AMDA Model Care Facility

Medical Staff Policies and Procedures

Policy Number: Clin.ORD.31

Subject: Ordering neuroleptics/major tranquilizers (and other psychotropic drugs)

Purpose:

1. To promote the utilization of psychotropic drugs in accordance with accepted principles of geriatric medicine and long-term care practice.
2. To establish procedures for the interdisciplinary management of psychobehavioral problems, including assessment, pharmacological and non-pharmacological management, and monitoring.
3. To comply with Department of Health and Health Care Financing Administration guidelines reflective of Goals 1 and 2.
4. To comply with [cite your state's abuse law, if any] prohibition of criminal mistreatment by chemical restraint.

Rationale: Psychotropic drugs are those intended to ameliorate psychiatric disorders and psychological symptoms by their known or presumed pharmacologic effect on the central nervous system. Classes of psychotropic drugs include antipsychotics (neuroleptics), anxiolytics, antidepressants, hypnotics, and miscellaneous. Accepted indications for psychotropic drugs are:

1. psychiatric disorders (meeting DSM-IV criteria);
2. short-term use for transitory psychological disorders, and under some circumstances short-term use on an as-needed basis for intermittent psychiatric symptoms;
3. delirium;
4. complicated dementia (with associated psychiatric features);
5. terminal palliation;
6. urgent sedation (including delirium), while awaiting medical or psychiatric management.

Psychotropic drugs are not justified for the restraint (sedation) of residents unless their behavior poses a danger to themselves or others; they are not to be used solely for the convenience of caregivers. Used for indication d), as is frequently the case in long-term care, antipsychotics have limited benefit (around 20% specific response in most studies) and are associated with hazards and complexities; thus, antipsychotic drugs for dementia-associated psychiatric features should be used as a last resort after (or adjunctive to) non-pharmacologic interventions. To ensure proper use of psychotropic drugs, currently accepted practice has been enacted into provisions of the Nursing Home Reform Act of 1987 (OBRA '87).

See also Commentary, below.

Primary Responsibility: Attending physician.

Scope: All facilities and programs.

Policy: The attending physician shall prescribe psychoactive drugs only:

1. after comprehensive assessment, identification of a medical indication, and documentation of the diagnosis on the medical record;
2. in coordination with appropriate concomitant interdisciplinary interventions;
3. in the lowest effective dose within a range suggested for the appropriate age group in published references;
4. with periodic (every 6 months for anti-psychotics, every 4 months for anxiolytics, every 2 months for hypnotics) reassessment of continued need, including attempted dose reduction or discontinuation when ordered for dementia-associated features. NOTE: Regulations allow an exception to the requirement for psychotropic dose reduction in the following circumstances:
   • two successive unsuccessful attempts (3 in the case of hypnotics)
   • serious medical contraindication, such as homicidal or suicidal behavior
   • specific conditions, namely
     - schizophrenia
     - schizo-affective disorder
     - delusional disorder
     - psychotic mood disorder (including mania and depression with psychotic features)
     - acute psychotic episode
     - brief reactive psychosis
     - schizophreniform disorder
     - atypical psychosis
     - Tourette's disorder
     - Huntington's disease
5. with appropriate monitoring for benefit and potential side effects.

Procedure:

1. The attending physician shall assess each resident for the presence of psychiatric disorders or psychobehavioral problems upon admission, annually, and when there is a "significant change."
2. The attending physician's comprehensive assessment shall investigate medical causes of psychiatric and psychobehavioral symptoms including underlying disease states, drug toxicity, or drug withdrawal syndromes.
3. The attending physician shall authorize psychiatric or psychological consultation or both when indicated. Such consultation shall also be authorized upon request from the interdisciplinary team unless an alternative assessment is planned that is mutually satisfactory to the team.
4. Psychoactive drug orders shall be coordinated with other interdisciplinary assessments and plans including:
   1. restraint management;
   2. behavior management;
   3. pain management;
   4. rehabilitation.
   Effects of psychoactive drugs on other aspects of function such as mobility and continence shall also be considered at each review of the care plan by the attending physician.
5. Nursing, Pharmacy and Social Work shall review psychoactive drug use periodically in accordance with applicable policies. The attending physician shall respond to concerns in one of three ways:
   1. accept the recommendation by means of an order;
   2. provide an alternative order mutually acceptable to the interdisciplinary team; or
   3. document a reason for rejecting the recommendation to the satisfaction of the Medical Director in conformity with applicable facility policies and regulatory standards.

Cross-References:

• Federal regulations (Tag): 42 CFR 483.13 (a) Chemical restraints (F222); 483.25 (f) Psychosocial adjustment difficulty (F319); 483.25 (l) Unnecessary drugs (F329); 483.60 (a) Drug regimen review (F429)
• State regulations:
• JCAHO standards: HR.3.2.1

Other Facility Policies:

• Admin.QUA.03 Drug regimen review (Not yet posted on this website)
• Clin.CAR.01 Resident rights (Not yet posted on this website)
• Clin.ORD.05 "PRN" Orders (Not yet posted on this website)

Key Words: Behavior management, Delirium, Dementia, Drug regimen review, Interdisciplinary team, Pain management, Pharmacist, Psychiatrist, Psychologist, Psychotropic drugs, Rehabilitation, Social worker.

Author: Duncan S. MacLean, MD, CMD

Commentary: MacLean, DS, "Psychotropic Drugs: When and How to Use," Caring for the Ages, Vol. 2, No. 2, February 2001, pp. 23-25. For more information or to subscribe, contact caring@lww.com.

Copyright: The author places this policy in the public domain. Attribution is requested.

Disclaimer: Use of this Policy is subject to the Terms of Use published on the AMDA Web site (www.amda.com). Neither AMDA nor the author assumes any responsibility for the consequences resulting from use of this model policy. Users are hereby advised to seek professional advice before implementing any policy.

Date Posted: February 15, 2001

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