A recent ruling by the U.S. Food and Drug Administration (FDA) highlights a nursing practice that may not serve our patients' best interests. The FDA now requires manufacturers of conventional antipsychotic drugs to add a black box warning to their labeling noting an increased risk of death in older people who take these drugs for dementia-related psychosis. In 2005 the FDA announced similar labeling changes for the newer atypical antipsychotic drugs. [Editor's note: For more information, see Drug Watch, October, and In the News, page 20.] Neither class of antipsychotic is approved to treat dementia-related symptoms. Off-label prescription of antipsychotic medications for patients with dementia is at the physician's discretion, but can have devastating effects.
A 2007 study by Fick and colleagues in Aging and Mental Health showed that many antipsychotics have a limited effect in patients with dementia and are associated with falls and fractures. Additionally, antipsychotic drugs can increase patients' risk of delirium and further cognitive decline. Moreover, a 2005 study by Briesacher and colleagues in the Archives of Internal Medicine found that more than a quarter of nursing home residents on Medicare were prescribed antipsychotics, and nearly a quarter of those lacked an appropriate indication. Considering the rising number of nursing home residents diagnosed with dementia, not to mention the shortage of nurses to care for them, I cannot help but wonder: are we chemically restraining our nursing home residents for our own convenience because we have inadequate numbers of well-trained staff?
It's surprising that more nurses don't fully acknowledge the depth of nursing home residents' apparent neglect, which is partly the result of inadequate staffing. When I took my certified nursing assistant students on a clinical rotation at a nursing home, what I saw shocked me. Sleeping patients were falling out of their wheelchairs. Patients sat in their own urine until someone found time to change them. Some of my students had expressed a desire to work with the elderly. I told them to be thankful that as students, their patient load will be small; they'll have time to get to know (and care for) their patients.
Although I know that most physicians, nurses, and aides working in long-term care are doing their best in a difficult situation, I'm not sure the same can be said of the health care industry as a whole. Nursing homes have no federally mandated minimum staffing ratios. Nationally, there are more than 100,000 vacancies in long-term care, including those for RNs, LPNs, and certified nursing assistants. The American Health Care Association and the National Center for Assisted Living have projected that this shortage will worsen over the next several years. I also wonder whether nursing homes may purposely minimize their staffs to lower costs, decrease fees to families, and maintain competitiveness-all of which increase profits.
Perhaps you've received e-mails, as I have, claiming that a year on a cruise ship or at a Holiday Inn is cheaper than one at a nursing home and offers better care and amenities. This reflects poorly on our profession. We must do more than merely quash symptoms in residents with dementia. Antipsychotic drug prescriptions for this population could decrease if we correctly identify and adequately tend to the needs that cause inappropriate behaviors. Even metabolic and endocrine problems may cause symptoms that masquerade as dementia.
We must consider whether antipsychotics are being prescribed appropriately. If we're using them as chemical straitjackets to make things easier on ourselves, we should show our patients that we care enough to look for better solutions.