Legal Considerations
By today’s standards restraint and seclusion are to be used as safety measures, not as part of the treatment plan. According to the United States Health Care Financing Administration (HCFA), “A drug used as a restraint is a medication used to control behavior or to restrict the patient’s freedom of movement and is not a standard treatment for the patient’s medical or psychiatric condition.”Documentation to demonstrate a clear need for medication or restraint given without a patient’s permission is necessary to protect the patient from receiving punitive treatment and to protect the staff from accusations of excessive force or coercion.
Managing agitation and aggression in the elderly nursing home population has additional considerations because of the Omnibus Budget Reconciliation Act (OBRA) implemented in 1990 and updated in 1999.Overall, OBRA requires residents of long-term care facilities to be free from “unnecessary physical or chemical restraints imposed for discipline or convenience.” An unnecessary drug is a drug given in an excessive dose, for an excessive duration, with inadequate monitoring or an inadequate indication, used in the presence of adverse effects, or given in duplication. Short-acting benzodiazepines can be used for agitated behaviors that are dangerous and pose a risk to self or others, but restrictions on the duration of use exist. Antipsychotics can be prescribed with no restriction for conditions such as schizophrenia, psychotic mood disorder and for behaviors from dementia that are documented, permanent, persistent and cause psychosis or danger to self or others. OBRA provides a long list of unacceptable uses for antipsychotics, including the presence of single symptoms such as poor self-care, restlessness, fidgeting, nervousness, or indifference to surroundings. A pharmacist making recommendations for treating agitation and aggression in the long-term care population should pay attention to the OBRA guidelines so they choose treatments and document their rationale and outcomes correctly.
Conclusion
Pharmacists can impact the course of agitation and aggression in their patients in several ways. Noncompliance to medication, leading to decompensation and reemergence of underlying pathology, is a very common cause of agitation and aggression in patients with serious mental illness. Pharmacists have a pivotal role in preventing and identifying noncompliance in their patients. They can also help identify drug-related causes, such as undetected antipsychotic-induced akathisia or medication-induced agitation. They also are suited to design individualized treatment approaches ranging from verbal support to oral lorazepam to IM antipsychotic injection. They can see to it that proper follow-up treatment is implemented to treat the underlying cause or minimize further episodes. Pharmacists should also ensure the behaviors of the patient are objectively described so the treatment team is clear as to the risk the patient poses. Finally, they must ensure that medications that become unnecessary are discontinued once the agitation is resolved, or different medications are initiated if the problems become chronic. Agitation and aggression remain important clinical issues in managing patients with psychiatric conditions. A careful assessment considering the wide array of treatment options is important to help the patient and ensure the safety of those around them.