Interventions for Behavioral Symptoms in Nursing Home Residents

Behavioral disturbances are common among nursing home (NH) residents. In 2000, it was estimated that approximately 60% to 80% of NH residents have dementia,¹ a condition that often leads to a range of challenging behavioral and psychological symptoms, particularly in its advanced stages. In addition, over 500,000 cognitively intact persons with a mental illness reside in NHs.² Then there are a range of other factors that can lead to psychological symptoms, including medications, sensory deficits, infections, substance abuse, and poor nutrition. On top of that, diseases that are prevalent among elders (eg, Parkinson’s disease) may lead to concomitant psychological disturbances. With so many factors to contend with in NHs, determining the cause of a resident’s disturbance and the best management approach can pose a considerable challenge.

After a thorough assessment and treatment of any underlying illness, nonpharmacological therapeutic approaches are preferred for many behavioral symptoms. In some cases, however, pharmacotherapies ultimately cannot be avoided. In this issue of Annals of Long-Term Care: Clinical Care and Aging^® (ALTC), we examine interventions, including the use of antipsychotics, to manage behavioral issues in patients with and without dementia. 

In our first article, “Evidence-Based Practice Intervention for Managing Behavioral and Psychological Symptoms of Dementia in Nursing Home Residents”, Rebecca Perkins, RN, reviews some of the nonpharmacological interventions that have been used to manage behavioral and psychological symptoms of dementia. These include staff education, sensory stimulation, and activity interventions. Based on her literature review, staff education had the greatest impact on these symptoms, whereas sensory stimulation and activity interventions had less of an impact; however, due to the paucity of studies examining such approaches, Perkins notes that further studies are needed, particularly to determine which ones may be most efficacious as a first-line approach for residents with dementia. She proceeds to review pharmacological interventions, including antipsychotics, cholinesterase inhibitors, and anticonvulsants, noting that such medications are indicated if nonpharmacological interventions fail and a resident’s behaviors are dangerous or the result of a nondementia-related psychosis. 

This brings us to our next article, “Delusional Disorder Leading to Precipitous Weight Loss”, in which Jullie Pullen, MS, and Jordan Teller, MS, outline the case of a resident with Parkinson’s disease who developed a delusional disorder that caused her to stop eating and lose 39 lb before an antipsychotic was prescribed. The resident’s delusion resulted shortly after admission to an NH, which followed a hospitalization during which she was found to have Parkinson’s disease. Both her admission to the NH and her recent diagnosis caused her a considerable amount of stress, and she developed an irrational fear of flatus in public areas and of being humiliated because of it, despite no history of flatulence. After testing ruled out any underlying pathology and nonpharmacological interventions failed, low-dose quetiapine was initiated. Shortly thereafter, she resumed eating in the dining room, regained 20 lb, and no longer vocalized a fear of passing gas. 

Due to the paucity of FDA–approved pharmacological treatment options for managing behavioral problems in elderly patients with and without dementia, most agents are prescribed off-label. This was the case with the aforementioned patient, who received low-dose quetiapine. But as this case demonstrates, off-label agents can have a role in treating patients when nonpharmacological interventions fail. Determining which agents to prescribe, however, is the challenge. A resource that can be invaluable when making such decisions is the American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.³ For instance, applying these criteria to Pullen and Teller’s case shows that while quetiapine is not approved by the FDA for patients with Parkinson’s disease, it can be tried in these patients when nonpharmacological treatments fail. In contrast, most other antipsychotics (with the exception of clozapine) should be avoided due to their propensity to exacerbate parkinsonian symptoms.³ With a lack of resources and so many diagnostic variables and confounding factors to contend with, geriatricians should make use of evidence-based resources like the Beers Criteria, while also recognizing that each case is unique and requires them to use their best judgment.    

As this year concludes, the staff of ALTC would like to wish you a wonderful holiday season and a healthy and happy New Year! We thank you for your readership and contributions to the journal and look forward to continuing to serve you.

Thank you for reading!

References

1. Marcantonio ER. Dementia. In: Beers MH, Jones TV, Berkwits M, Kaplan JL, Porter R, eds. Merck Manual of Geriatrics. 3rd ed. Whitehouse Station, NJ:Merck & Co., Inc.; 2000:357-371.

2. Grabowski DC, Aschbrenner KA, Feng Z, Mor V. Mental illness in nursing homes:  variations across States. Health Aff (Millwood). 2009;28(3):689-700.

3. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616-631.