Reasons for psychiatric medication prescription for new nursing home residents

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Reasons for psychiatric medication prescription fornew nursing home residentsVictor A. Molinari a , David A. Chiriboga a , Laurence G. Branch b , John Schinka c ,Lawrence Schonfeld a , Lyn Kos d , Whitney L. Mills e , Jessica Krok e & Kathryn Hyer ea Department of Aging & Mental Health Disparities, University of South Florida, Tampa,FL, USAb Department of Health Policy & Management, College of Public Health, University ofSouth Florida, Tampa, FL, USAc James A. Haley Veterans Affairs Medical Center, Tampa, FL, USAd Office of Sponsored Research, University of South Florida, Tampa, FL, USAe School of Aging Studies, University of South Florida, Tampa, FL, USA

Available online: 27 Jun 2011

To cite this article: Victor A. Molinari, David A. Chiriboga, Laurence G. Branch, John Schinka, Lawrence Schonfeld, LynKos, Whitney L. Mills, Jessica Krok & Kathryn Hyer (2011): Reasons for psychiatric medication prescription for new nursinghome residents, Aging & Mental Health, 15:7, 904-912

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Aging & Mental HealthVol. 15, No. 7, September 2011, 904–912

Reasons for psychiatric medication prescription for new nursing home residents

Victor A. Molinaria*, David A. Chiribogaa, Laurence G. Branchb, John Schinkac, Lawrence Schonfelda,Lyn Kosd, Whitney L. Millse, Jessica Kroke and Kathryn Hyere

aDepartment of Aging & Mental Health Disparities, University of South Florida, Tampa, FL, USA; bDepartment of HealthPolicy & Management, College of Public Health, University of South Florida, Tampa, FL, USA; cJames A. Haley VeteransAffairs Medical Center, Tampa, FL, USA; dOffice of Sponsored Research, University of South Florida, Tampa, FL, USA;

eSchool of Aging Studies, University of South Florida, Tampa, FL, USA

(Received 28 December 2010; final version received 25 February 2011)

Objectives: This article focuses on justification of psychoactive medication prescription for NH residents duringtheir first three months post-admission.Method:We extracted data from 73 charts drawn from a convenience sample of individuals who were residents ofseven nursing homes (NHs) for at least three months during 2009. Six focus groups with NH staff were conductedto explore rationales for psychoactive medication usage.Results: Eighty-nine percent of the residents who received psychoactive medications during the first three monthsof residence had a psychiatric diagnosis, and all residents who received psychoactive medications had a writtenphysician’s order. Mental status was monitored by staff, and psychoactive medications were titrated based onchanges in mental status. One concern was that no Level II Preadmission Screening and Annual Resident Review(PASRR) evaluations were completed during the admissions process. Further, while 73% had mental healthdiagnoses at admission, 85% of the NH residents were on a psychoactive medication three months afteradmission, and 19% were on four or more psychoactive medications. Although over half of the residents hadnotes in their charts regarding non-psychopharmacological strategies to address problem behaviors, their numberwas eclipsed by the number receiving psychopharmacological treatment.Conclusions: While the results suggest that NHs may be providing more mental health care than in the past,psychopharmacological treatment remains the dominant approach, perhaps because of limited mental healthtraining of staff, and lack of diagnostic precision due to few trained geriatric mental health professionals.A critical review of the role of the PASRR process is suggested.

Keywords: nursing homes; psychoactive medications; non-pharmacological care; PASRR

Background

Previous reports concerning the mental health ofresidents in nursing homes (NHs) have been sobering.Over two decades, results have consistently indicatedthat most NH residents have a mental disorder (Burnset al., 1993), with 40% suffering from depression(Randall, 1993), 30% suffering from symptoms ofanxiety (Parmelee, Katz, & Lawton, 1993), and at leasthalf with some type of dementia (Magaziner et al.,2000). More recent research confirms a significantprevalence of mental disorder (Grabowski,Aschbrenner, Feng, & Mor, 2009; Grabowski,Aschbrenner, Rome, & Bartels, 2010).

Despite documentation of high rates of psychiatricproblems, early studies suggested that mental healthtreatment was rarely offered by mental health profes-sionals (Shea, Russo, & Smyer, 2000), with mostinterventions in NHs provided on an ad hoc basis.Indeed, NHs have been called de facto psychiatricinstitutions that lack the requisite trained staff (Rovneret al., 1990). In one study, only 4.5% of NH residentswith a psychiatric diagnosis received treatment duringa one-month period (Burns et al., 1993). Even thoughmost NH treatment for mental health disorders ispsychopharmacological, up to 80% of residents withmental health problems have not seen a licensed mental

health professional, and the majority of NHs arewithout behavioral consultants (Reichman et al., 1998;Shea, Russo, & Smyer, 2000).

Accompanying longstanding concerns over the lackof mental health treatment are worries about the

appropriate use of psychoactive medications in NH

settings. Use of psychoactive medications have been

associated with a variety of deleterious outcomes for

older adults including increased fall risk, delirium, and

medical morbidity (Cooper, Freeman, Cook, &

Burfield, 2007; Draganich, Zacny, Klafta,

& Karrison, 2001; Gurwitz et al., 2000; Svarstad &

Mount, 2001), and there is evidence of a link between

total psychoactive drug load and risk of hospitalization

among NH residents (Cooper et al., 2007).Using a random sample of residents from 55 NHs

in the state of Massachusetts, an early study by Avorn,Dreyer, Connelly, and Soumerai (1989) found that55% were taking at least one psychiatric medication;39% of the residents were receiving anti-psychoticmedication, and 18% of these were receiving two ormore anti-psychotic medications. Surprisingly, halfhad no evidence of a physician participating inmental health decisions during the year of the study.Further, approximately one-third of the residents hadserious cognitive impairment, and 6% showed evidence

*Corresponding author. Email: [email protected]

ISSN 1360–7863 print/ISSN 1364–6915 online

� 2011 Taylor & Francis

DOI: 10.1080/13607863.2011.569490

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of moderate or severe tardive dyskinesia. The authorsconcluded that psychoactive drugs often were usedin NHs with little medical supervision. These findingsare congruent with more recent international research.One Danish study found that staff perceptions ofpsychiatric need outweighed standard diagnostic crite-ria as the basis for prescription of psychotropicmedications (Sorenson, Foldspang, Gulmann, &Munk-Jorgensen, 2001). Holmquist, Svensson, andHoglund (2003) reported that 73% of a sample ofSwedish NH residents took at least one psychoactivedrug, and 50% of these received psychiatric treatmentwithout a psychiatric diagnosis.

Federal actions to address concerns about mentalhealth treatment have a long history. The OmnibusBudget Reconciliation Act of 1987 (OBRA-87) man-dated that new residents be screened for mental healthproblems via an initial Preadmission Screening andAnnual Resident Review (PASRR 1) process. If thePASRR 1 screen identifies a psychiatric diagnosis inNH residents, a more extended mental health evalua-tion (PASRR 2) should be triggered so that a plan isin place either for their mental health needs to beaddressed within an institution or else for theirplacement within a less restrictive community setting.The act also provided guidelines to reduce inappropri-ate medication usage (especially prescription of anti-psychotic medication) and physical restraints, andencouraged non-pharmacological approaches viamore favorable reimbursement under Medicare(Norris, 2008).

Since passage of OBRA-87 there have been somereports suggestive of more judicious use of psychoac-tive medications (Ryan, Kidder, Daiello, & Tariot,2002), with reduction in certain types of psychoactivemedication (e.g., anxiolytics, sedative-hypnotics, andanti-psychotics) soon after OBRA passage (Lantz,Giambanco, & Buchalter, 1996; Semla, Palla, Poddig,& Brauner, 1994), but increases in other types, espe-cially anti-depressants (Datto et al., 2002; Lantz et al.,1996). Other research suggested little immediatechange in the usage of anti-psychotic drugs or imple-mentation of behavior management programs afterOBRA (Hawes et al., 1997). Over time, the trendtoward appropriate dispensing of medication actuallymay have been reversed. One investigation indicatedthat among Medicare beneficiaries of a 2000–2001database, there has been an increase in prescribed anti-psychotic medication to levels not seen in a decade,with over one quarter receiving at least one prescrip-tion for an anti-psychotic drug (Briesacher et al., 2005).The authors suggested that this increase might havebeen associated with the emergence of the neweratypical anti-psychotics. While the latter’s use may ormay not be warranted, less than half of the treatedresidents who received these newer medications were incompliance with NH guidelines. A most recent reportsuggests declines again in both conventional andatypical anti-psychotic usage in a national sample ofVA patients with dementia, with the atypical anti-

psychotic decline temporarily accelerated by FDA

black-box warnings posted in 2005 (Kales et al., 2011).The general thrust of the research findings appears

to be that despite OBRA rules intended to promotesuitable monitoring of psychoactive medication usage

and PASRR requirements to assure adequate mentalhealth treatment planning, the appropriateness of

treatment remains in doubt. A recent study by this

group investigated the general provision of mentalhealth services in Florida NHs (Molinari, Cho,

Chiriboga, Turner, & Guo, 2008; Molinari et al.,2010). Florida Medicaid claims data yielded evidence

that over 70% of the newly admitted NH residents

were placed on some psychoactive medication withinthree months of their admission. Most of these

residents appeared to have had neither a previousmental health diagnosis nor previous mental health

treatment, at least prior to the hospital admission

frequently preceding NH admission. However, we wereunable to develop a valid estimate of current diagnoses

with the Medicaid claims data because psychiatricservices in NHs are a ‘bundled service’ in Florida NHs

and physicians are not required to complete claims

forms in order to prescribe psychiatric medications.The research reported here represents a follow-up

to the above-noted findings of high psychoactive

medication use in NHs. We conducted intensive chartreviews of relatively long-stay residents in select

Florida NHs to determine if such use of psychoactivemedication is justified. Justification was documented

either through signed doctor’s orders, assignment of

a current psychiatric diagnosis, or at least a statedrationale indicating that psychoactive medications

were used to target specific symptoms or problembehaviors. Our objective was to ascertain whether there

was specific documentation in the charts of the need

for psychopharmacological interventions, and to deter-mine the effect of PASRR evaluation on mental health

treatment. Focus groups also were conducted toidentify reasons for the prescription of psychoactive

medications, and to establish why the non-pharmaco-

logical interventions specified by OBRA-87 may not beutilized as a first-line of treatment.

Methods

A convenience sample of seven small to midsize for-

profit NHs in the Tampa Bay area were chosen for

their willingness to participate in a study examiningNH records. We conducted chart reviews for all the

residents of the NHs (n¼ 73) who met the studycriteria of having been admitted to the NHs between

January 1 and June 30, 2009, and having been in

residence for at least three months. We also conductedsix focus groups at five of these NHs, with NH

administrative staff nominating members of the focusgroups often based on experience, good records,

and/or responsibilities. Two of the focus groups were

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conducted in the same NH with different levels of staffmembers.

Analyses

A research coordinator with a master’s degree incounseling (LK) reviewed all the notes in the residents’charts for the three-month evaluation period. A chartreview data form was developed and deemed easy touse via probing of specific data points (that were laterentered into an Excel spreadsheet) to promote thereliability of the data extraction process. The data formincluded basic demographic entries, but focused ondetailed documentation within the residents’ charts(including MDS) of psychoactive medication use(i.e., anti-psychotics; anti-depressants; mood stabi-lizers; anti-cholinergics; sleep medications; Alzheimerdisease medications) during the first three monthsfollowing admission. Diagnoses were mostly locatedon the medication print-out where the doctors’ orderswere entered. If the diagnosis was not located there,diagnoses were found in the doctors’ notes or on theMDS mental health assessment form. The items onthe chart review data form were intended to addressthe following questions: How many NH residents areplaced on psychiatric medications (i.e., are prescribedpsychoactive medication within three months follow-ing NH admission)? How many NH residents who areplaced on psychiatric medications are currently diag-nosed with a mental health problem? How many NHresidents who are placed on psychiatric medicationshave documented previous diagnoses of mental healthproblems? How many NH residents who are placed onpsychiatric medications are admitted with the samepsychiatric medications? What is the rationale for useof psychoactive medications? What problems are beingaddressed? Were other non-pharmacological strategiestried? How does the PASRR process affect psychoac-tive medication usage?

Focus groups were conducted onsite and in aprivate setting by a 3rd year doctoral student in agingstudies (JK). She was guided by a list of eightpre-arranged semi-structured questions and somefollow-ups that centered on the use of psychoactivemedications in NHs. For example, the first questionwas ‘In your experience, what are the typical mentalhealth or behavioral problems that you encounter?What are the most frequent?’ Focus groups wereaudio-taped for transcription purposes, and copiousnotes were taken based on a review of the tapes toassure fidelity of interpretation of responses.Preliminary themes regarding reported reasons fordiscrepancies between the guidelines and actual psy-chopharmacological practice were generated by two ofthe authors (VM and WM) through content analysis.This analytic process involved a thorough examinationof the transcribed recordings to identify and organizepieces of data (Crabtree & Miller, 2000). Through theprocess of ‘conclusion drawing’ (Huberman & Miles,

1994), the authors looked for patterns in the catego-rized data to create overarching themes. The twoauthors individually reviewed the focus group tran-scriptions and reached consensus on the overarchingthemes.

Results and discussion

Demographics

Of the 73 residents’ charts reviewed in the 7 NHs, 55%were female (Table 1). There was wide variability inage range (35–100 years of age): 74% were over the ageof 60, 23% were between 40 and 59, and 3% were intheir thirties. There was also wide variability in maritalstatus with the majority widowed, divorced, or sepa-rated (63%), but a significant number were stillmarried (21%) or never married (16%). Regardingrace, 84% were White and 15% were African/American. Regarding ethnicity, 11% considered them-selves Hispanic. The great majority of the NH resi-dents whose charts were reviewed were on Medicaid,with just a few residents private pay or on privateinsurance.

The six focus groups comprised a total of 15 White,12 Hispanic/Latino, and 13 Black participants. Therewere four men and 36 women. One of the men wasHispanic/Latino and the rest were white. Eleven of thewomen were Hispanic, 12 were White, and 13 wereBlack. The first group was composed of two LPNs,three CNAs, and three RNs. The second group wascomposed of eight CNAs. The third group was heldat the same facility as the second and consisted of

Table 1. Characteristics of the resident sample (n¼ 73).

(n) %

Age30–39 2 340–49 8 1150–59 9 1260–69 15 2170–79 6 880–89 20 2790–99 12 16100þ 1 1GenderFemale 40 55Male 33 45Marital statusNever married 12 16Currently married 15 21Previously married 46 63Race/ethnicityWhite non-Hispanic 53 73White Hispanic 8 11African-American 11 15Native Hawaiian 1 1Payment sourcesMedicaid 67 91Private insurance 2 3Private pay 2 3Other 2 3

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three RNs, two LPNs, and one MD. The fourth groupconsisted of two RNs, two LPNs, and four CNAs. Thefifth focus group consisted of three RNs, one LPN,and two CNAs. The sixth group comprised two socialworkers, two RNs, three CNAs, and one LPN.

Chart review results

Overview

Overall, 68% of the NH residents were admitted withat least one psychoactive medication (Table 2).In other results not presented in tabular form, 84%of the NH residents were admitted directly from ahospital, with 84% of these individuals having at leastone prescription for psychoactive medications. In total,73% of the NH residents had a psychiatric diagnosison admission; 25% of these carried a diagnosis ofdementia on admission. Seventy-nine percent of theresidents with a psychiatric diagnosis upon admissionwere admitted with psychoactive medications. Onadmission 84% of patients were found to display atleast one behavioral problem while 37% had two ormore behavioral problems. The most common behav-ioral problems were in the cognitive (77%), mood(15%), and disruptive (e.g., verbal abuse, wandering,15%) domains.

During the first three months following admission,most residents had active psychoactive medicationprofiles. Eighty-five percent of the NH residents wereon at least one psychoactive medication after threemonths; 19% were on four or more psychoactivemedications (Table 2). Out of the 73 cases, 23 (32%)

were on the same number of medications after

three months as they were on admission, and only

eight (11%) were never prescribed or given psychoac-

tive medications at any point during the three-month

period (not in tables). Sixty-three percent of the NH

residents had at least one new psychoactive medication

added within the three months following admission,

while 36% of the NH residents had at least one

psychoactive medication dropped within the three

months of admission.Table 3 presents cross-tabulations for select diag-

noses and medication types that have been reported in

the literature to be of most concern regarding use in the

NH population. Although it is clear that the trend is

for residents with specific diagnoses to be more likely

to receive the appropriate medication, it is also clear

that 8 of the 22 (36%) with diagnoses of ‘dementia

only’ did not receive any medication, while another 23

of the 73 (32%) received medications for problems for

which they had no diagnoses.Almost half of the NH residents received a mental

health consultation, often including an extensive

mental health assessment. Out of the 36 patients who

received a mental health consultation, most had

medication changes subsequently recorded during the

three-month period after admission.

Rationale for use of psychoactive medications

The chart review indicated that justifications were

provided for psychoactive medication use; 100% of the

NH residents who received a psychoactive medication

had a signed physician’s order for the medication.

Eighty-nine percent of the NH residents who received

a psychoactive medication had a mental health diag-

nosis; 83% of the residents who had a psychoactive

medication added or dropped had a target symptom

identified. At least 59% of those on psychoactive

medications had one attempt noted to monitor side

effects. In 74% of the charts, at least one note was

found that provided justification of psychoactive

medication prescription.The charts revealed substantial documentation of

behavioral monitoring and use of non-psychopharma-

cological treatment. Eighty percent of the residents

who had a psychoactive medication added had some

type of behavioral monitoring documented prior to

being prescribed psychoactive medications. Sub-ana-

lyses of 52 charts revealed that 92% had some notation

regarding one or more behaviors that merited atten-

tion. Sub-analyses of the same 52 charts revealed that

54% had at least one note regarding one or multiple

non-psychopharmacological strategies used, including

one-on-one (n¼ 18); involvement in activities (n¼ 7);

sensory stimulation (n¼ 4); soothing conversation

and/or speaking slowly (n¼ 4); orientation and

re-orientation (n¼ 6); validation/listening to the resi-

dent (n¼ 4).

Table 2. Psychoactive medication use in NH residents(n¼ 73).

(n) %

Psychoactive medications upon NH admissionNone 23 32One 16 22Two 17 23Three 8 11Four or more 9 12

Psychoactive medications added while in NHNone 27 37One 21 29Two 14 19Three 6 8Four 5 7

Psychoactive medications dropped while in NHNone 47 64One 16 22Two or more 10 14

Psychoactive medications after 3 months in NHNone 11 15One 15 21Two 18 24Three 15 21Four of more 14 19

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How does the PASRR process affect psychoactivemedication usage?

All but one of the 73 residents had a completedPASRR Level I form with a checked box stating thatthe individual had ‘no indications or a diagnosis ofa major mental illness as defined by DSM-IV-R’. NoLevel II forms, designed to confirm the presence ofserious mental illness (SMI), were found.

Focus group results

Content analysis of the focus group transcriptsrevealed four broad themes. First, many of the NHstaff responses regarding use of psychoactive medica-tion were judged to be relatively sophisticated andclosely aligned with current research findings. Thenurses perceived themselves as advocates for theresident’s well-being. Medications were viewed as alast resort by some; others suggested that in crisissituations one has to be flexible. Second, there was atleast one comment in almost all of the groupsregarding the perception that some of the NH residentswere admitted on too much psychiatric medication andthat it was their job ‘to clean up the situation’. Onemember noted, ‘We often get dementia patients dopedup from the hospital. It’s convenient for them’. Third,several innovative non-psychopharmacological pro-grams in the NH were described. One NH has a‘guardian angel’ program where staff have scheduledvisits with their residents; the same NH has an‘Autumn Leaves’ program that provides activities forsundowners; another NH mentioned ‘MerryCompanions’ relaxation/aromatherapy and ‘Starlight’Montessori-type programs. Almost all focus groupshad at least one participant comment that engagementin activities with residents helped reduce behavioraland mental health problems. Fourth, when asked theopen ended question ‘What will help you do your jobwell regarding dealing with those mental health andbehavior problems?’ a consistent response was bettercommunication between different staff members anddoctors. One focus group member added that,‘Teamwork is key’. The need for further educationregarding mental health, ‘on the job’ stress reduction,and the ‘ability to vent to other staff’ were importantbut secondary issues.

Discussion

This study followed up to a previous study on mental

health in NHs that was based on Medicaid adminis-trative data of relatively long-stay NH residents

(Molinari et al., 2010). In general, the present findingsfrom a chart review show both consistency and

inconsistency with our prior results. While differencesmay in part derive from the methodologies employed

(chart review vs. Medicaid database), it is clear thatadministrative data do not provide information on

actual process. The results of this study highlight theamount of psychoactive medications administered to

NH residents, with evidence for even more psycho-pharmacological treatment than in our prior study

(85% vs. 72% after three months of admission)despite usage of the same definitions and comparablecategories of psychoactive medication. However, the

number of residents who were taking four or morepsychoactive medications was similar (19% vs. 15%).

Our current data also suggest substantially greaternon-psychopharmacological care (54% vs. 12%) for

mental health problems in these seven NHs than wasfound in the previous study. One plausible explana-

tion is that this type of broadly defined mental healthcare is not necessarily reimbursed and therefore not

captured by the administrative data set used in theprior study. Nonetheless, this study was able to

identify the presence of non-psychopharmacologicalinterventions through the review of progress notes.

Interestingly, the number of residents with a psychi-atric diagnosis in this study (73%) and prior psycho-

active treatment (68%) dramatically differs from the29% and 36%, respectively, reported in our previousstudy. Perhaps the Medicaid Part B database used in

the previous study did not include the hospital mentalhealth data just prior to NH admission, and our

current study corrects this oversight. Alternately, itmay be that hospital practice patterns in the Tampa

Bay area differ from statewide practice patterns, orthat our small sample of 73 cases is not representative

of the Florida statewide data. Nevertheless, thecurrent findings provide important information that

the hospital stay just prior to admission may be a siteof origin whereby NH residents are diagnosed with

psychological problems and placed on psychoactivemedications.

Table 3. Medication type by diagnosis.

Medication type

Diagnosis of Dementiaand/or Psychosis None

Dementiaonly

Anti-psychotic/atypicalonly

Dementia andanti-psychotic/atypical drugs Total

None 26 5 8 4 43Dementia only 8 10 1 3 22Psychosis only 0 0 5 2 7Dementia and Psychosis 0 0 0 1 1Total 34 15 14 10 73

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An encouraging note is that these results suggestthat the concerns raised in early studies regardinglimited mental health treatment may no longer berelevant today. On a very general level, many residentshave mental health problems but most receive treat-ment both in the hospital prior to placement andduring their NH residence. Focus group data suggestthat the NH staff are reasonably knowledgeable abouthow to address the mental health problems of residents(e.g., to individualize treatment, be flexible, don’t usepsychopharmacology as a first resort).

One major concern is that no PASRR Level IIevaluations were completed at the time of admission.Almost all the PASRR Level I’s in the charts indicatedthat the incoming NH resident did not have a majormental disorder (despite the fact that 73% of theresidents were admitted with a psychiatric diagnosisand 68% were admitted with a psychoactive medica-tion). It is clear from these results that the PASRRprocess has a negligible effect on psychoactive medi-cation usage for those admitted to NHs, although itmay indeed restrict entry of those with diagnoses ofSMI, such as schizophrenia or bipolar disorder whoare more appropriately placed elsewhere (Borson,Loebel, Kitchell, Domoto, & Hyde, 1997; Linkins,Lucca, Housman, & Smith, 2006). Based on discus-sions with two NH administrators regarding thismatter, it appears that there is a genuine difference ofinterpretation regarding when a Level II PASRR isneeded. NH administrators believe that Level II’s aretriggered by longstanding diagnoses of SMI ratherthan the more common psychiatric problems reflectedin mental status changes related to adjustment diffi-culties, acute depression, anxiety, and dementia. Thelack of Level II reports notwithstanding, NH admin-istrators appear to be concerned about the mentalhealth problems of their residents, often resorting toreferrals regarding mental health consultation ratherthan relying on the PASRR system to evaluate thebehavior problems of residents. Consistent with con-cerns expressed by NH staff interviewed for a priorstudy that regulations interfere with their ability toproperly care for SMI residents (Molinari, Merritt,et al., 2008), the PASRR process may often be viewedas a bureaucratic hurdle rather than as a way to assureadequate mental health assessment of all NH residentswho need it. Perhaps these different interpretations ofPASRR justify continuing education on this issue,some further specification in guidelines, or even acomplete re-evaluation of the Level II PASRR processand whether the outcomes are consistent with theoriginal goals.

A second major concern is that 85% of the NHresidents were on a psychoactive medication withinthree months following admission, and 19% of theresidents were on four or more psychoactive medica-tions. This is consistent with our prior research sug-gesting heavy use of psychoactive medications, andhighlights continued concerns with adverse side-effects

and untoward medical events. It should be noted that68% of the NH residents were admitted with at leastone psychoactive medication. However, perhaps morestriking is the fact that 84% of the NH residents wereadmitted from the hospital, and that 84% of theseresidents were admitted on at least one psychoactivemedication. Indeed, focus group data reveal that NHstaff are concerned about how to deal with themedication regimens with which new residents aredischarged from the hospital. These results stronglysuggest that many NH residents are already on apsychoactive trajectory prior to admission to the NH,and that a part of discharge planning in the hospitalshould be determination of the appropriateness of eachresident’s psychoactive regimen. As suggested earlier,another potential way of assuring proper psychophar-macological care might be a broader interpretation ofthe need for PASRR Level II’s so that on admission anextended mental health screening can be conductedand linked to a mental health treatment plan that isregularly monitored.

A final concern is that although over half of theresidents had notes in their charts regarding non-psychopharmacological attempts to address problembehaviors, 85% ultimately received psychopharmaco-logical treatment, and prescription of specific classes ofpsychoactive medications were not always yoked to theappropriate diagnosis. The intent of OBRA was topromote non-psychopharmacological approaches asfirst line treatments to address psychiatric problems ofNH residents, but given that non-psychopharmacologyis used in just over half of the cases, this goal has yet tobe achieved. Although there may be other non-psychopharmacological strategies that are informallyutilized and therefore not noted in the charts, the non-psychopharmacological strategies that were identifiedin the charts are quite basic, generalist interventions.It is worth mentioning that there did not appear tobe any record of interventions delivered by trainedlicensed mental health professionals, although our datacollection process may have been unable to detect this.On the basis of this chart review it appears thatpsychoactive medication usage remains the primarystrategy to address the mental health problems ofNH residents.

Obviously, the main question raised by our studyfindings is whether the amount of psychoactive med-ications prescribed is justified given the nature of theNH resident population and their attendant mentalhealth needs. On the one hand, and as noted in theliterature review, the typical NH resident frequentlyhas serious psychiatric problems. Almost half merit adiagnosis of dementia (Magaziner et al., 2000), andthereby a medication may be warranted to slow downthe progression of Alzheimer’s disease like Donepezilin the early stage (Lanctot et al., 2003), or likeMemantine for moderate to severe dementia (Winblad,Jones, Wirth, Stoffler, & Mobius, 2007). In addition,depression and behavior problems are often associated

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with dementia (Alexopoulos & Abrams, 1991; Kohn &Mustafa Surti, 2008), and may be treated by anti-depressant and anti-psychotic medications. However,it should be noted again that concerns over thedeleterious side-effects of both conventional and atyp-ical anti-psychotic usage for those with dementia havemerited black box warnings (Kales et al., 2011). Pain(Ferrell & Ferrell, 1995) and fragmented sleep (Jacobs,Ancoli-Israel, Parker, & Kripke, 1989) are also rife inNHs and should be addressed. Given this multitude ofpsychiatric co-morbidities, perhaps it is no wonder thatsome NH residents are on multiple psychiatric medi-cations despite side-effect concerns. Indeed, uponadmission, 21% of the new NH residents who carried apsychiatric diagnosis were not on psychoactive medi-cations, suggesting that NHs might be prescribingmedications for residents who prior to admission werenot being adequately treated.

On the other hand, consistent with the intent of theOBRA rules and regulations, a major issue is whetherthere are non-psychopharmacological alternatives tomedications which can address mental health problemswithout the side-effects that have been associated withpoly-pharmacy. As noted above, this intent has notbeen realized. Indeed, there are well-validated long-standing behavioral programs aimed to treat late-lifeinsomnia (Stone, Booth, & Lichstein, 2008), to reducethe disruptive behavior of residents with cognitiveimpairment (Burgio & Burgio, 1990; Camp,Cohen-Mansfield, & Capezuti, 2002; Camp et al.,1997; Cohen-Mansfield, Marx, Dakheel-Ali, Regier, &Thein, 2010; Cohen-Mansfield, Marx, Thein, &Dakheel-Ali, 2010), and some recently developedtreatments for depression (Hyer, Yeager, Hilton, &Sacks, 2009; Meeks, Teri, Van Haitsma, & Looney,2006) and pain (Clifford, Cipher, Roper, Snow, &Molinari, 2008) in NH settings. Many of theseprograms intervene by providing training for the NHstaff to assist with the implementation of specificprotocols to manage the difficult behavior of residents.Given the feedback from the NH focus groups, thistraining should include modules on how to improvestaff communication and teamwork on all staffinglevels. Unfortunately, psychological interventionsappear to be under-utilized in most NHs, perhapsbecause the high turnover of NH staff (Donoghue,2010) dictates that training must be ongoing. Tocompound the problem, there continues to be adearth of geriatric mental health long-term careprofessionals who are qualified to provide the special-ized training and interventions needed. Additionalinternal and external challenges to the use of non-pharmacological interventions in NHs have been ablydescribed by Cody, Beck, and Svarstad (2002).

There are a number of limitations to the method-ology employed in this study that must be acknowl-edged. One, the results are based on only a smallconvenience sample of NHs in the Tampa Bay area andmay not be generalizable to other NHs in Florida or

across the country. Indeed the NH administrators were

self-selected and appeared to be interested in the issues

of mental health, suggesting that their NHs may bemore attentive to mental health issues. Two, our

definition of psychoactive medication usage is a

broad one, encompassing not only traditional psychi-atric medication classes such as anti-depressants but

also medications to treat Alzheimer’s disease. However,

supporting our main findings, additional analyses notreported found that just one-quarter of the residents

were admitted with a medication to slow the progres-sion of Alzheimer disease, and just one-third of the NH

residents were on an Alzheimer disease medication after

three months. Three, as noted earlier, there also may bean under-estimate of the non-psychopharmacological

attempts to address mental health problems because

notes in the charts do not necessarily reflect everythingthat occurs in the NH. Four, reviewing all the notes in

NH charts is a time-consuming endeavor, and it was

not feasible to conduct reliability checks to determinethe accuracy of all chart reviews. Five, the definitions

for certain variables were not as clear as one would haveliked, largely because NHs vary in the organization and

presentation of information. Six, we made no attempt

to cross-validate the MDS with the chart review data.Seven, focus groups consisted almost exclusively of

nursing personnel, and thereby may represent a

restricted range of disciplinary viewpoints. Finally,documentation that doctors’ orders were signed, that a

diagnosis was made, and that a note was written citing a

problem meriting psychoactive medication (even if theindividual was on multiple psychoactive medications)

are crude gauges for justification of medication usage.

Conclusions and implications

A review of the literature and our findings suggest thatrelative to the past there is a good deal of behavioral

monitoring and mental health care that now occurs inNHs. However, it does appear that psychopharmaco-

logical treatment continues to be a major strategy used

by NHs to address the mental health problems ofresidents. NH staff and administrators seem sensitive

to the mental health needs of their residents, but are

faced with residents with multiple medical and psychi-atric problems. The need for continued mental health

training of staff, a lack of available geriatric mentalhealth professionals to adequately assess, diagnose,

and treat mental health problems, and perceptions that

PASRR rules hinder rather than assist in targetingmental health problems, render psychopharmacologi-

cal care as the primary way of attempting to resolve a

NH resident’s distress. Cost-efficient quality assurancemechanisms must be developed and a variety of valid

non-psychopharmacological evidence-based mental

health programs be made available to assure that thespirit and intent of OBRA is realized.

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Acknowledgment

This study was funded by a contract from the FloridaAgency for Health Care Administration under ContractMED078.

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