Geriatric psychopharmacotherapy: issues and concerns. (Pharmacology and Older People)

Anumber of medications possess "psychoactive" properties that have an effect on the mind. These include antipsychotic medications, antianxiety drugs, sedative/hypnotics, and antidepressants. The use and misuse of these agents are discussed in this article.

Various surveys suggest that many older individuals take a large number of drugs, including psychoactive agents, on a regular basis (Guttman, 1978). Psychoactive drugs are among the most frequently prescribed agents in the elderly (Vestal, 1984). Some of the most troubling examples of misprescribing such drugs for the elderly can be found in our nation's long-term-care nursing facilities (NFs) (Beardsley, 1989), where historically they have been used to sedate and control the activities of facility residents.

Between 46 percent and 75 percent of long-term-care residents have behavioral, social, emotional, and mental disorders, but recipients of psychoactive drugs often do not have psychiatric diagnoses (Harper, 1985). A 1976 government survey of long-term-care NFs revealed that although only 10 percent of their sample had a clearly documented mental illness, nearly 50 percent of all residents were prescribed antipsychotic or sedative/hypnotic drugs (U.S. DHEW, 1976).

More recent surveys reveal that these numbers have not changed significantly since the 1976 report. A 1988 review of 850 residents of 12 NFs in Massachusetts found that more than half of all residents were receiving a psychoactive drug, with 26 percent receiving antipsychotic agents (Beers et al., 1988). A review of 5,902 residents in Tennessee long-term-care NFs found that 43 percent of these residents received antipsychotic drugs. The study's authors concluded that their findings provided "epidemiologic evidence suggesting misuse of antipsychotic drugs in nursing homes" (Ray, Federspiel and Schaffner, 1980).

In the NF setting, psychoactive drug therapy has frequently been employed as a pragmatic, symptom-based approach for the treatment of agitation in elderly individuals, although in recent years, this approach has changed significantly. Health Care Financing Administration regulations in the Omnibus Budget Reconciliation Act of 1987 (OBRA 87) specifically address this problem of psychoactive drug misuse (Federal Register, 1987). These regulations encourage the use of nondrug approaches and require that caregivers in NFs document the effectiveness (or lack thereof) of currently prescribed antipsychotic drugs. Under these regulatory changes, use of antipsychotic drugs to control undesirable behavioral symptoms in the absence of a legitimate psychiatric need results in loss of revenue for the nursing home.

According to a September 1993 personal communication from S. Kidder, pharmacist consultant with the Health Care Financing Administration, these regulations appear to have catalyzed a reduction in the level of antipsychotic drug prescribing in NFs across the country. While education remains the preferable approach to affecting prescribing patterns, apparently the fear of punitive action can be a strong motivator for practitioners to keep current and to practice carefully (Kane and Garrard, 1994).

A recent analysis of the changes in antipsychotic drug use in long-termcare nursing facilities during implementation of the OBRA 87 regulations found that during the 30-month study period, antipsychotic drug use decreased 26.7 percent. There was no concomitant increase in any other psychoactive drug use. The authors concluded that "although this decrease is consistent with an improvement in quality of nursing home care, further research is needed to determine the effects of this legislation on resident outcomes" (Shorr, Fought and Ray, 1994).

Until recently, clinicians believed depression was most prevalent in the elderly. However, epidemiologic surveys of community-dwelling elderly indicate that depression, particularly major depressive disorder is less common in late life than at other ages (Weissman et al., 1988). When the incidence of depressive symptoms rather than disorders is examined, the prevalence in older adults increases substantially but is still less than in younger persons. Methodologic and sampling problems probably account for only a small part of some of the age differences observed by researchers (Blazer, 1990).

Despite this, some investigators believe it is reasonable to suggest that depression is seriously underdiagnosed in U.S. nursing …