Antipsychotics and Your Terminally Ill Nursing Home Resident

The inclusion of the antipsychotic measure in the calculation of the Five-Star Quality Rating System for a nursing home has increased the scrutiny regarding administration of antipsychotic drugs. The goal of VITAS® Healthcare is to optimize symptom management; we prescribe antipsychotic treatment only when clinically substantiated. If antipsychotics are initiated for a specific symptom and the treatment is not effective, the treatment is discontinued.

Indications for Antipsychotics

Antipsychotics represent a key therapeutic medication class to help manage distressing symptoms in patients with advanced illness. Symptoms that may warrant and benefit from a trial of antipsychotics include perceptual disturbances (hallucinations, paranoia and delusions), nausea and vomiting, delirium and behavioral disturbances (agitation and terminal restlessness). Agitation and terminal restlessness are particularly common near the end of life, with prevalence rates reported more than 50% and 80% of the time, respectively.

Multidisciplinary Evaluation of Agitation and Terminal Restlessness

Agitation and terminal restlessness benefit from a multidisciplinary assessment that identifies potential contributors to the symptom burden. Such contributors should be assessed and managed in light of goals of care and life expectancy to promote patient-centered care. A thoughtful approach is displayed in the table below.

Non-Pharmacologic Management

In patient-centered care, non-pharmacologic approaches are incorporated as part of the care plan, along with considerations for pharmacologic treatment. Examples of non-pharmacologic techniques include sensory interventions (music or touch), care mapping (the social world that surrounds a person impacts well-being) and communication skills training. But non-pharmacologic techniques may be substantially less beneficial for people near the end of life.

That is, those most likely to respond to non-pharmacologic interventions tend to have higher levels of cognition, greater ADL independence, the ability to effectively communicate, the ability to speak and responsiveness. People less likely to respond to behavioral interventions tend to have physical symptoms, such as pain. The presence of agitation and terminal restlessness should include non-pharmacologic interventions, particularly music and touch, with the recognition that such treatments do not obviate the use of antipsychotics if deemed appropriate by the interdisciplinary team.

Pharmacologic Management

Antipsychotic use is reserved for patients who exhibit significant distress and/or endanger themselves, other patients or a caregiver. While no medication is FDA approved for the management of agitation or terminal restlessness, several therapies have demonstrated clinical effectiveness based upon published randomized clinical trials. Medications found to be effective for the management of agitation in advanced illness, particularly dementia, include antipsychotics, citalopram, benzodiazepines and dextromethorphan/quinidine. For refractory agitation not responding to other treatments, phenobarbital may be a therapeutic option. Importantly, common agitation-related symptoms such as calling out/shouting, repetitive movements and day/night reversal should not be considered for antipsychotic therapy.

Scoring of the Minimum Data Set 3.0 at the End of Life

When an antipsychotic is given and the resident dies in the nursing home, the discharge screen does not ask whether the resident received an antipsychotic, and thus the antipsychotic does not impact the quality measure. If, however, the resident is discharged alive—for example to the hospital—the question of whether the resident received an antipsychotic is asked. Election of hospice is not adjusted for this measure. For the comfort and well-being of the resident and for the least impact on quality measures, it is beneficial to help the resident remain in the nursing home.

VITAS Can Help

VITAS has decades of experience caring for nursing home residents near the end of life. Our care plans incorporate a multidisciplinary assessment and management approach to identify and treat contributors to agitation and terminal restlessness, such as pain, shortness of breath, anxiety, depression and constipation. As part of our patient-centered care plan, VITAS offers non-pharmacologic sensory therapies. Also, Intensive Comfort Care® provides shifts of care for appropriate patients up to 24 hours during difficult times so your resident remains at the nursing home and out of the hospital.

At VITAS, patients and families come first. We choose partners who have the same values. Together we can ease the burdens and grief at the end of life through appropriate administration of medications.

Disclaimer: Each patient’s situation is unique. While this has been created for clinicians, it cannot replace the professional judgment of a physician or other healthcare professional.