The outcry over antipsychotics has ranged far and wide. Everyone from governmental agencies to senior advocacy organizations have pointed to the abysmal data. Antipsychotics have a negative impact on morbidity and mortality. They say we are chemically restraining those who are too fragile to stick up for themselves. They say we are sedating instead of treating.
And I disagree wholeheartedly.
I manage a large group of moderately to severely demented nursing home patients. They are agitated and delirious on a regular basis. Often searches for infections, pain, constipation, depression, and other inciting factors come up empty. Their behavior is disruptive, dangerous, and heartbreaking for their loved ones.
The correct treatment: impeccable environmental controls, one-to-one supervision, and extensive counseling for the patient and family are often not available or too expensive. Our choices become limited.
We have moved away from physical restraints in the skilled nursing facility environment. They are dangerous, inhumane, and often add to agitation.
Sedatives (the benzodiazepine class: Ativan, Xanax, clonazepam) can increase agitation and are frowned upon among geriatricians.
Leaving patients floridly delirious without treatment is unduly burdensome to the family and nursing staff, pulls clinical support away from others who need help on the unit, and leaves patients upset and suffering.
Antipsychotics are effective. They calm quickly with few physical side effects.
Using antipsychotics in a demented person suffering delirium is a prime example of palliative care. They are prescribed for patients with moderate to severe dementia who have a low-quality existence.
This is what defines palliative care. We trade quality for quantity in a patient population that suffers deeply, and often is only obliquely aware of their surroundings.
It’s good for patients. Good for families.
It’s excellent palliative care.
The author is an anonymous physician.
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