Abstract
It is estimated that one in five residents is taking antipsychotic drugs without a diagnosis of psychosis, while 62% of older adults in Canadian long-term care homes have been diagnosed with dementia (Canadian Institute of Health Information, 2020). The overprescribing of psychiatric medications in long-term care homes could potentially put older adults at greater risk for adverse events, and it is especially harmful for frail, older adults with cognitive impairment, such as persons with dementia. Research studies have found serious side effects of antipsychotics including nervous system problems, cognitive decline, stroke, and increased risk of death in persons with dementia, while benzodiazepine use in older adults is associated with increased falls, pneumonia, and death (Howard et al., 2020). According to a recent study of 623 licensed long-term care homes in Canada, the prescriptions of antipsychotics, anti-depressants, benzodiazepines, and sleeping medications for long-term care residents increased between March and September 2020 (Stall, 2021). Similar patterns were found across the long-term care homes in the United States, where antipsychotics were given to persons with dementia without any mental health condition, as a kind of chemical restraint to control behavioral and psychological symptoms of dementia (Crystal et al, 2020). In particular, an increasing pattern of over-prescribed antipsychotic medications was found to be associated with the negative impact of prolonged social isolation and increasing mental health concerns among persons with dementia during the lockdown and social distancing measures associated with the current pandemic. It was suggested that health care providers might have been less likely to prioritize the use of non-pharmacological interventions for the management of responsive behaviors due to restricted caregiver visits, limited availability of resources, and inadequate staffing levels in the long-term care homes.
To manage over-prescribing of inappropriate medications, it is imperative that nurses take the lead in the daily management, administration, monitoring, and evaluation of medications for their patients. Due to their vital role in medication management, nurses are in the best positions to advocate for appropriate deprescribing to reduce drug-induced harm and promote the safety and well-being of older adults, especially persons with dementia in long-term care. Deprescribing is one important strategy to ensure antipsychotic medications are being used for the right symptoms, at the right dose, and only for as long as needed. Nurses can utilize “The Appropriate Use of Antipsychotics” approach which focuses on deprescribing of antipsychotics that no longer benefits and potentially causes harm for persons with dementia (Healthcare Excellence Canada, 2021). This approach has been shown to improve older adult’s quality of life and safety, the work-life of health care providers, and the satisfaction of family members and care partners. By applying the Appropriate Use of Antipsychotics approach, nurses focus on providing person-centered care and creating a supportive care environment for persons with dementia, rather than the misuse of chemical restraints through antipsychotic medications.
Nurses can support medication optimization through administering, monitoring, and evaluating medications based on professional and clinical judgment, as well as the integration of evidence-based deprescribing guidelines available from the Canadian Deprescribing Network and US Deprescribing Research Network. In developing a therapeutic nurse–client relationship, nurses can assess ongoing medication interactions, monitor for adverse side effects of medications, evaluate therapeutic effectiveness, and engage in comprehensive medication reviews with interdisciplinary team members to safely deprescribe antipsychotic medications for older adults (Sun et al., 2021). The social and mental health needs of persons with dementia must be addressed using a holistic approach, including tailoring care to their habits and preferences; regularly investigating possible causes for negative personal expressions or behaviors; as well as maximizing the use of non-pharmacological interventions to meet any unmet needs to manage responsive behaviors. Prescribing medications for the purposes of controlling behavior without a therapeutic purpose is considered to be a form of chemical restraint. It is of critical importance for nurses to advocate for deprescribing of inappropriate medications to promote the safety and quality of life for persons with dementia, as well as protecting their rights, dignity, and bodily integrity in long-term care homes during the pandemic and beyond.
