Long-term care providers have made remarkable progress in reducing antipsychotics. Now it’s time to turn the attention to antidepressants.
A recent quality improvement project, which had results published in the Annals of Long-Term Care, was a fascinating look into how this can succeed, and how barriers come up.
Alicia Harbison, D.O., and Joseph Mwesige, M.D, oversaw the project at a nursing home in 2017. Their goal was decreasing the use of antidepressants among 55 residents by 25% within three months.
Around half of the residents involved had dementia, not depression, which can have similar symptoms. Harbison noted that many of the residents were no longer able to tell the clinicians how long they had been on a specific medication, and there was no access to their previous electronic health records.
“A common issue is that our elderly patients were placed on a medication and were never told when to stop it,” she said. “As they aged and have other medical conditions, then they have blood pressure medications and various other drugs, and no one has thought, ‘When do we stop the antidepressant?’”
In a conversation with Harbison, one aspect that struck me was the resistance she and her colleagues faced.
The first, somewhat expected, was from family members.
“We’d hear, ‘She’s been super happy with it. Why would you change that?’ Or, ‘My father’s physician tried to wean him off constipation medication and then he felt terrible, so why should we trust you?’” she said.
In these cases, Harbison and Mwesige would patiently listen and explain that the resident seemed happy, and that the antidepressant was interacting with other medications that can cause more harm than good.
“On average about half of the patient’s families were willing to work with us on stopping the medications,” she said. Nurses would alert her team if a family was known to be resistant to change, in which case Harbison could direct her attention toward those more interested in moving forward.
Yet one disappointing aspect of the project, to me, was the resistance from many of the nurses. Before Harbison began her project, she gave a presentation on the project to explain the risks and benefits. While mandatory, only about a fourth of the nurses showed up.
“We were really trying to get the nurses involved,” she said. But the lack of communication meant some nurses became upset when Harbison began reducing medications, especially if it meant the resident began wandering.
I get it — nurses don’t feel they can spend time to listen to a presentation. They are busy. But to complain afterward makes me itchy. It’s a little bit like when you tell your child they’ll lose the use of the car if they bring home a lousy grade. Just because they weren’t listening to you likely doesn’t sway your decision to take the keys away.
Harbison is to be commended for her work, especially given the lack of studies on the effects of the medications in the long run. (As she noted, it’s tough to get funding for a project such as this.) She says they’re looking at new ways to make sure nurses hear the presentation when it’s given in the future.
After all, we’re ultimately all on the same team around improving quality. Blood pressure spikes or drops, hypertension, dizziness, fractures, gastrointestinal upset and drug-to-drug interaction are all what we want our residents to avoid, and they can be exacerbated by these antidepressants.
“A lot of residents were on five-plus medications,” Harbison said. “For most people, many medications you grow out of, or change so that you don’t need them anymore.”
Follow Senior Editor Elizabeth Newman @TigerELN.