Complexity of As-Needed Antipsychotics in Residential Care Requires System-Level Perspective

The complexity surrounding the use of as-needed antipsychotic medications to manage behavior in people with dementia or cognitive impairment in assisted living/residential care facilities was highlighted in a recent study published in Innovation in Aging.

The study featured interviews with 11 workers associated with the issue, specifically, 3 direct care direct care staff, 2 licensed nurses, 4 administrators/executive directors, and 2 consultant pharmacists. All interviewees worked in assisted living/residential care facilities in Oregon.

“For those closest to the situation, such as direct care staff, the negotiation is informed by rules, training, and the needs of the person in front of them,” reported researchers from Oregon Health and Science University-Portland State University. “For those further removed from the situation, such as consultant pharmacists, the negotiation is informed by professional standards, training, and an awareness of the challenges presented by some behavioral expressions.”

The researchers used situational analysis to identify and describe various views, by job role, on using antipsychotic medications for resident behavior management on an as-needed basis.

Among the findings were three broad processes that underlied discussions on the issue: justification, moralization, and balancing local practices (such as resident behavioral expressions) with nonlocal practices (professional authority, for example), according to the study.

“People involved in the situation of antipsychotic medication use in assisted living/residential care describe positive and negative justifications, and personal moral positions that frame as-needed antipsychotics or nonpharmaceutical interventions as ‘right’ or ‘wrong,’ driving various approaches to behavior management,” the authors reported.

On the whole, researchers observed a “converse orientation” between workers’ perceived authority and their proximity to medication administration: direct care staff and nurses closest to the situation expressed less agency than off-site physicians and policymakers not involved in day-to-day facility practices.

“Balancing regulatory goals with resident-centered practices underscores the need for a system-level perspective,” the authors advised.

Reference:
Dys S, Carder P. Beyond the medication pass: attitudes, ethics, agency, and antipsychotic medications in assisted living/residential care. Innov Aging. Published online August 17, 2022. doi:10.1093/geroni/igac052