As a nurse in a long term care facility, I can say this righ there is a load of bullshit.

THey have causality reversed. Usually when an elderly altered mental status patient is put on psych meds, it is usually because they are agitated, behaviorally disruptive, and a HUGE fall risk already. These drugs REDUCE falls, not incrase them, and I'll explain why.

State rules, being set by colossal retards, mandate that nursing staff cannot restrain a patient. We can not use 4xs bed rails, we cannot tie a patient in his chair with a seatbelt, we cannot use a lap buddy (a pillow-like device attached to the patient's lap to discourage him from standing unassisted)... these things must be careplanned and very good reason needs to be in place. If a nursing home has all their patients restrained with clickable/soft belts, they will get in trouble with the state. If the state sees 4x bed rails, you're in big trouble.

But, if you DON"T stop these demented fragile patients from getting up, they will break their hips and be very injured.

So, what to do?

You call the resident psychiatrist. He pops by and puts your little 90 yr old demented walker on a sleeping pill of seroquel or a spot of remeron, with PRN ativan for agitation, and viola, grandma is now sleepy and calm and does not want to stand anymore.

I have first hand observed these drugs used to reduce falls and injury, not cause them. They calm patients (dementia causes confusion anger and agitation and wandering) and they prevent, not cause falls.

If anyone is causing falls it is the state and their stupid unrealistic rules about how to care for the demented and elderly.

News flash, state idiots: the ratios of patient;staff in a lot of the more terrible nursing homes makes it impossible to take care of patients without restraining them. Some patients simply require 1:1 and cheap ass nursing homes are not paying for that staff. In my state, by law, in LTC a nurse can only take 30 patients... but many crappy homes in my area put as many as 40 to 1 nurse. That is so insane.

Anyway, the connection between drugs and falls is that patients who wander and fall end up being put on these drugs to reduce the risk for falls.

The non-ambulatory patients don't end up on these drugs (unless they are behaviorally disturbed) because the #1 reason for giving elderly people baby doses of seroquel and mirtazapine is a propensity to agitation and wandering.

No, that's not an indicated reason. But that is the REAL reason. And the psychiatrist in his progress notes will emphasize anger/agitation/aggression, but the real reason is the wandering and falling.

So when the state does their assessment of pts with high falls they look at the meds they are on, and instead of concluding that psych drugs are given to reduce falls, instead they conclue psych drugs CONTRIBUTE to falls. Because, you know, they are big big big big big morons like that.

Trust me, as a nurse, govt is totally inept about understanding anything related to nursing care. This does not surprise me. Its because of these fools we need to even use seroquel and remeron and stuff, if they let us more easily use seatbelts and lap buddies none of this would be necessary.

If the pt truly has depression he'll end up on seratraline or something. Docs don't give 50 of seroquel and remeron for depression, they give that for agitation and being a danger to themselves.

Noone, I don't get how you can say sedating drugs don't contribute to falls. That's like saying if I get boozed up I'm less likely to stumble around and fall because I'll be sleeping. How many drunks fall flat on their face? Sedating drugs DO contribute to falls, and it's goofy to argue otherwise.

As a former aide in nursing homes I agree with noone. I worked in more than one crappy home, here and in Ireland. Restraints can be--and were--abused. But so can drugs. I'd much rather have my loved one physically restrained than drugged or risk falling because it's really unreasonable to think any facility can provide constant 1:1 care. Actually, that level of supervision would be pretty intrusive.

Similar line of thinking as no one- the patients with more problems should be both higher likelihood to have one, or more, psych meds, and more likely to fall. --It is surprising that narcotics, unlike benzo's, have no influence upon likelihood of a fall- I would have thought they would contribute. also, pharmacologically, I cannot think of a reason why an SSRI would make a fall more likely - no one is probably dead-on: this may be a list of leading drugs for "agitated" patients who were tied-down in the good ol days.

"trust me as a nurse" NO THANK YOU "NO ONE". Oh My God! where do you work? the nursing homes Dr Michael Reinstein loaded up patients on Seroquel?

You are upset, pissed that you cannot use physical restraints on a patient?

I don't who you are, but this comment you left at 1:42am 12-7-09 represents the sickening example of care of mental health and elderly patients in this country.

Maybe your comment is a joke, I hope it is one.

"noone" or is it "julian"

Your comment is so absurd and idiotic that it doesn't deserve much of a response. I really have to question if your just here writing as a certified "rabble rouser" anywise.

If you are actually a "registered nurse" dispensing these drugs to the elderly as deemed chemical restraints; then you are as directly culpable and guilty as any doctor writing the prescription.

Though I have a sneaking suspicion you feel absolutely no shame or guilt for your blatant abuse of the elderly. Job well done ----.

You are very much a part of this very dangerous criminal problem in our Health Care System that needs to be addressed urgently at every level of care.

My grandpa, a WWII veteran, fell quite often. But his end of life experience, though very sad, showed me what caring, good doctors and nurses were like, they never prescribed him any psych med because he would fall and he was always treated with respect. So "noone" I honestly hope you consider a new career. From what you have written it sounds like you are herding cattle rather than truly caring about our elders. These are people who have experienced far more than you ever have, how would you want to be treated if you were in their place?

@ disgusted One can only hope karma will come back and bite noone on the butt.

When I was on neuroleptics, I kept falling down because they messed with my motor systems. I had tremors and muscle weakness, and developed tardive dystonia; one leg is still prone to spasming out from under me. The EPS were brushed off at the time. Luckily, I was young and fairly healthy, and never broke anything!

Elderly people are at particular risk of developing EPS from neuroleptics, also from SSRIs--"in particular in medically ill patients with underlying brain disease", such as dementia.

My grandmother suddenly developed Parkinsonian tremors and a drooping eyelid after being given Zoloft; that led to some falls, which were thankfully not as bad as they could have been. To my knowledge, EPS were never considered during the neurological workup, but this was in the mid '90s. These symptoms largely went away when she was taken off the SSRI.

I shudder to think how many older people probably do get EPS, with the adverse effects just being taken for symptoms of dementia. Whether the elderly person had dementia starting out or not.

Interesting, Urocyon, I never knew that. Makes sense, I have an underlying neurological condition and developed "fly-catcher's tongue" after ONE DOSE of a neuroleptic. Thank heavens it went away.

Hey, what's the *absolute* risk?

There are a myriad of issues related to medicating residents with psychotropic medications in nursing homes. The first, and most salient, issue in my opinion is the lack of diagnosis. Per Federal regulations "agitation" is not a diagnosis and must be accompanied by a diagnosis and quantified episodes of behaviors to support the use of psychotropic medications.

The second issue is that behavioral interventions are generally not attempted prior to medications and/or even after the medications are in use.

The third issue is that the FDA has (twice) issued black-box warnings related to use of anti-psychotics in the elderly; the use is primarily related to the use of anti-psychotics for "off - label" use (i.e. dementia).

The problem with the diagnosing of the elderly is that many times they are diagnosed with "atypical psychosis" or some other psychotic disorder without supporting evidence of the illness. "Atypical psychosis" could actually be exhibiting due to a resolvable factor such as acute illness, reaction to anesthesia, and so forth.

The nursing home industry faces numerous challenges and many of them are rising to the occasion (and many are not). The better performers are taking an Interdisciplinary approach to fall prevention and ensuring Gradual Dose Reductions (GDRs) are occurring per Federal regulations. Fall and behavioral management should be multi-factorial - strong Social Work assistance, Activity Programming in place during peak Incident/Accident times, Physical/Occupational therapies in place, restorative exercise programs, nursing interventions, and so forth.

One of the biggest problems currently is related to admitting residents from hospitals, where the use of psychotropic medications for the elderly is not regulated in the same manner as nursing homes, that have "junk" diagnosis and who have to dose reductions and be taken off the medications.

As a side bar, nursing homes are being fined and receive citations related to the use of pyschotropic medications. Regulations were expanded in 2006 related to the use of the medications and requiring (formal) Monthly Medication Regimen Review for each resident by a pharmacist. This does not necessarily keep unscrupulous operators from dispensing psychotropic medications like candy but it is beginning to limit the widespread use that used to be evident.

From my experience, almost 20 years in the Nursing Home industry, any type of psychotropic medication presents risk and the best process is a risk/benefit analysis and Interdisciplinary approach. I think we do have a tendency to overmedicate the elderly and misdiagnose mental illness.

Thank you for the interesting comments and thought-provoking discussion. This has been helpful.

"Noone",

If you actually read Stephany's blog you would probably come to realize that she cannot bring her daughter home even if she wanted to. Don't be so judgmental of someone you barely even know, it just makes you seem even more insensitive and cruel, not a nurse I would ever want to care for me or my family.
The "kooks" who read this blog are people who are dissatisfied with current psychiatric treatments and the mental health system, because face it, its lacking.
So you're upset that the people here were not happy about giving these medications to seniors? Some of these readers had terrible reactions to these drugs that weren't even acknowledged by their own doctor.
Yes your jobs sucks because. as you said, there are too many patients per nurse at your job and that's tragic, but that doesn't mean you should lose your ability to feel for other people's pain - including other commenters on this blog.

Having family members who also work as aids in elderly care homes I can identify with much of what noone has to say. They give the best effort they can, and to accuse them, like noone is being here, of criminal acts is absurd. And the doses of antipsychotics used are very low and the side effects minimal. And they work effectively. One-to-one care is simply never going to happen and this seems to be the best alternative. If anyone has something _constructive_ to add, I'd be happy to pass it along.

Gosh, I hope no body thinks I'm in favour of drugging the elderly. Not by a long shot. I do understand, however, that patients who are agitated and prone to wander and for whom physical restraints are forbidden, are prime candidates for these drugs. And, at the point where you have so overdrugged them--not hard to do with people who have geriatric livers and kidneys--you are, indeed, preventing falls. But the picture of anyone drugged into submission like that disturbs me far more than the geri chairs and physical restraints we used in the nursing homes in which I worked.

The problem wasn't the restraints. I do NOT expect anyone to have 1-on-1 24/7 supervision. If I were a patient it would literally drive me crazy. The problem was the places in which I worked required us to yank these people out of bed at 4:00 am, dress them, get them ready for the day and make all the beds before we left at 7:00 am. And then leave them flopped over and nodding off in a geri chair until 7:30 when the day shift woke them out of their unhappy stupors to give them breakfast. Many of these people slept poorly. One woman, in particular, used to toss and turn (and yes, try to get out of bed) all night, dropping off to a sound sleep in the wee hours of the morning--only to be yanked out of bed and sat up. I used to let her sleep as long as I could but I had to have her up by 7:00.

I do hope someone will take mercy upon me and toss me under a bus before I end up in a nursing home or ICU. My sweetie really doesn't understand my fear of these institution. But he's never worked in them. Trust me, they're much worse than psych hospitals and your insurance never runs out so there's no escape.

Sorry to interject such a note of holiday cheer into the proceedings. How about them Red Sox, everyone?

An addendum: I worked in nursing homes before the advent of SSRIs and newer antipsychotics. And I can tell you that in addition to using physical restraints (which I consider to be way more humane than drugs, but that's me and perhaps we should allow pre-nursing home advanced care directives in that area) there was a whale of a lot of drugging going on also.

I have a serious problem giving any of the atypicals to an elderly person because of (du-uh) the black box warning. Does anyone know why they even put those on medications? They seem to be ignored on a wholesale basis.

"I have a serious problem giving any of the atypicals to an elderly person because of (du-uh) the black box warning. Does anyone know why they even put those on medications? "

The black box warnings are for therapeutic doses for schizophrenia or mania. This is tens of times higher than the dosages used in nursing homes. Big difference.

Oh please let me be able to choose restraints instead of drugs. Yeah, either choice sucks, but at least my mind will be in tact. And yeah, I second Sherry, someone just please shoot me when it gets to that point.

noone,
You are fortunate to be working in a good home. I was not. And the people I know who are in these places today do not have the resources to be in a good place. No one in my income bracket can afford the kind of long term care insurance required to get into a good place. In my state the best strategy is to have enough money to pay for one year in a good home as a private patient. So far, in this state, they don't dump you out when you go on Medicaid after that. In one state where I worked as a geriatric social worker, this was not so. They dumped people once they used up their savings.

In the end, quality home care is better and more desired by consumers than nursing homes ever will be. But we do not put our money there.

Maybe Brazilians nurses are more ethical, or I don't know.
I was talking to a friend and she knows a nurse who gave up her career.
She said she could not stand what she was witnessing and changed the profession.
I will try to have a meeting with her.

"The psychiatrist knows very well not to use psychotropics unless it is indicated and he will always wait for evidence of extreme agitation/risk of harm to self or others before he puts them on the psychotropic. His medical license is not something he wants to lose." (emphasis mine)

LOL

This is from someone who claims that is reporting the REAL WORLD!

LOL

ROLF

I love when the pharma comes here and repeat and repeat their bible.

It's always welcome because it is becoming funny to see their behavior not changing through the years.
The chemical imbalance theory is state of the art for them.
LOL

Funny a nurse today because we had a prescriber nurse from Harvard at the post below.

ROLF

Now I understand why!
Once again I applaud the parents for suing Harvard and I hope all the best for them.
No money will give his son back but at least some justice is being done, I hope they treat this case with care and justice, and it is a relief to know that someone is doing something.

I just wanted to read the whole article but I don't have access to it.
I want to know if they have any explanation for the falling, if it's due to a side effect like dizziness, jelly legs or another one.
If someone could send me the article thanks in advance.

Re: junk diagnosis in hospitals. No, that isn't a problem. When we get a resident from the hospital and see they are on haldol, we discontinue that stat. If the nurse doesn't, the psychiatrist will.

What is this planet please? I want to go there.
I'm just remembering... Dguller, the resident psychiatrist not the intern patient. Please come back!
:) :) :)

Sherry- luckily I bought LTC coverage last year at the age of 29. It covers $250 a day for 5 years. Most states do have provisions where Medicaid cannot move you to a crappier place after your LTC runs out. Still, I read discussions like this one and I swear, I'd rather just be shot.

Okay, i really am not seeing why people here are mad about the use of restraints, rather than being mad about the understaffing of nursing homes. How then would you suggest that one aide keep several out-of-control patients safe?

I'm not saying that there aren't overmedicated patients -- a friend of mine was fired for her constant clashes with the nursing staff on that subject; she happened to be quite good with developing behavioral techniques to calm her Alzheimer's patients -- but honestly, can't we be realistic here?

Correlation does not equal causation, as we all well know.

I was restrained once. I only remember waking up with scraped up arms, but i am told it kept me from yanking out the tube down my throat that was helping the ventilator breathe for me, and now i'm still alive, which is probably good.

i'm closing this thread and have banned 'no one' due to his/her harassment of stephany.