Download F-tag 329: Unnecessary Drugs

Mental Health Needs of
Persons Residing in Skilled
Nursing Facilities
A Learning Module for Effective Social
Work Practice with Older Adults
Dr. Robin P. Bonifas, MSW, PhD
Arizona State University
School of Social Work
Acknowledgements
 The development of this curriculum
module was made possible through a
Gero Innovations Grant from the CSWE
Gero-Ed Center's Master's Advanced
Curriculum (MAC) Project and the John A.
Hartford Foundation.
Geriatric Mental Health: Psychiatric
Conditions and Behavioral
Management
 Overview:
 Behavioral management principles
 Common causes of behavioral symptoms and potential
interventions
 Understanding federal regulations regarding
psychotropic medication usage in skilled nursing
facilities (SNFs)
Behavioral Management
 Components of behavioral management:
 Recognition and documentation of
behavioral symptoms
 Common causes of behavioral symptoms
 Potential behavioral interventions
 Monitoring behaviors
Behavioral Management
 Things to keep in mind:
 Behavioral symptoms are very common among older
persons with mental health conditions.
 The incidence of behavioral symptoms is very high in
SNFs because of the extent of mental health
conditions among facility residents.
 Behavioral symptoms are a form of
communication:
 All behavior has meaning.
 Behavior represents an expression of some need or
desire.
 Behavioral symptoms are influenced by
physiological function and medical illnesses.
 All behavioral symptoms have underlying causes.
Perhaps at this point you are
wondering, what are these “behavioral
symptoms?”
This terms captures behaviors such as hitting,
kicking, pinching, throwing things, continuous
disruptive yelling, making verbally abusive
comments, throwing things, sexually acting
out…
Recognition and Documentation
 One of the primary components of behavioral
management is recognizing it and documenting it - this is
how you determine the severity of the problem and
whether or not your intervention is working.
 Effective clinical documentation requires:
 The ability to recognize, describe, and document behaviors.
 The ability to analyze and address specific underlying causes
(with the help of other disciplines as needed).
 The ability to describe the behavior's characteristics: its
nature, scope, severity, duration, frequency, and
consequences, including its impact on other individuals.
Characteristics of Behavior
Characteristic Key Questions
Nature &
Relevant
Factors
When did the behavior start, and what were the
circumstances surrounding its onset? What happens
while the behavior is occurring? Did any specific
circumstances contribute to the behavior? What
makes it better? What aggravates it?
Extent
Why is the behavior a problem, and to what extent?
For example, does it affect the individual, others in
the same living environment, or his/her caregivers?
Scope
How often does the behavior occur?
Severity
What risk does this behavior pose to the individual
or to others? What is the degree of social or
household disruption?
Common Causes of Behavioral
Symptoms
 Several things can contribute to behavioral
symptoms:
 Medications
 Physical health status
 Psychiatric illness
 Environment
 Personal or health care tasks
 Interactions with others
 Next we’ll look at the specifics of each of these
things, plus potential social work interventions
for each…
Medications
 Review medications that could be contributing to
change in mental status or behavior, examples:
 Cardiac antiarrhythmics (i.e. verapamil, digoxin)
 Anticholinergics (i.e. artane, cogentin)
 Consultant a pharmacist as needed to help recognize
medications that may be associated with changes in
mental status or behavior.
 If high-risk or problematic medications are identified,
the individual’s physician or other appropriate health
care provider should be notified.
Physical Health: Conditions that
May Contribute to Behavioral
Symptoms
 Medications or noncompliance with medication
regimen
 Fluid or electrolyte imbalance
 Infections
 Hypo- or hyperglycemia
 Recent hospitalization
 Recent surgery under general anesthesia
 Recent change in living situation or environment
 Recent fall or other trauma
Physical Health: Conditions that
May Contribute to Behavioral
Symptoms
 Significant pain
 Alcohol or drug abuse
 Hypo- or hyperthyroidism
 Nutritional deficiency
 Recent stroke or seizure
 Primary or metastatic brain tumors or other
malignancies
 Cardiac arrhythmia or myocardial infarction
Source: American Medical Directors Association (AMDA). (1998).
Altered mental states: clinical practice guideline. Columbia,
MD: American Medical Directors Association (AMDA).
Physical Health
 If delirium or another medical cause is
suspected or identified, the client’s
physician or other appropriate health care
provider should be notified promptly.
 Remember delirium is a medical
emergency and requires medical rather
than social work intervention - our role
here is educating the family to decrease
their fears.
Psychiatric Illness
 It is important to consider whether
psychiatric illnesses might be causing
problematic behavior.
 For example, worsening of schizophrenia or
recurrence of major depression.
 Consult a psychiatrist if necessary.
 While not a psychiatric illness per se,
anniversary reactions associated with grief
and loss can also contribute to behavioral
symptoms.
Environment
 Review and identify environmental factors that
could be causing or contributing to problematic
behavior - this is a common issue in SNFs.
 For example:
 Not enough structured activity
 Space too large
 Too much noise
 Another person’s behavior contributing to agitation
 Recognize that boredom is a form of anxiety that
commonly results in agitation and is not an
indication for drug treatment.
Personal or Health Care Task
 Consider functional causes of problematic
behavior.
 For example a task (such as getting dressed or
using the toilet) may:
 Be too complicated
 Involve too many steps
 Not be modified for increasing impairment
 Be unfamiliar in a new environment
 Here, the solution may be as simple as helping
the individual approach the task differently.
Interactions with Others
 Consider causes of problematic behavior related to
interactions with others.
 For example:
 The caregiver may be too loud or seem threatening many persons living in SNFs, due to the culture of
their birth cohort, are afraid of men or persons of
color.
 The individual may be unable to understand or make
him/herself understood.
 Examples of relevant approaches might include
changing a caregiver’s approach or separating two
individuals who are not getting along.
Seek and Address Complications
of Treatments
 Some treatments for problematic behavior, such
as medications and physical restraints, can have
adverse consequences.
 Monitor clients for complications related to drugs
and devices.
 Change in appetite, falling, gait problems, decline
in function, exacerbation of behavioral problems,
or onset of new symptoms.
 Complications may occur within days of the initial
use or after weeks or months of longer-term use.
Consider and Address Adverse
Drug Reactions (ADR)
 Psychotropic medications can affect other body
functions, such as blood pressure, appetite, and
urinary continence.
 If a possible ADR is identified, this needs to be
communicated to the individual’s physician or
other appropriate health care provider, who can
then address possible complications.
Psychotropic Medications as
Interventions for Behavioral Symptoms
A review of federal regulations
guiding usage
Psychotropic Medications
 Psychotropic medications may be used as an adjunct
to behavioral interventions in skilled nursing facilities.
 Sometimes the combination of both types of
interventions helps residents to achieve better control of
distressing symptoms, thereby enhancing quality of life.
 Sometimes residents are so distressed that such
medications are necessary before behavioral
interventions can even be effective.
 Because of the negative side effects discussed in
proceeding slides, and the potential for misuse, the
prescription of such medications in SNFs is highly
regulated; it is important for social workers to be
aware of these regulations.
Psychotropic Medications
 F-tag 329: Unnecessary drugs
 F-tag 330: Antipsychotic drugs specific
conditions
 F-tag 331: Antipsychotic drugs dose
reductions
F-tag 329: Unnecessary Drugs
 Each resident’s drug regimen must be free
from unnecessary drugs. An unnecessary
drugs ia any drug when used:
 In excessive does (including duplicated
therapy); or
 For excessive duration; or
 Without adequate monitoring; or
 Without adequate indications for its use; or
 In the presence of adverse consequences
witch indicate the dose should be reduced or
discontinued; or
 Any combinations of the reasons above.
F-tag 329: Unnecessary Drugs
 The goal of these regulations and guidelines is to
stimulate appropriate differential diagnosis of
“behavioral symptoms” so the underlying cause of
the symptoms is recognized and treated
appropriately.
 The goal of these regulations is also to prevent the
use of psychopharmacological drugs with the
“behavioral symptom” is cause by conditions such as:
 Environmental stressors
 Psychosocial stressors
 Treatable medical conditions
F-tag 329: Unnecessary Drugs
 Long-acting Benzodiazepine Drugs
 Should not be used unless a shorter-acting
benzodiazepine has failed.
 After a shorter-acting benzodiazepine has failed, longeracting benzodiazepine should not be used unless:
 Evidence exists that other possible reasons for the
resident’s distress have been considered and ruled out.
 Its use results in maintenance or improvement in the
resident’s functional status.
 Daily use is less than four continuous months unless an
attempt at gradual dose reduction is unsuccessful; and
 Its use is less than or equal to the total daily dose listed in
Guidance to Surveyors (see pp-313) unless
contraindicated.
F-tag 329: Unnecessary Drugs
 Benzodiazepine or other
Anxiolytic/Sedative Drugs
 Use for purposes other than sleep
induction should only occur when:
 Evidence exists than other possible reasons for
the resident’s distress have been considered and
ruled out.
 Use results in a maintenance or improvement in
the resident’s functional status.
 Daily use is less than four continuous months
unless an attempt at gradual dose reduction is
unsuccessful (Twice within one year).
F-tag 329: Unnecessary Drugs
 Use is for one of the following indications:
 Generalized anxiety disorder
 Delirium, dementia, and amnesic and other cognitive
disorders with associated agitated behaviors, which are
quantitatively and objectively documented, which are
persistent and not due to preventable reasons and which
constitute sources of distress or dysfunction to other residents
or represent a danger to the resident or others.
 Panic disorder
 Symptomatic anxiety that occurs in residents’ with another
diagnosed psychiatric disorder.
 Use is equal to or less than doses listed in Guidance
to Surveyors, (see pp 316) unless contraindicated.
F-tag 329: Unnecessary Drugs
 Drugs for sleep induction should only be
used if:
 Evidence exists that other possible reasons for
insomnia have been ruled out.
 The use of a drug to induce sleep results in
the maintenance or improvement of the
resident’s functional status.
 Daily use of the drug is less than ten
continuous days unless an attempt at gradual
dose reduction is unsuccessful (3 times within
6 months).
 Use is equal to or less than doses listed in
Guidance to Surveyors, (see pp 318) unless
contraindicated.
F-tag 329: Unnecessary Drugs
 Antipsychotic Drugs
 Dosage limitations exist for use in delirium,
dementia, and amnesic and other cognitive
disorders unless contraindicated (see Guidance to
Surveyors, pp-321)
 Monitoring required:
 Tardive dyskinesia
 Postural hypotension
 Cognitive/behavioral impairment
 Akathisia;
 and Parkinsonism
 See pp-326 for examples of documentation
supporting use outside of the guidance when it is
in the resident’s best interest.
F-tag 330: Antipsychotic Drugs
 Residents who have not used antipsychotic
drugs are not given these drugs unless
antipsychotic drug therapy is necessary to treat
a specific condition as diagnosed and
documented in the clinical record.
F-tag 330: Antipsychotic Drugs
 Antipsychotic drugs should not be used unless the
clinical record documents that the resident has one
or more of the following “specific conditions”:
 Schizophrenia
 Schizoaffective disorder
 Delusion disorder
 Psychotic mood disorder
 Acute psychotic episodes
 Brief reactive psychosis
 Schizophreniform disorder
 Atypical psychosis
 Tourette’s disorder
 Huntington’s disease
F-tag 330: Antipsychotic Drugs
 Antipsychotic drugs should not be used unless the
clinical record documents that the resident has one or
more of the following “specific conditions”:
 Delirium, dementia, amnesic and other cognitive
disorders with associated psychotic and/or agitated
behaviors
 Which have been quantitatively and objectively
documented
 Which are persistent
 Which are not caused by preventable reasons
 Which are causing the resident to:
Present a danger to himself/herself or to others,or
Continuously scream, yell, pace if these specific behaviors
cause impairment in functional capacity, or
Experience psychotic symptoms which cause the resident
distress or impairment
F-tag 330: Antipsychotic Drugs
Antipsychotic drugs should
not be used if one or more
of the following is/are the
only indication:
 Wandering
 Unsociability
 Poor self care
 Indifference to
surroundings
 Restlessness
 Impaired memory
 Anxiety
 Depression (without
psychotic features)
 Insomnia
 Fidgeting
 Nervousness
 Uncooperativeness
 Agitated behaviors
which do not
represent danger to
the resident or
others.
F-tag 331: Antipsychotic Drugs
 Residents who use antipsychotic drugs
receive gradual dose reductions, and
behavioral interventions, unless clinically
contraindicated, in an effort to discontinue
these drugs.
 Clinically contraindicated when:
 Resident has specific condition
 Gradual dose reduction attempted twice in one
year resulting in return of symptoms
 Physician provides justification, see Guidance
to Surveyors pp-341 for details on what
justification must include.
An Example Care Plan for
Psychotropic Medications
An Example Care Plan for
Psychotropic Medications