According to a new report from RÚV, one out of four individuals living in Icelandic nursing homes is prescribed psychotropic drugs (often used for schizophrenia) even when patients haven’t been diagnosed with any psychosis. Instead, these medicines are often used as sedatives for patients who have dementia and represent a challenge to the staff because of behavioural problems.
Major tranquilisers, or not?
Chief of geriatrics Pálmi V. Jónsson told RÚV that while neuroleptics have the effect of major tranquilisers, the long-term effects can be particularly difficult to predict. Psychotropic drugs are mostly developed for young people, and the body of research that analyses their effects on the elderly is dangerously scarce. “Depending on which medicine is prescribed, the patient can develop symptoms that are not dissimilar to Parkinson’s disease,” he explains. “It can also lead to falls, bone fractures and so forth.”
The Directorate of Health is the public institutions that inspects and supervises the quality of nursing homes through a system that analyses the data and indicators sent three times a year by various nursing homes. One of these indicators analyses exactly how often medicines are given to patients without any medical diagnosis behind it.
It turns out that an average 24% of patients living in nursing homes between March and October of 2017 were given psychotropic drugs without any diagnosis of schizophrenia. The percentage was higher in the capital area, where it spiked up to 26%. Interestingly enough, the percentage of residents prescribed is well below the 31% mark identified by the Directorate of Health as the maximum allowed.
The last resource
The liberal use of antipsychotics in nursing homes in the West has been denounced in the past by the Human Rights Watch, which has likened them to a modern version of straitjackets. The drugs, in fact, are often prescribed in understaffed nursing homes to kill two birds with one stone: making unruly patients more manageable while keeping salary expenses low.
According to Pálmi, that’s not the case in Iceland, but a better quality control service needs to become top priority. “To do so we need better infrastructure, and I think this is something that the Directorate of Health should take care of,” Pálmi says. “Treatments in nursing homes are done well, it’s not like the staff administers really high doses or harmful drugs, but I think we can still do better.”
For instance, psychotropic drugs should be the last possible resource sought in nursing homes. Pálmi advises nurses to engage with antidepressants instead, when possible. In case antidepressants do not work, however, neuroleptics should be dispensed with extreme attention. Staff should therefore administer medicines that were developed specifically for older people, in very low doses and only for a short period of time (similarly to antibiotics therapy), as well as being on the look-out for any suspicious side effects.
A thorough job
According to María Fjóla Harðardóttir, nurse and Director of the Health Department in local nursing home Hrafnista, nurses are doing their job to the best of their capabilities, and the administration of antipsychotics has nothing to do with being understaffed or easing the nurses’ workload, as mentioned by the Human Rights Watch. On the contrary, individuals on psychotropic drugs can often stop moving, and as they need assistance to sit up, get dressed and taking care of muscular atrophy, the attention needed increases.
As of now, the percentage of administered antipsychotics in Hrafnista falls well below the national average, around the 20% mark. However, there is still space to improve. “What often happens to people affected by dementia is that they become aggressive, they try to hurt themselves, they cry and scream,” María Fjóla says. “But we try to look at all the possibilities first. It can be difficult for people with dementia with express themselves and say why they’re angry. So we check whether they’re in pain or whether something in the environment is upsetting them. We try everything before we take into considerations that these are just symptoms of dementia”
The decision to administer psychotics is taken not by a single nurse but by a team of professionals, and only after the patient has been monitored for one or two weeks. In case the symptoms of dementia become really similar to schizophrenic seizures (for instance, in case of hallucinations), antipsychotic drugs are administered, relatives are informed and the treatment is then reconsidered within a month.