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ANTIPSYCHOTIC DRUGS SAFELYU s i n g

MANY OLDER ADULTS sufferingfrom dementia receive antipsychoticdrug therapy. So, whether you care forolder adults in a long-term-care facilityor a hospital, you may be administer-ing these drugs to them. In this article,we’ll discuss these drugs, how to assessyour patient who’s using them, and howto use nondrug interventions. But first,let’s look at why an antipsychotic drugmay be indicated for an older adult.

Looking at the statisticsNearly 10% of all people over age 65and up to 50% of those over age 85are thought to have Alzheimer’s dis-ease (AD) or another form of demen-tia.1 During hospitalization, manyolder adults experience depression ordelirium. In addition, some olderpatients have preexisting psychiatricdiseases such as schizophrenia orbipolar disorder. All in all, 35% to65% of long-term-care patients areprescribed psychotropic drugs.2

Antipsychotic drugs are some ofthe most commonly prescribed psy-chotropic drugs in long-term-carefacilities today.3 If a patient takingone of these drugs is admitted to yourunit for treatment of an acute illness,you’ll be responsible for helping tomanage her drug regimen. Let’s take acloser look at this class of drugs.

Dementias spur more usageAntipsychotic medications are indicat-ed to treat schizophrenia and otherpsychotic disorders and to manageaggressive behaviors associated withpsychosis. For older adults, they’reoften used to treat signs and symp-toms of psychosis and agitated behav-iors related to AD and other demen-tias.3 However, a major retrospectivestudy recently found that usingantipsychotic drugs in older patientswith dementia even for a short timeincreases their risk of being hospital-ized or dying.4

Antipsychotic drugs can be classi-fied as typical (first-generation orstandard) or atypical (new-generationor novel). (See Sorting out typical andatypical antipsychotics.) Low-potencytypical antipsychotic drugs, such aschlorpromazine (Thorazine), aren’ttolerated well by older adults becauseof their anticholinergic and sedatingeffects. At low doses, high-potencytypical antipsychotics such as halo-peridol (Haldol) are better toleratedand have been the drugs of choice forolder adults.

In recent years, however, the neweratypical antipsychotics such as olanza-pine (Zyprexa) have gained favor.These drugs were thought to causefewer adverse reactions, especially

those involving abnormal musclemovements, in older adults. But ongo-ing research about their safety hasmade this view controversial. Severalstudies of atypical antipsychotics inpatients with dementia have found noevidence that these drugs are any saferor more effective than older antipsy-chotic drugs.4,5

In 2005, the FDA issued a warningthat older adults who’ve been treatedwith atypical antipsychotic medica-tions for behavioral disorders relatedto dementia have increased mortalitycompared with those taking a place-bo. Causes of death include heart-related problems (heart failure, sud-den death) or infections (mostlypneumonia). The FDA requires thesedrugs to carry a warning label aboutthe risks of therapy. A meta-analysisconducted after the warnings wentinto effect concluded that atypicalantipsychotic drugs carry a small butstatistically significant increased riskof death compared with placebo.6

In published guidelines, the Centersfor Medicare and Medicaid Services(CMS) prohibits giving antipsychoticmedications to patients unless theyhave a specific condition or diagnosis(such as schizophrenia or Tourette’sdisorder) that’s well documented.7 (SeeWhen can antipsychotics be used?) Inaddition, brain dysfunction due tophysical or physiologic problems(rather than psychological problems)associated with psychotic or agitatedbehaviors is an acceptable indicationfor antipsychotic drugs if these behav-iors have been documented and under-

Do you know how to monitor an older adult who’s receiving anantipsychotic drug? Learn the benefits and the pitfalls so you cankeep your older patients safe.By Lisa M. Abdallah, RN, PhD; Ruth Remington, ANP, GNP-BC, PhD;Karen Devereaux Melillo, ANP-BC, GNP, PhD, FAANP; and Jane Flanagan, ANP-BC, PhD

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins.

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DRUGS SAFELYi n o l d e r p a t i e n t s

lying environmental, psychosocial, andmedical causes have been ruled out.

Under CMS guidelines, antipsychot-ic therapy is appropriate when thepatient’s signs and symptoms: • are persistent and not due to revers-ible causes• are dangerous to the patient or others• impair the patient’s ability to function• cause the patient distress.8

These drugs may also be pre-scribed for the short-term treatment(7 days) of hiccups, nausea, vomit-ing, or pruritus.

Antipsychotic drugs shouldn’t beused for inappropriate reasons,including wandering, poor self-care,impaired memory, anxiety, depres-sion (without psychotic features),insomnia, or agitation that isn’t adanger to the patient or others. If anantipsychotic drug is prescribed, theCMS guidelines call for clinicians togradually reduce the dosage andinstitute behavioral interventions sothe drug can be discontinued as soonas appropriate. The guidelines alsorequire clinicians to document that:• the drug has been prescribed for anappropriate reason • the patient is taking the minimaleffective dose • the patient is being closely monitoredfor adverse reactions, particularly tar-dive dyskinesia (repetitive, involuntary,purposeless movements caused bylong-term use of neuroleptic drugs),orthostatic hypotension, cognitive orbehavioral impairment, akathisia (rest-lessness or inability to be still), andparkinsonism.7

Now let’s review why older adultsare more susceptible to adverse drugreactions.

A matter of ageNormal age-related changes can alterthe way any drug is metabolized,increasing the risk of toxicity. To com-plicate matters, older adults may takemany other medications, setting thestage for potentially dangerous druginteractions.

Compared with younger patients,older patients are much more vulnera-ble to adverse reactions associated withantipsychotic drugs, including seda-tion, orthostatic hypotension, changesin heart rate and rhythm, and decreasedappetite. Any antipsychotic medicationcan interfere with temperature regula-tion. These adverse reactions also putthem at a high risk for falls and frac-tures and other serious complications.So how do you administer these drugssafely to your older patient?

First, you’ll need to obtain yourpatient’s history. Find out what othermedications she’s taking and make sure

the antipsychotic drug chosen doesn’tinteract with or enhance any actions ofher other drugs. Perform medicationreconciliation and flag any drugs in herregimen that may be unnecessary toreduce her “pill burden.”

Is it delirium or dementia?Next, perform a physical assessment.Assess your patient for any change inher baseline cognitive level and behav-ior. If she’s a new patient, you mayneed to ask a family member or care-giver if he sees changes in her behav-ior. Before she starts on antipsychotictherapy, try to sort out whether herbehavior is related to dementia or new-onset delirium, which probably has atreatable cause. Being in an unfamiliarenvironment like a hospital may pre-cipitate delirium, an acute state of con-fusion that’s common in older patientsand constitutes a serious medicalemergency.

An abrupt cognitive change can be atelltale sign of an acute medical condi-tion such as a newly acquired infection,medication effect, or pain that may be

Sorting out typical and atypical antipsychoticsDrug type

Typical antipsychoticdrugs (low-potency)Typical antipsychoticdrugs (high-potency)Atypical antipsychoticdrugs

Examples

chlorpromazine (Thorazine), thioridazine (Mellaril)

haloperidol (Haldol), perphenazine (Trilafon), thiothixene (Navane)aripiprazole (Abilify), clozapine (Clozaril), olanzapine (Zyprexa), quetiapine (Seroquel),risperidone (Risperdal), ziprasidone (Geodon)

Source: Saltz BL, et al., 2000.9

causing a change in behavior. Notifyyour patient’s health care provider ofany abnormal assessment findings ordiagnostic study results.

Medications are a common cause ofdelirium in older patients. Review thepatient’s medication record to deter-mine if the onset of delirium is relatedto any newly prescribed medications.Medications that are more likely tocause delirium in older adults are psy-chotropic medications, cardiac med-ications, histamine2 antagonists (suchas cimetidine and ranitidine), anal-gesics, anti-inflammatory drugs, andover-the-counter drugs, especiallythose with associated anticholinergicadverse reactions, such as cold medi-cines and sedatives.2

Detailed information about somepotentially inappropriate medicationsfor older adults, known as the Beers’Criteria, can be found at the HartfordInstitute for Geriatric Nursing Web siteat http://www.hartfordign.org/publications/trythis/issue16.pdf.Some of these medications are inappro-priate because of the frequency andseverity of their adverse reactions.These criteria have limitations anddon’t identify all potentially inappro-priate medications for older adults.This list isn’t a substitute for soundprofessional judgment about yourpatient’s individual medical needs.

Look for these effectsOnce medical, pharmacologic, andother treatable causes of your patient’sbehavior have been ruled out, herhealth care provider may prescribe anantipsychotic. If she’s taking this med-ication, you’ll need to assess her forthese common adverse reactions toantipsychotic drugs: • Anticholinergic effects, the most com-mon problem associated with antipsy-chotic drugs, include constipation, drymouth, urinary retention, blurredvision, and increased intraocular pres-sure. In addition, anticholinergic ef-fects can affect the central nervous sys-tem, leading to disorientation andshort-term memory loss. If these effects

are severe, your patient may experi-ence visual hallucinations and in-creased agitation. Document yourpatient’s baseline cognitive level andclosely monitor her for signs andsymptoms of central or peripheral anti-cholinergic effects.8

• Orthostatic hypotension increases therisk of falls and fractures. Assess yourpatient’s fall risk and institute fall riskprecautions, if needed. Teach her tochange position slowly and to drinkenough fluids to avoid dehydration.• Neuroleptic malignant syndrome isan uncommon but potentially life-threatening adverse reaction that usu-ally occurs shortly after a patient startstaking an antipsychotic medication. Itcauses hyperthermia, muscle rigidity,tachycardia, and hypotension or hyper-tension. If your patient develops thesesigns and symptoms, call her healthcare provider or your facility’s rapidresponse team.9

• Parkinsonism, including tremors,increased muscle tone, bradykinesia(slow movements), drooling, andunstable shuffling gait, usually disap-pears when the patient is switched tolower-dose therapy or an atypicalantipsychotic because its parkinsonismeffects may be less severe.9

• Akathisia (restlessness or the inabilityto sit still) may improve with a lowerdrug dosage.9

• Dystonia, which occurs less com-monly in older adults, is described assustained muscle contractions. Thepatient may also exhibit repetitivetwisting movements or abnormal pos-tures. If it occurs soon after she beginsantipsychotic medications, the doseshould be lowered immediately. Treat-ment may also include anticholiner-gics or antiepileptic medications. Moreoften, dystonia develops with contin-ued use of antipsychotic medicationsand may not be reversible.9

• Tardive dyskinesia involves involun-tary, repetitive, and purposeless move-ments, especially of the lower face,such as tongue thrusting, repetitivechewing, jaw swinging, or facial gri-macing. These movements may bereversed if the antipsychotic medica-tion is stopped early on, but they maybecome permanent in an older adult.The risk of developing tardive dyskine-sia may be reduced by using low-dosetherapy, discontinuing antipsychoticmedications, or using an atypicalantipsychotic.7

• Agranulocytosis, a serious blooddyscrasia that decreases white bloodcell production, is specifically linked toclozapine (Clozaril). Because of thiseffect, it isn’t a drug of choice for olderadults.3

• Hyperglycemia and diabetes mellitus inolder adults is associated with mostatypical antipsychotics except aripipra-zole (Abilify), which doesn’t appear toaffect glucose metabolism.10 If yourpatient’s receiving one of these antipsy-chotics, she should have periodicblood glucose monitoring.

Key observationsYou’ll need to perform a physicalassessment before your patient isstarted on antipsychotic treatment,then monitor her response to treat-ment. Your assessments will help theprescriber choose an appropriate drug and dose and modify therapy ifnecessary.

After your patient starts on antipsy-chotic medication, monitor her close-ly for both beneficial and adverse drug

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When can antipsychotics be used?According to the CMS guidelines,antipsychotic drugs may be indicat-ed for older adults with:• schizophrenia• schizoaffective disorder• delusional disorder• psychotic mood disorders (in-

cludes mania and depressionwith psychotic features)

• acute psychotic episodes• brief reactive psychosis• atypical psychosis• Tourette’s disorder• Huntington disease.Source: CMS, revised 2006.7

effects. Assess her daily when she firststarts therapy, then at least weekly.

Never hesitate to contact the pre-scriber anytime you have a concernabout your patient’s behavior. If shedoesn’t improve within 4 weeks, alertthe prescriber, who’ll reevaluate her.She may benefit from a change indosage or medication.

If her behavior improves andremains stable, also inform the pre-scriber, who may order a dose reduc-tion if indicated. In addition, the pre-scriber may order drug holidays or tryto taper and discontinue the drug treat-ment. Giving the lowest effective doseof the medication will minimize poten-tial adverse reactions.2

Obtain postural vital signs to assessfor orthostatic intolerance and monitorfor increases in body temperature. Alsofrequently monitor your patient forabnormal movement disorders.

Antipsychotic medications are gen-erally contraindicated for patients withParkinson’s disease—except for thosewith parkinsonian dementia with psy-chosis. These patients may need drugtherapy if they have distressing symp-toms, such as hallucinations, delu-sions, and paranoia, or if they’re athreat to harm themselves or others.Some antipsychotic medications areless likely than others to aggravateParkinson’s disease symptoms. Clo-zapine or quetiapine (Seroquel) arepreferred for a patient with Parkinson’sdisease and olanzapine and risperidone(Risperdal) should be used with cau-tion.3

Any patient taking an antipsychot-ic medication should be evaluatedfrequently using the Abnormal Invol-untary Movement Scale test to assessfor abnormal movements that canindicate tardive dyskinesia, startingwith initiation of antipsychotic treat-ment. Then she’ll need to see herhealth care provider to be assessedevery 6 months.

If these adverse reactions do begin,she may need to discontinue the anti-psychotic medication or switch to adifferent medication. Most important,

you should look at how you canincorporate nonpharmacologic inter-ventions, outlined next, to help man-age the patient’s behavior whethershe’s taking an antipsychotic or not.

Try a new approachYou should always try nonpharmaco-logic measures to deal with a patient’sagitated behavior when you can. Manyinterventions based on behavior mod-els have been successful in managingdementia-related behaviors. With thepatient’s permission, ask her family orfriends to bring in supplies and engageher in activities such as games or craftsshe enjoys.

Other behavioral theories are basedon the belief that patients withdementia can’t cope with stress. Usinginterventions that ease stressful situa-tions may decrease agitation. Forexample:• speak in a calm, reassuring way• provide an atmosphere of acceptance• teach staff to approach a patientcalmly and to explain their actions• give her a few realistic choices aboutcertain aspects of her care, such aswhether to have a bath in the morningor evening.

An environment that’s not stimulat-ing enough can also trigger agitatedbehavior. If this is the case, encourageher visitors or hospital volunteers toentertain her. You can also give herrepetitive tasks, like folding towels.

Using consistent routines and pro-viding adequate rest can help decreaseagitated behaviors. Ask her simplequestions such as, “Do you want tea orcoffee?” rather than “What do youwant to drink?” Too many choices canbe overwhelming. Asking her aboutsignificant pleasant life events can helpto trigger soothing memories.

Music has a positive effect onpatients with agitated behaviors. Askfamily members to bring in audiotapesor CDs of soothing music or any musicthe patient likes. Other strategies thatwork for some patients include thera-peutic touch, hand massage, and pettherapy.

Teaching the familyIf a patient has symptoms or behav-iors that are frightening to the familybut not to the patient, you may needto educate them about why medica-tions aren’t appropriate. If antipsy-chotic drugs are appropriate for thepatient, teach family members thatthe drugs need time to work so theydon’t expect to see improvementsovernight. If nondrug approaches areappropriate, teach the family aboutthem and enlist their help in the hos-pital and after discharge.

Your well-informed nursing carewill help to maintain your olderpatient’s dignity and quality of life. G

REFERENCES1. American Association for Geriatric Psychia-try. Geriatrics and mental health—the facts.http://www.aagpgpa.org/prof/facts_mh.asp. Accessed June 14, 2005.

2. Centers for Medicare and Medicaid Services.Resident Assessment Instrument: Appendix C-17Psychotropic Drug Use, 2002.

3. Jeste DV. Comparison of conventional vs. atyp-ical antipsychotic drugs: Focus on elderly pa-tients. Long-Term Care Forum. 1(2):10-13, 2002.

4. Rochon PA, et al. Antipsychotic therapy andshort-term serious events in older adults withdementia. Archives of Internal Medicine.168(10):1090-1096, May 26, 2008.

5. Lee PE, et al. Atypical antipsychotic drugs inthe treatment of behavioral and psychologicalsymptoms of dementia: Systematic review. BMJ.329(7457):75, July 10, 2004.

6. Schneider LS, et al. Risk of death with atypicalantipsychotic drug treatment for dementia: Meta-analysis of randomized placebo-controlled trials.JAMA. 294(15):1934-1943, October 19, 2005.

7. Centers for Medicare and Medicaid Services.State Operations Manual, Appendix PP: Interpre-tive Guidelines of Long-Term Care Facilities: Un-necessary Drugs. 483.25(l), revised December2006, 272-338. http://www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf. Accessed July 7, 2005.

8. Chutka DS, et al. Inappropriate medicationsfor elderly patients. Mayo Clinic Proceedings.79(1):122-139, January 2004.

9. Saltz BL, et al. Side effects of antipsychoticdrugs: Avoiding and minimizing their impact inelderly patients. Postgraduate Medicine. 107(2):169-178, February 2000. http://www.postgradmed.com/issues/2000/02_00/saltz.shtml. Accessed September 13, 2007.

10. Bezchlibnyk-Butler KZ, Jeffries JJ (eds).Clinical Handbook of Psychotropic Drugs, 16thedition. Hogrefe & Huber Publishers, 2006.

Lisa M. Abdallah is an assistant professor, RuthRemington is an associate professor, and KarenDevereaux Melillo is professor and chair of the De-partment of Nursing at the School of Health andEnvironment at the University of MassachusettsLowell. Jane Flanagan is an assistant professor at theConnell School of Nursing at Boston College. Dr.Abdallah is also a John A. Hartford Institute GeriatricNursing Scholar at New York (N.Y.) University.

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