Forward by Kim Warchol
I present this article for two benefits. First, I think the content is valuable in and of itself. Since I am not a nurse, it is important to hear the professional perspective regarding medications for behaviors directly from nursing as they are a very key member of the dementia management team. Second, I think this article epitomizes the congruence in philosophy and approach needed between therapy and nursing for optimum success. Clearly, the author shares the goal of minimizing meds and maximizing non-pharmacologic interventions to control behaviors. In addition, this nurse shares our philosophy on pain management.
Medications should always be evaluated when considering a possible cause for a change in behaviors or a decline in functional or cognitive status. Remember you have to be the chief investigator because the dementia resident/client will be unable to fully communicate their reaction to the medication regime. Reviewing the resident/client chart will offer valuable information as to whether or not their medications could be the explanation/cause of the behavior. Therefore a chart audit is always in order.
A quick audit of the Physician Orders should include:
- newly prescribed medication,
- recent discontinued medication,
- an increase or decrease in dosage,
- any medication that is being refused,
- medications that could have toxic levels (such as Digoxin,Lithium), and
- medications that should be monitored by therapeutic lab values
- Thyroid
- Diabetic agents
- Iron and other vitamins
- Blood thinners
- Diuretics
- Check the accuracy of the current meds against the hospital discharge or previous/current home list.
- Pain Management: Narcotic and non-narcotic usage
- Managing pain with prn medication administration is not recommended for optimal results with the dementia resident. Often they will respond to the nurse's questions "No, I'm not in pain" when in fact their body language is telling you something quite different.
- Pain management with the just right dosage is vital. Too little pain control limits function, mobility and motivation. Too much pain medication will cause increased drowsiness, confusion, GI disturbances and constipation, increasing the risk for falls and behaviors. The dementia resident is dependent on the staff to make sure this balance is maintained for their wellbeing. Consistent reassessing after administering a pain medication with a standardized scale will give you the needed information to meet the residents' need.
- Atypical anti-psychotic drug usage (Risperadol, Seraquel, Zyprexa)
- A study of atypical anti psychotics vs. placebo to manage behaviors in the Alzheimer's population out of USC revealed "no significant differences between the groups in symptoms with regard to improvement."
- The study acknowledged the "first line of treatment must be looking at behavioral factors" such as changes in daily routine, feeling rushed or crowded.
- Recognizing all behaviors are sending us a message, and if we become experts in meeting our resident's unique needs, we will minimize usage of this class of drugs.
- Side Effects: sedation, increased confusion, Parkinson like symptoms.
- Anti-anxiety agents
- Teaching staff and changing the culture that this class of drugs is not the first line of treatment with regard to behavior management. Always determining the trigger and meeting that unmet need is the priority.
- Audit for current Alzheimer drug therapy that could decrease the progression of the disease.
You have been entrusted to maintain your resident's/client's quality of life. Keep a close watch on their medication regime. Remember all medications have the possibility to cause adverse side effects to your fragile Alzheimer client and therefore should be used with caution. The goal must be to recognize the message behind their behavior, understand their feeling, validate that feeling, meet their needs, and prevent further occurrences.