Sunday, January 23, 2011

Antipsychotic Drugs and Chemical Restraints

At the GreatRep, and pretty much all long term care or memory care facilities, there is a Bill of Rights list for all the residents posted prominently around the building. One of these rights is "to be free of all restraints, including chemical restraints". Logical, right?

As an aide, I have very little to do with the residents' medications. I report symptoms to the charge nurse, who then decides what to do from there. A few of the residents are on frequent doses of the same medications for certain behaviors or symptoms and so we all know what they will probably get in response to our reports of their symptoms. Lillian has severe pain and it's very obvious when it's not being controlled well, so when she hurts we all know she needs her Morphine. LuLu repetitively hits herself, which lets us know it's time for more Haldol or Ativan for her.

A lot of science news articles state that the use of antipsychotic drugs for dementia is a bad practice. It's not intuitive, because if you look at the list of symptoms of say, schizophrenia:
"They include disorganized thought processes and disorganized behavior as well as delusions and hallucinations. The disorganized thought processes are seen primarily in speech such as rambling and 'word salad'. The patient may babble about various different topics one after another, which to the normal person, do not appear to be connected in any way. The phrase 'word salad' describes a patient’s incoherent speech, which lacks correct grammar and any obvious purpose. Disorganized behavior will be discussed in a following section. Hallucinations are false perceptions; patients believe they can hear voices others can’t and sometimes see or feel things others don’t. Delusions are misinterpretations of events and their purpose such as when patients believe the CIA is plotting against them or that their psychiatrist is involved in an assignation attempt against them. Schizophrenics cannot be reasoned with over their delusions; reasoning and discussion leads to the patient’s mistrust and anger." (1)

All of that is very typical of dementia patients as well. You'd think since the symptoms are so similar that the treatments can be as well. But apparently not, since the use of antipsychotics in dementia patients increases their death risk, for reasons unknown(2).

To be clear, it seems like Doctors are warning against antipsychotics to control behavior that is merely "annoying" for caregivers such as wandering, agitation, uncooperativenesss, etc. For behavior that is truly dangerous for the patients or everyone around them (self-injury, extreme combativeness that can physically injure both caregivers and the patient, etc) I think it can still be merited.

Which is why when I read articles like this one, "Alzheimer's Therapy Focuses on Care: Giving Alzheimer's Patients their Way, Even Chocolate"(3) part of me gets really frustrated. It seems like outsiders and the media tend to think that some of the interventions we routinely do on our patients are for our own convenience, and therefore wrong. I loved that it explained about emotional states lasting longer than the patient's ability to recall or explain the reason for the emotion; however I would have liked to have seen a few more realistic examples of how this can be implemented. Things like when one of my widowed residents becomes anxious, thinking her husband is injured and missing, it's more productive to let her talk about that briefly, then steer the topic to her children, who are all alive and well. She calms down and gets happier as she tells us about what they were like when they were little, and shows us the quilt her daughter made her. That way, when the conversation ends, it ends on a happier note, which is more likely to stop her anxiety cycle about her husband. And of course there are the more conventional redirections like trying to get her involved in an activity or focused on something else.

I just hate the idea that we're somehow failing LuLu because sometimes medication is the only way to get her to stop hitting herself. You can redirect her, feed her, hold her hands gently, all sorts of things, but if she's in that mood she will not be deterred and it's not safe for her.

Patients have the right to refuse care, for example. But an incontinent person who refuses to be changed for 8+ hours isn't making a reasonable choice and is endangering themselves by hugely increasing their risk for a pressure ulcer. So sometimes we just have to force someone to let us perform very basic hygeine on them. And it sucks. And sometimes the only way to do that without anyone ending up seriously hurt is to premedicate them, and sometimes even that doesn't work. I wish there were a magic wand to make combative people cooperate when you're trying to help them.

But for all the caregivers and family members who read that article, I want to tell them that baby dolls and chocolate are a part of the answer, and can be good tools, but we need more solutions. And that even as a profession, caregiving is rarely "convenient"; that's not why we do this work. So please give your facility the benefit of the doubt and ask first before assuming they're chemically restraining people for no good reason. It's a last resort, but sometimes it's the only way.

And I don't know if it really belongs on any patient's Bill of Rights. Because the truth is, they do have the right not to be restrained unless they're hurting themselves or others and nothing else will stop them.

1. About schizophrenia
2. Antipsychotics and death risk increase
3. Giving Alzheimer's Patients Their Way


  1. Girl, you are so right. Just the other day we had a severely anemic Alzheimer's patient continually trying to rip out her IV and get out of bed during her blood transfusions. We tried the baby doll. We tried giving her snacks (she slapped the nurse).The doctor refused to order restraints. He finally ordered Ativan, which did not help. We didn't have a tech, so a nurse had to stay in there with her at all time to make sure she did not pull out that IV or get out of bed. What a mess.

  2. Well thought out...and well said. Thank you, and maybe you can find out how to get the bill of rights revised so that it reflects the best interests of the patients.