do you have any advice with regard to what we’ve been talking about for families who might be listening who might be watching? What are some of the questions that you think they should bring to the nursing home if their loved one is on these types of drugs and it seems maybe in their eyes that they’re being chemically restrained or sedated on purpose? What are some things that you would advise for those families?

What should families ask about their loved ones medications?

Birtley: I would advise the families first of all to get a list of the medications and get information about the medications. They will Google it. They will look the medications up. They will see the risks and it’s important for them to talk to a provider about what are these medications, why were they prescribed? Why were they prescribed particularly for my Mother? Can we attempt a dosage reduction?

It’s important not to just stop at cold turkey and depending on the dose, if it’s a real low dose, we can attempt a reduction very quickly. In fact the federal regs recommend a dosage reduction with at least a month between attempts, so if you’re got a drug at 10 milligrams and you bump it down, knock it down to 5 milligrams, waiting a month before you do the next reduction, because when they wrote these regs, they understood there’s a chance the symptoms are going to come back. And if they truly need an antipsychotic for true psychosis and you completely discontinue it quickly, there’s a real good chance they’re going to end up on the drug in a higher dose because it was reduced too quickly.

So the regulations allow for that, but I have found in my practice that most of the time I am able to successful get my clients off of these drugs because they’re not truly psychotic. And I educate the family. I educate them just as we talked today – how do these drugs work? What are they usually used for? What are the dangers? What are the risks? How do we reduce them? How can we intervene and talk with Mom when she gets upset because these drugs aren’t just prescribed in nursing homes for caregivers to be able to provide care – these drugs are also prescribed as first choice in the home for individuals who are caring for dementia residents in their own home and it’s a first choice there also. And it’s really easy for a wife to give her husband a Seroquel rather than have to battle with him about bathing or leaving the house at night. So the family learning different ways to intervene with the residents just as you would educate the staff on different ways to intervene – how to validate rather than reality orient, how to reassure them that they’re safe and secure and that you care for them.

Schenk: And that’s a theme throughout many of the episodes of this podcast is family involvement. We have covered how to get medical records, how to order medical records, how to request them, what a care plan meeting is, why to participate in them, and I think that you just underscored that. Understanding your loved one’s medication regiment, their care plan, the interventions that are in the care plan, that will definitely educate you on what the nursing home should be doing or should not be doing or is not doing enough. So that’s the blueprint and you hit it right on the head, I think. The first thing is get ahold of that care plan, get ahold of what their prescriptions are. So I think that’s super important.

Well Dr. Birtley, we really, really appreciate you coming on and talking to us today about this subject. Like I said, we haven’t really covered it in depth in the past and I feel like I learned a lot. And even preparing for this show, I looked over the regulations and I realized I have the old regulations, that these regulations have been updated and I’m like, “Oh my goodness, I’ve got to…” Will and I have the watermelon book, which you may or may not know is the surveyor guide, Will, I guess has all the regs in it, and so I’m realizing as I’m going through this new watermelon book that I’ve got to update my actual regs that I’ve printed off maybe five or six, seven years ago. I’m like, “Oh my goodness.” Anyways, so there’s been changes to these regulations that I need to learn about. So again, appreciate you coming on the show and a lot of great information.

Birtley: Well thank you so much. And certainly if there’s any more you want to talk about in the future, I’m happy to come back. This is a topic I’m very passionate about and as you just said, the regulations do change and many providers don’t keep up with those regulations, and it is very important to keep up with those and help the residents in the facility be able to maintain compliance, because that compliance is going to keep the resident safer and healthier.

Schenk: That’s right. Thank you so much.

Birtley: Thank you.

Schenk: Yeah, this is, again, we talked about chemical restraints in an episode way back when but I don’t remember getting into the nitty gritty of antipsychotics. We talked about physical restraints in other episodes but I’m really glad that we had this one. Dr. Birtley was fantastic. We’ll definitely have to have her on again.

If you’re watching the episode, you’ll see periodically me hold a coffee cup up to my face, and Daniela and I went to a place, we went to go visit my family, but we went to a place in South Pittsburg, Tennessee, which just sells cast iron stuff, so it’s the Lodge Cast Iron Store, and we bought a bunch of cast iron skillets.

Smith: It’s all that I use is a cast iron skillet.

Schenk: It’s the best.

Smith: Yeah. You got to maintain it, keep it up, seasoned.

Schenk: And I have to get my own, because I’m “ruining” all of her pots and pans, so I had to buy my own cast iron skillet for rib-eyes that we cook. So anyways, I guess that’s the only update that I have. So anyways, I’ve got about two minutes left before this Zoom meeting runs out because we’re too cheap to buy Pro, so with that, new episodes every other week, that’s twice a month on Mondays. Again, check out our YouTube channel. We have hundreds of hours of videos for you to watch, learn more about nursing home care, nursing home safety. And with that, we’ll see you next time.

Smith: See you next time.