Nursing Home Staff Shortages Tied to More Inappropriate Antipsychotic Use

(HealthDay News) — Nursing homes with staffing shortages have higher inappropriate antipsychotic medication use, particularly among nursing homes in severely deprived neighborhoods, according to a study published online April 24 in JAMA Network Open.

Jasmine L. Travers, Ph.D., R.N., from New York University Rory Meyers College of Nursing in New York City, and colleagues evaluated whether reported inappropriate antipsychotic medication use in nursing homes differs in severely and less severely deprived neighborhoods and whether these differences are impacted by levels of total nurse staffing. The analysis included a national sample of nursing homes linked across three large datasets for 2019.

The researchers identified 10,966 nursing homes, including 17.0 percent in severely deprived neighborhoods. In an unadjusted analysis, inappropriate antipsychotic medication use was greater in nursing homes located in severely deprived neighborhoods (mean, 15.9 percent of residents) compared with those in less deprived neighborhoods (mean, 14.2 percent of residents). A similar pattern was seen in adjusted models, with inappropriate antipsychotic medication use higher in severely deprived neighborhoods versus less deprived neighborhoods (19.2 versus 17.1 percent; adjusted mean difference, 2.0 percentage points) in nursing homes that fell below critical levels of staffing (less than three hours of nurse staffing per resident-day).

“These findings suggest that addressing staffing deficiencies in nursing homes, particularly those located in severely deprived neighborhoods, is crucial in mitigating inappropriate antipsychotic medication use,” the authors write.

Antipsychotic medications in nursing homes

Antipsychotic medications, primarily used for schizophrenia and other psychotic disorders, have become increasingly common in nursing homes. While these drugs can manage some symptoms in residents with dementia or behavioral issues, their use raises significant concerns.

Several factors contribute to the use of antipsychotics in nursing homes. Residents with dementia may exhibit behaviors like aggression, agitation, or wandering. Antipsychotics can have a sedating effect, making them easier to manage. In some cases, dementia patients experience hallucinations or delusions. Antipsychotics can help alleviate these symptoms. However, a troubling reason for their use is understaffing. Facilities with limited staff and resources may find antipsychotics a quick and convenient way to manage challenging behaviors, even if not the ideal solution.

Side effects of antipsychotic use

Despite potential benefits, antipsychotics can have serious side effects in older adults, particularly those with dementia [2, 3]. Increased risk of falls and injuries is a major concern. Antipsychotics can cause drowsiness and dizziness, making falls more likely and potentially leading to fractures. These medications can also worsen existing cognitive decline in dementia patients. Studies have shown a link between antipsychotic use and an increased risk of stroke in older adults. Additionally, antipsychotics can cause tardive dyskinesia, a movement disorder characterized by involuntary tremors or tics.

Ethical concerns

The use of antipsychotics in nursing homes raises several ethical concerns. Critics argue that these medications are sometimes used as chemical restraints to control residents, rather than addressing the root cause of their behavior. This raises the question of informed consent. Many dementia patients lack the capacity to make informed decisions about their medication use. Decisions about their medication are often made by family members or caregivers, adding another layer of complexity. While antipsychotics may manage some symptoms, they can also leave residents lethargic and unable to participate in activities. This impact on quality of life is a significant ethical consideration.

Alternative approaches to antipsychotics

Fortunately, there are several non-pharmacological approaches that can be used to manage behavioral issues in dementia patients. Modifying the physical environment to reduce triggers and create a calming atmosphere can be helpful. Validation therapy, which involves acknowledging and validating residents’ feelings, can de-escalate situations. Untreated pain can contribute to behavioral issues, so ensuring proper pain management is crucial. Ultimately, facilities with adequate staffing and staff trained in dementia care are often better equipped to manage behavioral issues without medication.

Antipsychotic medications can be a valuable tool, but their use in nursing homes requires careful evaluation. The potential risks and ethical concerns necessitate a cautious approach, prioritizing non-pharmacological interventions whenever possible. The goal should be to improve the quality of life for residents with dementia, not simply control their behavior. Increased staffing, dementia-specific training, and a focus on creating a positive and stimulating environment are all crucial steps towards achieving this goal.

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