Vocally Disruptive Behavior in the Elderly: A Helpful Strategy
(1/9/08)- The results of a recent small study of the usage of antipsychotic drugs to quiet disruptive individuals indicates that it is not doing the job, and that these drugs are being overused for off-label purposes when they should not be used for this purpose.
The study tracked 86 adults with low IQs in community housing in England, Wales and Australia for more than a month of treatment. Caregivers tracked the participant's behavior. The researchers focused on two drugs, i.e. Risperdal by Jansen, and an older drug Haldol. Dr. Peter J. Tyrer, a professor of psychiatry at Imperial College London led the research team.
The 86 people involved in the study varied in age from 18 to 65. They were divided into three groups for purposes of the study. One group received Risperdal; one group received another antipsychotic, the generic form of Haldol; while the third group members were given a placebo.
After a month, people in all three groups had settled down, losing their temper less often and causing less damage when they did. Those in the placebo group improved the most, significantly more so than those who were on medication.
(12/13/07)- In the December 4, 2007 issue of the Wall Street Journal, Lucete Lagnado, wrote a very interesting article entitled" "Prescription Abuse Seen in U.S. Nursing Homes". The article was subtitled: "Powerful Antipsychotics Used to Subdue Elderly: Huge Medicaid Expense".
The article states: "In recent years, Medicaid has spent more money on antipsychotic drugs for Americans than on nay other class of pharmaceuticals-including antibiotics, AIDS drugs or medicine to treat high-blood pressure".
Drug expenditure records from the Centers of Medicare and Medicaid Services indicate that nearly 30% of the total nursing home residents receive antipsychotic drugs on an off-label basis. This means that even though the drugs have not been approved for the treatment of some of these residents, doctors are however prescribing them.
Nearly 21% of nursing-home residents who don't have a psychosis diagnosis are on these drugs according to the CMS. The usage of these drugs escalated sharply when a federal law was passed in 1987 that sharply restricted the use of physical restraints on residents of nursing homes.
IMS Health, the drug care data consulting firm show that the sales of antipsychotic drugs have risen from$6.6 billion in 2002 to $11.7 billion last year. Prescription drug treatment for Alzheimer' residents have increased disproportionately in the last few years. After all, what better way for many of the understaffed and poorly managed homes to deal with their Alzheimer patients was there then to quiet them down with antipsychotic drugs even if the resident did not have any psychotic problem.
Republican Senator Charles Grassley, the ranking Republican on the Senate Finance Committee, which initiates all new legislation regarding Medicare and Medicaid called this whole matter "disturbing and alarming," . He sent a letter to the inspector general of the Department of Health and Human Services calling for an investigation of how such drugs are being used in nursing homes, and why the cost to the government is rising so rapidly for the usage of these drugs.
The senator also sent a letter to the three leading drug companies seeking documents about any marketing efforts that may have targeted nursing home patients directly or indirectly.
The three drug companies are: Johnson& Johnson Inc., and its subsidiary Jansen LP the makers of Risperdal; Eli Lilly & Co., the makers of Zyprex; and AstraZeneca PLC's subsidiary AstraZeneca Pharmaceutical, the maker of Seroquel, the number 1 drug in the Medicaid program in 2005 and 2006.
All these drugs carry the " black box" warnings that elderly dementia patients taking these drugs are at higher risk of death. In 2005, Medicaid spent $5.4 billion on atypical antipsychotic drugs.
(11/9/99)- Have you ever been in a nursing home or related senior living facility and been taken aback by loud screams and groans or the repetition of certain words? Have you attributed it to staff behavior or the behavior of other residents or any other persons in the environment? Research studies do not back-up this opinion. (See: Cohen-Mansfield J, Bellig N. (1986). Agitated behaviors in the elderly. I. A conceptual review. Journal of the American Geriatric Society; 34:711-721.)
Vocally disruptive behavior generally means verbal and vocal behavior including groans, screams, sighs and similar noises. The etiology of this behavior has yet to be determined (See below for theoretical explanations.). It appears to be more common among women. A common profile of an individual who exhibits this behavior would include both severe cognitive and functional impairment, a tendency to fall, increased sleep disturbance, and probably has had an introverted personality with a tendency to control emotions. Social isolation may exacerbate these behaviors. Music seems to reduce calling out behavior.
A review of the literature on vocally disruptive behavior indicates incident rates between 10% - 30% in long-term-care facilities, depending on the definition of verbal disruption used in the study.
This behavior tends to occur when a person is alone in a room, more often at night or when awakening in the morning or before meals and/or when physically restrained.
There are a number of theories that attempt to explain this behavior. One involves the concept that individuals lose their inhibition because of the cognitive impairment. Another sees vocally disruptive behavior as an expression of physical discomfort or an expression of mental suffering. Repositioning of the person may be important here. (Think of times you may have screamed aloud when you are all alone and feeling frustrated or were subject to muscle cramping.)
Another theory views it as a form of getting attention from staff (operant learning). A more complex theory is related to the outcome of feeling sensory deprivation as well as social isolation. As one ages and with the advent of chronic diseases, the ability to process sensory input is diminished. Added to this is the generally monotonous "institutional life" with all its feelings of loneliness (more than 60% of individuals have no visitors during their stay in these residents) and boredom, along with the fear associated with a new place. The vocal behavior is a response to negative emotions and a coping mechanism to stimulate oneself. The greater the amount of activities an individual is exposed to, the less the vocal disruptive behavior.
Strategy for dealing with this behavior:
This strategy is based on the theory that excessive noise making behavior is contingent on the social or physical environment of the resident, so that by manipulating the environment with psychosocial interventions, noise making is reduced. It is a two pronged or complementary strategy: ignore noisy behavior and at the same time, reinforce quiet behavior with extra stimulation. It can include reprimands and lectures to the vocally disruptive individual but done with a sense of respect for the dignity of the individual. Some touching and holding of the individual, if appropriate, would seem important to convey a sense of caring. Accompanying this with conversation appropriate to the person involved is a necessary component of this approach.. Psychotropic medications should be used in a cautious manner, but would be appropriate in situations where professional geriatric physicians think it could be of help.
This intervention calls for consistent delivery of the message that noise making is inappropriate, without continually stating this message. The message is incorporated into the behavior of the caretaker. Such an approach is non-invasive and not a threat to the resident. It should be carried out by all staff in collaboration with family members and significant others. A robust trial of this treatment would take at least three weeks and be continuous (day and night) with some kind of contingent reward for reduced vocal behavior. The success of this treatment could be measured in terms of the number of vocally disruptive behaviors at the beginning of the treatment and compared with the number of outbursts at the end.
Residents should not be drugged into compliance. There are more appropriate ways to reduce this behavior and make the final home of these residents more palatable.
FOR AN INFORMATIVE AND PERSONAL ARTICLE ON PRACTICAL SUGGESTIONS WHEN SELECTING A NURSING HOME SEE OUR ARTICLE "Selecting a Nursing Home"
Harold Rubin, MS, ABD, CRC, Guest Lecturer
updated January 9, 2008
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