Dementia and Chemical Restraints

BY: Karlene Stefanakos, M.A., CCC-SLP on Monday, 12 September 2011. Posted in All, Dementia, Speech Pathology

Psychoactive (psychotropic/pharmacological) drugs are among the most frequently prescribed medications for the elderly in skilled nursing facilities and assisted living facilities designed for dementia residents. Psychoactive drugs are medications designed to alter behaviors through their tranquilizing effects, reduction of anxiety and depression, and sedative and hypnotic effects. CMS (Center for Medicare Services) has mandated that these medications are NOT to be used unnecessarily. The regulations state that an unnecessary drug is any drug when used in excessive doses (including duplicate therapy), for excessive duration, without adequate monitoring, without adequate indications for its use, in the presence of adverse consequences which indicate the dose should be reduced or discontinued, or any combinations of these reasons.” Duplicate drug therapy is defined as “any prescribed medication that duplicates a particular effect on an individual.”  This includes two or more drugs used in combination to produce a similar effect on behavior. Duplicate drug therapy should always be analyzed for accumulative adverse effects. (Long Term Care Guidelines, CMS, 1992).

When used appropriate and judiciously, these medications can enhance the quality of life of many residents who need them. However, it has been found that all psychoactive drugs have the potential for producing undesirable side effects or aggravating existing problems or symptoms when used unnecessarily. The goal for use of these drugs should always be to enhance the individual’s quality of life while minimizing the side effects or risks associated with psychoactive medications. The following drug categories have been identified as triggers for further investigation of possible unnecessary, excessive or duplicate drug therapy and must have written monitoring by the psychoactive drug teams (committees) in the SNFs. The Speech Language Pathologist should be a representative on these teams/committee’s for monitoring of cognitive side effects of these drug categories:

  • Long Acting Bensodiazepine Drugs
  • Bensodiazepine, Anxioltic, or Sedative Drugs
  • Sleep Inducing Drugs
  • Antipsychotic Drugs

When it is determined that a psychoactive drug in indicated by the psychoactive drug team, including the physician, the following criteria must be present:

  • It must be the least restrictive alternative to modify the behavioral symptoms
  • The risks and benefits must be specifically identified and described to the individual and/or the authorized representative.
  • There must be evidence that the benefits outweigh the potential risks
  • There must be indications that the drug of choice enables the functional independence of the individual
  • A specific plan must be developed that addresses the potential risks, monitoring of the individual while under the influence of the drug, and steps to provide alternatives if appropriate.

In all cases, the lowest possible dosage is prescribed, monitored for its effectiveness and any potential side effect. In the presence of adverse effects, an alternative plan must be implemented to reduce or discontinue the drug. Gradual dose reduction is monitored by state surveyors and should be attempted and documented at least twice a year. Reducing dosage is a key factor in promoting quality of life for all individuals. Each member of the team in the facility needs to be sensitive to the issues surrounding the use and reduction of the psychoactive drug therapy for an individual because this is a center wide effort. Listed are some examples of drugs which are “suitable for the elderly":

* Not drug of choice, but listed for potential use

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