By Victor Molinari and Laurence G. Branch

Mrs. M. is an 82-year-old Florida widow with two married children living in other states. A petite woman who has always had a pleasant, outgoing personality, she likes walking to keep fit. For the past five years, though, she has resided in assisted living and exercises less. She has had three chronic conditions, including Parkinson’s disease, for many years, and is being treated with medications prescribed by a specialist.

Recently, Mrs. M. developed a moderate case of bacterial pneumonia and was hospitalized. She was put on antibiotics, sleeping pills and an increased L-Dopa dosage for Parkinson’s. In the last five days of her two-week stay, she was prescribed antipsychotic medication to ameliorate her declining mental status and to control hallucinations she had begun experiencing. When discharged to a nursing home, Mrs. M. had deteriorating mental status and recently prescribed antipsychotic medication—but no psychiatric evaluation or behavioral health diagnosis.

Nearly every month, reports appear documenting the untoward side effects of psychotropic medication, especially in elders in nursing homes. Particularly troubling are medications dispensed to treat behavioral problems among residents with dementia. In 2005, the FDA issued “black-box” warnings on medication bottles designating both atypical antipsychotic medication (which refers to medications with fewer side effects, such as extrapyramidal symptoms or tardive dyskinesia); in 2008, FDA warnings appeared on traditional anti-psychotic medications.

These cautions followed years research that questioned antipsychotic medications’ effectiveness and documented their deleterious consequences—including morbidity and mortality. The issue of overuse of antidepressants and sedatives in elders also has been raised.

Medications Misused?

Nursing home residents are often admitted without a long-term history of either psychiatric diagnoses or treatment. However, research conducted in 2010 at the University of South Florida has demonstrated that within three months of admission, 70 percent or more of nursing home residents are on at least one medication with psychoactive properties, and 15 to 20 percent are on four or more. We note in an “in press” article, “Reasons for Psychiatric Prescription for New Nursing Home Residents,” in Aging & Mental Health, that while there is often adequate justification and monitoring of psychoactive medications, the use of non-psychopharmacological approaches to address behavioral problems and psychiatric symptoms lags behind psychoactive medication use.

And there is a well-documented high prevalence of mental health problems in nursing homes. Barry Rovner and colleagues, in International Psychogeriatrics (2:1, 1990), suggested that nursing homes can be viewed as de facto psychiatric institutions. There are three main categories of residents with psychiatric problems: those with serious mental illness (schizophrenia, bipolar disorder, schizoaffective disorder), those with dementia and behavioral problems and those who are anxious or depressed because of reduced functioning caused by medical problems and difficulties adjusting to nursing home life.

A Multi-Layered Issue

Researchers, educators and advocates must recognize the complexity of the problem. Contrary to what is often portrayed, many nursing home administrators are sensitive to the mental health needs of their residents, and strive to ensure adequate care, as we concluded in Aging & Mental Health (13:3, 2009).

“Over-medicating” nursing home residents could be considered a rational response of administrators trying, with limited resources, to help residents with multiple mental health symptoms. It also could reflect the society-wide trend of increased psychiatric medication use. Another factor is that despite mandatory nursing home staff training in mental health care in some states, there is woeful inattention to such matters in state nursing home regulatory statutes, other than federally legislated screening for those with serious mental illness, according to Debra Street and colleague’s 2006 Nursing Home Residency and Serious Mental Illness: State Experiences report to the state of Florida.

In Gerontology and Geriatrics Education (29:1, 2008) we noted that staff recognize the need for more mental health training, but feel ill-equipped to handle complex behavior problems.

Assessment, Education and Compensation

Our research suggests this is a systemic issue that calls for a systemic solution. There are billing codes in place to reimburse mental health services such as psychotherapy and counseling. We need more geriatric mental health professionals, especially those trained in long-term care, to be competent enough to use them.

Education on non-psychopharmacological means of managing psychological problems is essential. Jiska Cohen-Mansfield and Barbara Jensen wrote in the Journal of the American Medical Directors Association (9:7, 2008) that interventions implemented by nursing home staff have been effective in reducing disruptive behaviors; when doctors learn of these methods they tend to embrace non-psychopharmacological treatment.

Given the high number of nursing home residents on medication combinations deemed inappropriate, there should be computerized warning systems in place to red-flag residents who could be on improper prescription regimens, and a geriatric psychopharmacologist on call to reassess such situations, according to a study in Health Services Research by Denys Lau et al. (39:5, 2004).

Another strategy would be preventive work, starting with brief evaluations at admission that identify not only mental health problems but also document enduring interests and personal strengths. In a 2011 pilot study, Effect of Mental Health Assessment on Prescription of Psychoactive Medication for New Nursing Home Residents, we found that implementing such a simple mental health assessment may decrease psycho-pharmacology use as a first line of treatment when findings are communicated to the nursing home staff.

We must adequately compensate physicians skilled in geriatrics and geropsychiatry for treating residents with mental health problems, and for participating in multi-disciplinary team meetings. We need comprehensive regulatory reforms promoting mental health in nursing home residents by designating quality indicators for individualized care. Reducing unnecessary medication would render immediate cost savings, including savings due to fewer emergency hospitalizations from medication side effects.

The overarching goal of long-term care is to improve the quality of life of our most vulnerable elders. With this in mind, we return to Mrs. M’s story.

To see if Mrs. M. had a serious mental illness that could be better treated elsewhere, the nursing home conducted the federally mandated Pre-Admission Screening and Resident Review. The multi-disciplinary, geriatrics-trained team included a physician, social worker, nurse and psychologist. They found that Mrs. M. did not have a serious mental illness, and eliminated the antipsychotic medication while reducing the L-Dopa, which may have triggered the psychotic symptoms. Properly adjusting her medications took months, but Mrs. M. is improving daily, with the possibility of returning home to assisted living.

Victor Molinari, Ph.D., is a professor in the School of Aging Studies and Laurence G. Branch, Ph.D., is a professor in the Community and Family Health and the Health Policy and Management departments, College of Public Health, University of South Florida (USF). Contributing authors include David A. Chiriboga, Ph.D., professor in USF’s Department of Child and Family Studies, Kathryn Hyer, Ph.D., associate professor in the School of Aging Studies, plus Lawrence Schonfeld, Ph.D., professor in the Department of Mental Health Law and Policy.

Editor’s Note: This article appears in the November/December, 2011, issue of Aging Today, ASA’s bi-monthly newspaper covering issues in aging research, practice and policy nationwide. ASA members receive Aging Today as a member benefit; non-members may purchase subscriptions at our online store.