One of the fears caregivers often have about placing a loved one in a Nursing Home is that the home will “drug” them to keep them placid and manageable. While it is true that there are often situations when medication is prescribed to control an elderly person’s behaviour, both in a Nursing Home and in their own home, sometimes this is an appropriate way to help. However,sometimes medication is inappropriately prescribed or maintained. To determine appropriate use of medication, it is important to understand the meaning of these behaviours, their context, the medications which are used and when they should and should not be prescribed.
Behaviours which lead to the prescription of medication can include agitation, wandering, aggression, intrusiveness, and anger. These behaviours can often be place specific, for example they arise in a Nursing Home because it is a situation of group living where people are in close proximity to each other. The same behaviours can also be the result of physical illness, such as urinary tract infections, or other physical problems, such as thyroid problems. They can indicate pain, constipation, sleep disorders, or medication reactions. They can be an emotional response,triggered by fear, anxiety, a move or change in environment, or having been abused. Sometimes they are the symptoms of dementia, such as in the case of restlessness and wandering.
Before any medication is prescribed, a thorough assessment of the behaviours and investigation as to their potential causes should be undertaken. The assessment needs to examine both the individual, those in close proximity to the individual, and the environment. A modification of environment or social interaction may decrease or eradicate the need for the medication.
Unfortunately, there are times when medication is prescribed without a thorough assessment, and primarily as a way to control behaviour. Essentially, this becomes chemical restraint, and it is different only in kind to the use of physical restraints such as tying someone down.
Medication can be an appropriate response to an individual’s needs. If they are anxious and scared, unable to nourish themselves, unable to sleep, or causing others to be aggressive towards them,medication may be the most respectful, unintrusive, and safest method of relieving distress. If an individual is particularly aggressive or intrusive, medications may be the only effective option, given parameters of caring for someone at home or in a Nursing Home; however, it should be a last resort.
Both use of medication and the dosage which is prescribed should be monitored and reviewed regularly and an assessment done to see if it is still necessary. Unfortunately, this does not always happen. Once an individual is put on a behaviour controlling medication, they may not be taken off it. Monitoring may have to come from family members, and the family may have to be the ones to instigate the tapering or stopping of the medication.
As discussed in our October, 2007, prescriptions for the elderly need to take into account age related changes in the body abilities to metabolize and excrete medications. “Start low, go slow” is the maxim that describes how dosages should be determined. Similarly, when medication is discontinued, care should be taken as to whether it can be discontinued all at once, or needs to be tapered, as is the case with some antidepressants or medications which may have led to either a physical or psychological dependence.
Older people and caregivers should always be aware of the purpose for which a medication is prescribed. They should also be aware of the potential side effects. They should be part of the decision making process when any medication is prescribed. Ideally, Nursing Homes should always inform a family and resident when a medication is prescribed for behavioural reasons. However, the reality is that caregivers need to let the Home know that they expect this level of communication and involvement in care decisions.
Common Medications Used for Behavioural Concerns
The following is for information only. Any questions or concerns should be directed to your physician or pharmacist. The inclusion of medications on this list does not constitute a recommendation, a criticism, etc. Please note that it is common for medications developed for one concern to be used for others. All medications have side effects and may interact with other medications. Persons using these or other medications need to balance the risks against the benefits. The first name is a common brand name, the name in parentheses is the generic name.
Seroquel (Quetiapine) Original purpose antipsychotic. Used in elderly for anxiety, paranoia, agitation, aggressive behaviour or mood stabilization
Risperdal (Risperidone ): Original purpose antipsychotic. Used in elderly for anxiety, paranoia, agitation, aggressive behaviour or mood stabilization
Zyprexa (Olanzapine): Original use with schizophrenia. Used with older persons for anxiety, paranoia, agitation, aggressive behaviour or mood stabilization .
Zopliclone (Imovane): Used for sleep disturbance.
Desyrel (Trazodone): Original purpose as anti depressant .Now used as sleeping aid. Sometimes used in small doses to control daytime symptoms of anxiety or restlessness .
Ativan (Lorazepam): Anti- anxiety. Generally not recommended for the elderly. Part of benzodiazepine family and can be addictive.
Depakene (Valproic Acid): Originally used to treat seizures or bipolar disorder. Used with the elderly as mood stabilizer.
Neurontin (Gabapentin): Original use as anti-seizure, also used for control. of pain related to nerve damage. May also be used with the elderly as mood stabilizer.
Celexa (Citalopram ). An antidepressant.
Paxil(Paroxetine) An antidepressant.
Prozac(Fluoxetine): An antidepressant. Not generally recommended as a first choice for the elderly.
Possible Side Effects of Medications
- Delirium and confusion
- Decreased alertness
- Interactions with other medications
- Mood disturbance
- Dryness of mouth
- Weight loss/gain
- Appetite changes
- Changes in bladder or bowel function
- Effects on other systems/organs in the body such as liver, kidney, heart.
For information on medications or drug interactions, click on the sites below.
Older people are not often offered counselling as an alternative to medication. Yet counselling is often the more appropriate intervention in response to behaviour changes. For caregivers, a qualified counsellor can help to lower stress and anxiety, deal with feelings of helplessness, identify depression and assist with coping mechanisms. This, in turn, can decrease the need for medicating a loved one. Adult children and professionals caring for the elderly should always consider counselling as a front line intervention