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Psychotropic drug prescribing patterns in the nursing home

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Psychotropic drug prescribing patterns in the nursing home

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Content PSYCHOTROPIC DRUG PRESCRIBING PATTERNS
IN THE NURSING HOME
by
Mark C. Krueger
A Thesis Presented to the
FACULTY OF THE LEONARD DAVIS SCHOOL OF GERONTOLOGY
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE
(Gerontology)
May 1994
Copyright 19 94 Mark C. Krueger
UMI Number: EP59003
All rights reserved
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a note will indicate the deletion.
Oisssrtation PuMisNng
UMI EP59003
Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author.
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UNIVERSITY OF SOUTHERN CALIFORNIA
)
LEONARD DAVIS SCHOOL OF GERONTOLOGY
University Park 3599^ ' ^
Los Angeles, CA 90089
This thesis, written by
under the director of h 15 Thesis Committee, and approved by all its
members, has been presented to and accepted by the Dean of the Leonard
Davis School of Gerontology, in partial fulfillment of the requirements for
the degree o f_______________________________ __________________
/ i L / â
i n .________________________________
Dean
Date â jlîJ /y im
O
11
Table of Contents
List of Tables
page iii
Abstract
page iv
Introduction
pages 1-4
Materials and Methods
pages 5-6
Results
pages 7-10
Discussion
pages 11-17
References
pages 18-20
Tables 1 through 6
pages 21-27
Appendices A through F
pages 28-33
Ill
List of Tables
Table 1--Number of Routine Prescription Drug Orders by
Facility page 21
Table 2--Psychotropic Drug Orders by Class and Mode of
Prescription page 22
Table 3--Profile of Psychotropic Drug Orders by Class and
Within Class pages 23-24
Table 4--Criteria for Potentially Inappropriate Use of
Psychotropic Drugs page 25
Table 5--Medication Errors of Routine Psychotropic Drug
Orders page 2 6
Table 6--Problems Associated with Routine Non-Psychotropic
Drug Orders page 2 7
IV
Abstract
Objective: To study the prevalence and appropriateness of
psychotropic medication prescriptions in nursing homes using
consultant pharmacist services during the post-OBRA 1990
period.
Design: Chart review of all patients with a consultant
pharmacist.
Setting: Three proprietary rehabilitation and nursing
facilities in the Greater Los Angeles area.
Participants: All patients residing in the facilities
during the one-month study period (June 1-July 1, 1993),
N=240.
Measurements: Tabulation of all psychotropic drug orders by
drug class, mode of administration, appropriateness of dose,
frequency, and/or duration.
Main Results: The mean number of prescription drugs ordered
on a routine basis was 4.35. 42.9% of the study population
had orders for at least one psychotropic medication. A
total of 132 psychotropic drug orders were written for 103
of the 240 study patients, with half of those orders (66)
for medications to be given on a PRN basis. Of 132
psychotropic orders, anti-depressants accounted for 27.3%,
anti-psychotics accounted for 25.0%, and sedative/hypnotics
accounted for 47.7%. The most frequently prescribed anti-
V
depressant was nortriptyline (27.8%). Haloperidol
represented most (81.8%) anti-psychotic orders, and
lorazepam was the most frequently prescribed
sedative/hypnotic (25.4%). The error/inappropriateness rate
for all psychotropic orders was 28.8%, while the rate for
non-psychotropic medications was 3.5%.
Conclusions: In comparing our results with earlier studies,
it appears that there is no change in psychotropic drug
prescribing patterns after the OBRA legislation amendments
of 199 0 mandating consultant pharmacist audits and further
psychotropic drug control. The role and skills of consultant
pharmacists in determining drug appropriateness is obvious,
but their recommendations tend to be underutilized.
1
Introduction
Inaccurate psychiatric diagnoses, the use of chemical
restraints, and polypharmacy are only a few of the problems
that the Nursing Home Reform Amendments of the Omnibus
Budget Reconciliation Act of 1987 (OBRA Public Law 100-203)
hoped to resolve. The OBRA. legislation and regulations
written by the Health Care Financing Administration (HCFA)
interpreting the law refer to many aspects of nursing home
care. Part of the Nursing Home Reform Amendments mandate
the use of consultant pharmacists to monitor the
appropriateness of drug use in the nursing home setting
(Regulation Number 483.60). Interpretive guidelines issued
by HCFA regulate the use of unnecessary drugs and
psychotropic medication use (Regulation Numbers 483.13 and
483.25) (Appendices A-C) . Although the amendments took
effect in October of 1990, few studies have attempted to
look at the probable impact these regulations have had on
psychotropic medication prescribing practices in the long
term care setting.
Old age is characterized by decreased physiologic
reserve and increased morbidity from multiple chronic
illnesses.^ Physiologic frailty makes the elderly at once
more in need of appropriate drug treatment and at risk for
adverse reactions. Within institutional care settings, both
medication errors and adverse drug reactions or drug-related
2
problems are significant sources of increased morbidity and
mortality in older geriatric patients.^
Drug-related errors in the nursing home setting may
include: omission, wrong drug, wrong dose, wrong schedule,
extra doses, documentation errors, and improper stop-order
procedures.^ Adverse drug reactions may also occur when the
drug of choice interacts with another drug or an altered
physiologic state.
A study by Beers and colleagues reports that 40% of
1106 nursing home patients had at least one inappropriate
medication order.® Another study by Barker et al. found
that 58 long-term care facilities had a mean medication
error rate of 12.2%.’ ^ Cooper et al. report that
documentation errors are the most common nursing facility
problems, accounting for about one-fourth of all errors.®
Psychotropic medications represent the fifth most
frequently prescribed drug class for elderly individuals,
with most orders made in the nursing home setting. ^ The
frequency of psychotropic medication prescribing prior to
the 1990 OBRA Nursing Home Amendments has been well-
documented. Avorn et al. found that of 1201 nursing home
residents, 55% took at least one psychotropic medication.
Other studies have documented psychotropic drug usage at
percentages of 34.6%, 65%, 60.1%, and 32.7%, respectively.^^”
Although percentages vary, any prevalence of psychotropic
3
drug orders is most always associated with sedation,
confusion, orthostatic hypotension, anti-cholinergic
reactions, cardiac side effects, and/or extra-pyramidal side
effects for the institutionalized geriatric patient.^®
Several studies have documented the prevalence of
specific psychotropic drug groups. It is estimated that
skilled nursing facility residents are eight times more
likely to receive anti-psychotic drugs than community-
dwelling elders.^® Gurian and colleagues found that 57% of
the patients they reviewed were receiving neuroleptics.
A 197 9 study in one California nursing facility found that
86% of the patients were receiving an anti-psychotic drug,
with 32% of those on two or more neuroleptics concurrently.^®
Morgan, Gilleard et al. performed longitudinal studies
demonstrating that between 33.5% to 35% of patients were
receiving at least one sedative/hypnotic agent.
The present study was designed to examine the specific
medication errors most likely to occur, along with the
overall prevalence of psychotropic drug prescribing.
Criteria for inappropriate use were defined, consistent with
the relevant OBRA rules and regulations concerning
psychotropic medications (Table 4). In addition, specific
psychotropic drug comparisons were included regarding
optimal drug selection for the geriatric patient (Appendices
D-F). Routine and PRN (pro re nata or "as needed") orders
for both psychotropic and non-psychotropic medications were
reviewed for errors, and the results used to identify trends
in practice. From such an analysis, the crucial impact of
the OBRA 1990 Reform Amendments and of the consultant
pharmacist in long-term care settings can be extrapolated en
hopefully decreasing the frequency and route to
inappropriateness of psychotropic medications as a whole;
thereby, increasing the overall quality of life that the
geriatric nursing home patient deserves to receive.
5
Materials and Methods
Patterns of psychotropic drug usage were evaluated in
three, free-standing proprietary skilled nursing facilities
in Los Angeles, California. Medical charts of all residents
in each facility were reviewed during the consultant
pharmacist's monthly audit, as required by OBRA legislation
(N=240).
Prescribing practice information was obtained directly
from the medical chart order sheets. For each patient, the
total number of drugs ordered on a routine basis was
recorded, and medication data were collected for
psychotropic medications in each of three classes : anti
depressants, anti-psychotics/neuroleptics, and
sedative/hypnotics.
Several drugs were excluded from each class due to a
low frequency or lack of usage or because it was unclear
whether or not they were given for the above indications
(e.g. methylphenidate, chloral hydrate, lithium, and
valproic acid) . Diphenhydramine was the only anti-histamine
prescribed with some frequency for behavioral control and/or
insomnia, and thus was included in the sedative/hypnotic
drug class. Other drug classifications with known
psychoactive properties were not included.
For each psychotropic medication order, information was
obtained regarding the name of the drug, dose, frequency of
6
dosing, and the nature of the order (routine or PRN). For
drugs given on a PRN basis, the past monthly frequency of
such an order was examined to verify compliance with OBRA
regulations. Psychotropic drugs that were discontinued in
the last month prior to review were also recorded to check
for patterns of discontinuation or dosage reductions.
The second phase of the study involved one consultant
pharmacist for error/inappropriateness documentation of all
medications, psychotropics and others. Criteria for
inappropriate-ness of psychotropics were formulated (Table
4), but much confidence was placed on the pharmacist's
knowledge, expertise, and experience. Insufficient
documentation of reasons for use, and inadequate monitoring
of use for adverse reactions or toxicity were also noted.
No attempt was made in this study regarding the inclusion
and recording of psychiatric diagnoses.
Results
Demographics and Overall Drug Use
The total sample consisted of 240 patients in three
facilities in the Greater Los Angeles area. There were a
total of 1,044 prescription orders on a routine basis, with
66 routine psychotropic drug orders and 978 routine non
psychotropic orders. One facility had 31 of the 66 routine
psychotropic orders, with the other two facilities having 17
and 18 orders respectively. The average number of different
prescription orders on a routine basis per patient during
the month of analysis was 4.35, with a low of 3.62 and a
high of 4.80 (Table 1). Only 12 patients (5.0%) had no
routine medication orders. Within the month prior to the
analysis, there was a total of eight psychotropic drug
discontinuations, four of which were drug discontinuations
for the sedative/hypnotic drug class.
Psychotropic Drug Orders
Approximately 43% or 103 of the 240 study patients had
at least one order for a psychotropic medication. There was
a total of 132 psychotropic drug orders. Table 2
illustrates that 66 of the psychotropic drug orders were
written on a routine basis, with the other 66 written as
PRN. Of the routine psychotropic orders, 3 6 were for anti
depressants, 18 were for anti-psychotics, and 12 were for
sedative/hypnotics. In addition, 51 of the 66 PRN
8
psychotropic orders were for sedative/hypnotics.
Approximately one-half (63) of the 132 orders were for
sedative/hypnotics, and the remaining orders were about
equally divided between anti-depressants (36) and anti
psychotic medications (33),
There were 21 of the 103 patients (20.4%) with two or
more psychotropic drug orders, with 7 (6.8%) having three or
more. Of the 103 patients receiving at least one
psychotropic drug, 7.8% (8) had orders for two psychotropic
drugs on a routine basis. The 2 0.4% having two or more
orders were actually prescribed 37.9% (50) of the total 132
orders. Approximately one-fifth (22.0%) of the 132 total
orders were prescribed for patients already having at least
one other psychotropic drug order. For patients in this
study, 38.1% of those receiving more than one psychotropic
medication received the second or third psychotropic drug
from the same drug class.
Specific Drug Class and Medication Frecaiencv
Table 3 lists the number of orders for the three drug
classes. Of the 3 6 routine and PRN anti-depressant drug
orders, 11 (30.6%) of the orders were for nortriptyline,
with bupropion, phenelzine, and imipramine prescribed least
frequently with one order each. In addition, 27 of the 33
total anti-psychotic medication orders (81.8%) were for
haloperidol, with three orders (9.1%) for thioridazine.
9
Approximately one-fourth (16) of the sedative/hypnotic
orders were for lorazepam. The majority of
sedative/hypnotic drug orders (60.3%) were for either
lorazepam, temazepam, and/or flurazepam. Approximately
14.3% (9) of all sedative/hypnotic drug orders were for
diphenhydramine, with three orders (4.8%) for diazepam.
About one-fourth (23.9%) of all the sedative/hypnotic orders
were for long-acting drugs. Four orders for lithium
carbonate, two orders each for valproic acid and
methylphenidate, and one order for chloral hydrate were not
included in the statistics under any specific drug class
because of low frequency and uncertainty regarding reasons
for use.
Over half of the routine psychotropic drug orders
(54.5%) were for anti-depressants, with over one-fourth
(27.3%) as anti-psychotic orders. Most of the 66 PRN
psychotropic orders (77.3%) were for sedative/hypnotics. In
all, according to Table 3, nearly one-half of all routine
and PRN orders were for sedative/hypnotics (47.7%), with 36
orders (27.3%) for anti-depressants, and 33 total orders
(25.0%) for anti-psychotics.
Psvchotrooic and Non-osvchotrooic Drug Aoorooriateness
Table 4 lists the criteria for potentially
inappropriate use of psychotropic drugs. According to Table
5, the consultant pharmacist documented 19 errors from the
10
66 total routine psychotropic orders for an error rate of
28.8%. These pharmacist error write-ups were related to
inappropriate or excessive use, insufficient documentation
of reason for use, inadequate monitoring of use, etc. Of
the 18 routine anti-psychotic orders, 10 were deemed
inappropriate for an error rate of 55.6%. In addition, when
the sedative/hypnotics were prescribed on a routine basis,
there was a 50.0% error rate (Table 5).
In terms of non-psychotropic drug error documentation
by the consultant pharmacist, 34 of 97 8 routine non
psychotropic prescription orders (3.5%) were documented as
having the possibility for misuse. The majority of write
ups were for either lack of indication or diagnosis (35.3%),
or the need for an electrolyte laboratory panel (23.5%)
(Table 6) . It should be noted that the medication error
rates for both psychotropic and non-psychotropic drugs are
not necessarily related to actual drug appropriateness, but
may be due to other factors such as poor documentation or
inadequate monitoring.
11
Discussion
Without overgeneralizing, our limited data suggest that
despite the growing literature on the possibilities and
likelihood of psychotropic drug misuse, prescribing patterns
in the long-term care setting require further
scrutinization. And though the average number of
prescription drugs taken by the residents during the month
of survey was quite low compared to previous studies;
when psychotropics are prescribed on a routine basis, the
risk of inappropriateness and/or misuse becomes much more
exaggerated.
Several factors should be noted in regards to how this
specific study was carried out. Much attention and reliance
was based on the consultant pharmacist's knowledge and
expertise, and assumptions were made that the psychotropic
medications were actually administered according to the
order sheet. In addition, the OBRA criteria of Appendices
A-C, the criteria from Avorn et al. (Table 4), and drug
comparisons from Salzman et al. (Appendices D-F) were all
used as well-defined criteria for psychotropic drug
appropriateness. No attention was paid to the gender, age,
or diagnosis of the skilled nursing facility patients.
Medicaid verses private pay patient distinctions were also
not made, which may have had an impact on drug selection.
Finally, all residents resided in an urban southern
12
california nursing home; therefore, the results may not be
applicable for other demographic populations.
The prescribing frequency of psychotropic medications
on both a routine and a PRN basis was 42.9% for the 240
patients included in this study. Approximately 2 0% of those
receiving psychotropic medications had orders for two or
more, and were consuming 3 8% of all the orders. Although
sometimes appropriate, the use of multiple psychotropics
could very well be detrimental to the cognitive and
functional status of the elderly patient because the elderly
are much more sensitive to the effects of psycho tropics than
younger age groups.
In addition, there were the same number of routine as
PRN psychotropic orders with greater orders for both the
sedative/ hypnotic and anti-depressant drug classes than for
the more tightly regulated anti-psychotic grouping. Because
the OBRA Amendments of 1990 primarily affect the anti
psychotic drugs (Appendices A-C), perhaps physicians are
prescribing more of the psychotropics from less regulated
drug classes.
Some discussion is necessary regarding the use of
specific drugs under each classification. In terms of anti
depressants, the high rate of nortriptyline usage is
positive in terms of lower side-effect potential for the
geriatric patient.However, 13.9% of all routine anti
13
depressant orders were for amitriptyline. Amitriptyline is
known to have the highest anti-cholinergic and sedating
properties of all anti-depressants, and is least favored for
geriatric patients.Other anti-depressant medications are
clearly less toxic and just as beneficial such as the
secondary amines.
In terms of anti-psychotic usage, haloperidol appears
to still be the geriatric drug of choice due to lower
orthostatic hypotension and sedation potential.
Approximately 15% of the anti-psychotic orders were for
thioridazine or thiothixene, both of which are not highly
recommended for elderly patients.Perhaps these drugs were
given due to lower extra-pyramidal side effect potential, in
which case a choice must be made between possible over
sedation or pseudo-parkinsonism side effects. The physician
must decide which side effects would be least detrimental
and/or most desirable for each specific patient. Finally,
the 15 PRN anti-psychotic drug orders lead to the assumption
that such drug orders were written for episodic behavioral
control rather than for treatment of a chronic underlying
diagnosis.
Regarding the use of sedative/hypnotic drugs, it
appears that in many cases, the best drug may have been
underutilized. The high usage of flurazepam and other long-
acting benzodiazepines is clearly not recommended because of
14
possible daytime accumulation in elderly patients. In
addition, the strong anti-cholinergic properties of
diphenhydramine make this drug highly ill-advisable for
insomnia in geriatric patients especially when used for
already confused patients.^® Routine use of
sedative/hypnotics is a glaring error. Sedative/hypnotics
should not be used for prolonged periods of time due to a
likelihood of addiction and/or drug tolerance.^®
Appendices D-F illustrate important pharmacologic
considerations for the use of psychotropic medications in
geriatric patients.
When psychotropics were prescribed on a routine basis,
the potential for errors and/or misuse was 28.8%. When
anti-psychotics or sedative/hypnotics were prescribed on a
routine basis, approximately one of every two orders was
potentially inappropriate or needed re-evaluation. Even
though anti-psychotic prescribing appears to be lower than
previous studies ; trends suggest that when they were
prescribed, their appropriateness was still severely
questioned. Furthermore, the error rate for non
psychotropic drugs (3.5%) was approximately one-tenth of the
rate for psychotropics.
It appears the impact of the OBRA 1990 drug regulations
on psychotropic prescribing practices remains unclear. One
other post-OBRA study found a 3 6% reduction in prescriptions
15
for neuroleptics over six months before and after the
regulations, with no increase for the sedative/hypnotics and
a slight increase for the anti-depressants.^ When compared
with pre-OBRA studies, the results from this study do not
show a change in regards to psychotropic prescribing
frequency and appropriateness. in addition, the
results may also suggest that the OBRA regulations pay too
much attention to the anti-psychotics, and not enough to the
other psychotropic drug classes.
The potential value of the pharmacist for error
prevention and medication reviews as mandated by OBRA in the
nursing home setting should be emphasized. One study prior
to OBRA in 1981 found that at the end of the study, 3 6% of
the nursing home residents were receiving psychotropics
after consultant pharmacist recommendations verses 90%
before the pharmacist intervention.®^ Other studies have
documented that consultant pharmacist drug regimen reviews
have significantly reduced the potential for harm resulting
from errant or inappropriate medication orders.®^"®® Even
though a consultant pharmacist has been attending to and
making recommendations in the nursing homes in this study,
the high error rates would suggest that the recommendations
are not followed by physicians. The physician, the
consultant pharmacist, and the director of nursing all
receive copies of the recommendations, but no actual
16
notation is made on the patient’s chart.
One option not utilized in the current study could
involve the implementation of an educational visit on
psychotropic prescribing practices. A study in 1987 found
that such an educational visit by a trained physician
counselor did not reduce the overall prescribing of anti
psychotic drugs, but another more recent study proved that
an educational program did reduce overall psychotropic drug
use when performed by a clinical pharmacist.^ Perhaps
future educational interventions need to be performed by
clinical geriatric pharmacists to make use of their greater
expertise in the area of psychotropic medications and the
elderly.
Even though the 1990 OBRA regulations provide
guidelines for PRN anti-psychotic drug usage, PRN orders are
still likely to be overused and can adversely affect patient
care by placing the responsibility of drug implementation on
the nursing staff. Such studies have shown that the PRN
order is often inappropriate and indiscriminately
followed.®^"®® The high usage of PRN orders in this study
(50% of all psychotropic orders) , may be an excuse to avoid
the stricter regulations and surveillance regarding usage on
a routine basis. In addition, such PRN orders are carried
out by the nursing staff who are often not adequately
trained and poorly monitor the need for such an order. PRN
17
orders need to be further examined as to their
appropriateness in combination with other concomitant drug
orders.
Even with limited data, the findings of this study
clearly indicate that much more emphasis and effort needs to
be placed in improving the use of psychotropic medications
in the nursing home setting. High frequency of usage, poor
drug monitoring, and overall drug selection appear to be the
three primary problems associated with inappropriateness and
likelihood for misuse. The value of the OBRA regulations
and the role of the consultant pharmacist need to be re
evaluated and re-defined to greater affect psychotropic drug
prescribing.
Further studies are required to determine why such
psychotropic drug prescription prescribing still occurs
despite increased regulations. Reforming psychotropic
prescribing practices in the future will improve the quality
of care for institutionalized geriatric patients. It is
clear that better informed healthcare providers can help
prevent further and unnecessary disability in this
population.
18
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Geriatr Soc 1977 ; 25 : 83-84.
36. Brown C, Kirk K. PRN drug utilization in Indiana long
term care facilities. Hosp Pharm 1984;19:692-696.
21
Table 1
Number of Routine Prescription Drug Orders by Facility:
Number of
Residents
Total Number
Prescription
Orders
Mean Number
of Drugs
Facility 1
Facility 2
Facility 3
84
81
75
304
380
360
3.62
4.70
4.80
Totals 240 1, 044 4.35
22
Table 2
Psychotropic Drug Orders by Class and Mode of Prescription,
N=132:
Number of Number of Totals
Routine Orders PRN Orders {%)
Anti-Depressants 3 6 0 3 6
(27.3)
Anti-Psychotics 18 15 33
(25.0)
Sedative/Hypnotics 12 51 63
(47.7)
Totals 66 66 132
(100%)
Table 3
Profile of Psychotropic Drug Orders
Class, N=132:
by Class and
23
Within
Class Number (%) of Orders
Within Class
Number (%) of Orders
Per Class
Anti-Depressants : 36 (27.3)
nortriptyline 11 30.5)
trazodone 7 19.4)
amitriptyline 5 13.9)
doxepin 3 8.3)
sertraline 3 8.3)
fluoxetine 2 5.6)
desipramine 2 5.6)
imipramine 1 2.8)
bupropion 1 2.8)
phenelzine 1 2.8)
Anti-Psychotics : 33 (25.0)
haloperidol 27 81.8)
thioridazine 3 9.1)
thiothixene 2 6.1)
molindone 1 3.0)
Sedative/Hypnotics : 63 (47.7)
lorazepam 16 25.4)
temazepam 12 19.0)
flurazepam 10 15.9)
24
diphenhydramine
triazolam
oxazepam
diazepam
clonazepam
alprazolam
Total Orders Routine and PRN 132 (100%)
25
Table 4
Criteria for Potentially Inappropriate Use of Psychotropic
Drugs :
I. Anti-depressant drugs
A. PRN use
B. Use of tertiary amines
C. High dose ex) desipramine > SOmg/day
II. Anti-psychotic drugs
A. Any use
B. Use of chlorpromazine due to side effect potential
C. High dose ex) haloperidol > 2mg/day
ex) thioridazine > SOmg/day
III. Sedative/hypnotic drugs
A. Long-term use
B. Use of diphenhydramine due to anti-cholinergic
effects
C. Use of long-acting benzodiazepines flurazepam,
diazepam
D. High dose ex) diazepam > 5mg/day
ex) oxazepam > 30mg/day
Adapted from Avorn J, Soumerai SB, Everitt DE et al. A
randomized trial of a program to reduce the use of
psychoactive drugs in nursing homes. N Engl J Med
1992;327:168-173.
26
Table 5
Medication Errors of Routine Psychotropic Drug Orders, N=66:
Error Type Anti- Anti- Sedative/ Totals
Depressants Psychotics Hypnotics
Drug-induced problem 0
Appropriate drug, 1 1
no indication
Inappropriate drug for 2 2
diagnosis, but indicated
Inappropriate drug, 1 1
appropriate class
Inappropriate dose, 1 6 7
re-evaluate dose
Drug-drug interaction 0
Poor monitor of ADR 0
Side effect potential 3 1 4
Too long of duration 3 3
Appropriate drug,
inappropriate time 1 1
Total Number of Errors 3 10 6 19
Error Rate in % (*) 8.3 55.6 50.0 28.8
* Total Number of Errors/Total Number of Orders x 100
27
Table 6
Problems Associated with Routine Non-Psychotropic Drug
Orders, N=34:
Error Type Number (%)
Need electrolyte panel 8 (23.5)
Need thyroid panel 3 (8.8)
Need CBC tests 3 (8.8)
Need drug volume test 3 (8.8)
No indication/diagnosis 12 (35.3)
Re-evaluate dose 3 (8.8)
Appropriate dose, inappropriate time 2 (5.8)
Total 34 (100%)
28
Appendix A
OBRA 1990 Legislation and HCFA Interpretive Guidelines
Regarding Overall Drug Therapy and Unnecessary Drugs :
Level B Requirement : Drug Therapy
Unnecessary drugs Each resident's drug regimen must be
free from unnecessary drugs: 1) drugs given in excessive
doses, for excessive period of time, without adequate
monitoring, or in the absence of a diagnosis or reason for
the drug or 2 ) a drug for which monitoring data or undue
adverse consequences indicate that the drug should be
reduced or discontinued entirely or 3 ) a drug that is
prescribed only in anticipation of an adverse consequence
of another prescribed drug.
Anti-psychotic drugs---Based on a comprehensive assessment
of a resident, the facility must ensure that :
Residents who have not used anti-psychotic drugs are
not given these drugs unless anti-psychotic drug therapy is
necessary to treat a specific condition, and residents who
use anti-psychotic drugs receive gradual dose reductions,
drug holidays or behavioral programming, unless clinically
contra-indicated, in an effort to
discontinue these drugs.
From The Federal Register, vol 56, no. 187, September 26,
1991, pp 48865-48921.
29
Appendix B
HCFA Interpretive Guidelines Regarding Specific Indications
for Neuroleptic Drug Use:
Anti-psychotic drugs are not to be given to residents unless
they are necessary to treat a specific condition (one of the
following):
1. Schizophrenia
2. Schizo-affective disorder
3. Delusional disorder
4. Psychotic mood disorder
5. Acute psychotic episode
6. Brief reactive psychosis
7. Schizophreniform disorder
8. Atypical psychosis
9. Tourette's disorder
10. Huntington's disease
11. Nausea, hiccups, itching
12. Organic mental syndromes (QMS), such as Alzheimer's
dementia. Organic Brain Syndrome (OBS) with dementia. Multi
infarct dementia, or Parkinson's dementia, with agitated
and/or psychotic features : 1) The OMS must result in
behavioral symptoms which cause the resident to present a
danger to self---present a danger to others interfere with
care of patient by staff
2) Or, the OMS must have psychotic symptoms such as
hallucinations, which impair the resident's functional
capacity (eating, tioleting,sleeping, etc.).
From The Federal Register, vol 56, no. 187, September 26,
1991, pp 48865-48921.
30
Appendix C
HCFA Interpretive Guidelines for when Anti-psychotic
Medications may or may not be used:
Anti-psycho tics should not be used if one or more of the
following is the only behavioral problem symptom:
restlessness, nervousness,anxiety, insomnia, indifference to
surroundings, wandering, uncooperativeness, depression,
unsociability, poor self care, impaired memory, fidgeting,
or unspecified agitation.
Anti-psychotics may be used for the behavioral problem
symptoms of crying out, screaming, yelling, or pacing if the
resident has a diagnosis of OMS and the behavior is
continuous and impairs functional capacity (eating,
sleeping, toileting, etc.).
PRN use will be allowed five times in any seven day period,
but the psychiatric diagnosis and behavior problem must
still be identified.
From The Federal Register, vol 56, no. 187, September 26,
1991, pp 48865-48921.
31
Appendix D
Anti-Depressant Drug Comparisons for the Geriatric Patient :
Generic Sedation Hypotension
Name Potential Potential
Anti-cholinergic
Side Effects
Cardiac
Effects
Tertiary Amines :
amitriptyline + + + ++ + +++ ++ +
imipramine + + + ++/+++ ++
doxepin ++/+++ ++ +++ + +
trimipramine + 4-4- ++ +++ + + +
clomipramine + + + 4-4-4- +++ +++
Secondary Amines :
desipramine + +/++ + +
nortripty1ine + + + + +
amoxapine + ++ + + + +
protriptyline + 4- 4- + + + ++
maprotiline + +/++ + ++ + + +
Atypical :
trazodone + + ++ + + / + +
fluoxetine unusual none none none
sertraline unusual none none none
bupropion unusual none none none
+=Mild ++=Moderate +++=Severe ++++=Very Severe /=Between
Adapted from Salzman
Psychopharmacology/ 2nd.
Wilkins, 1992.
C.
Ed.
Clinical Geriatric
Baltimore: Williams and
32
Appendix E
Anti-Psychotic Drug Comparisons for the Geriatric Patient :
Generic Sedation Hypotension Anti-
Name Potential Potential Cholinergic
Potential
Extra-
Pyramidal
Potential
chlorpromazine +++ +++ +++ ++
thioridazine +++ +++ + + + /++
perphenaz ine ++ ++ ++ ++
molindone ++ + + ++ + +
loxapine ++ ++ ++ ++
theothixene ++ ++ + + / + ++/+++
tri fluperaz ine ++ ++ ++/ + ++/+++
fluphenaz ine + + + ++ +
haloperidol + + + +++
+=Mild ++=Moderate +++=Severe /=Between
Adapted from
Psychopharmacology,
Salzman C
2nd. Ed.
Clinical Geriatric
Baltimore: Williams and
Wilkins, 1992
33
Appendix F
Sedative/Hypnotic Drug Comparisons
Patient ;
for the Geriatric
Generic Name Usual Geriatric Dose Range Older Adult
(mg/day) Half-Life Hours
(*)
Long-Acting :
flurazepam 15-30 100-200
clonazepam 0.25-2 38-100
diazepam 2-2 0 75
chlordiazepoxide 5-40 30
Intermediate-Acting :
alprazolam .25-2 12-15
lorazepam 0.5-2 12-18
temazepam 15-30 10-20
Short-Acting:
oxazepam 10-45 10
triazolam 0.125-0.25 2-5
* Half-Life is the amount of time that it takes half the
amount of the drug to be deactivated or eliminated from the
body.*
Adapted from Salzman C. Clinical Geriatric
Psychopharmacology, 1st. and 2nd. Ed. Baltimore: Williams
and Wilkins, 1984 and 1992.

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Creator Krueger, Mark C. (author)

Core Title Psychotropic drug prescribing patterns in the nursing home

Contributor Digitized by ProQuest (provenance)

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