Antipsychotics
Dr. Kohenof the department of clinical psychology at Albert Einstein College of Medicine and an attending faculty member at Zucker Hillside Hospital, both in New York, said that about two-thirds of patients in skilled nursing facilities have diagnosable mental disorders, mostly cognitive impairment. Up to 25% have clinically significant depression, 6%-12% have delirium, and 2% have schizophrenia.
In 1986, a study indicated that nursing homes used sedatives and physical restraints on up to 85% of residents, leading to the passage of OBRA 1987, said Dr. Kohen.
Turning to his own research, Dr. Kohen said that the prevalence of antipsychotic use in nursing homes declined after that event and now is 15%-27% (J. Am. Med. Dir. Assoc. 2010 Sept. 30 [Epub ahead of print]).
However, he said other researchers have reported increasing use of antipsychotics since 1999 because of the advent of new medicines with reduced side effects. The Food and Drug Administration reacted against this trend in 2005 with a "black box" warning that elderly patients with dementia are at increased risk of death when they are prescribed antipsychotics.
Citing the NADONA/LTC study, Dr. Kohen said that 64% of nursing homes give antipsychotics only when family members sign consent forms. The study found that 65% of the facilities were using lower doses of antipsychotics since the FDA warning, but only 39% reported a reduced use of antipsychotics overall. Just over half had increased their use of nonpharmacologic interventions, and a similar proportion was using other types of medications, such as anticonvulsants and benzodiazepines.
Other researchers have found that facilities with higher staff-to-resident ratios use less antipsychotic medication, and the same is true of those that educate staff about these issues, said Dr. Kohen. But one or two staff training sessions won’t do the trick, he said. "My concern is that you have a lot of turnover in nursing homes. You have to keep [training] consistently."
Sexuality
The sexuality of nursing home residents presents a different set of challenges, said Dr. Lester. "There is a myth that the elderly are asexual beings." Citing unpublished data from the NADONA/LTC survey, she said that 71% of directors of nursing reported "issues regarding residents’ sexual activities."
Of these, 58% involved residents having sex with other residents, while 22% involved residents having sex with visitors and 60% involved residents masturbating.
The directors were divided on whether nursing homes should allow residents with moderate-to-severe dementia to have sexual relationships. Forty-five percent said yes, 28% said no, and 27% weren’t sure.
A clear majority (83%) said residents’ responsible parties should be notified if a resident with dementia wanted to have sex with another person, while 5% said no, and 12% were unsure.
Only 37% of the facilities had a policy regarding sexual activity, and a similar 35% had a designated space for trysts. Of the facilities with policies, 52% applied these policies to all residents, regardless of mental condition.
Dr. Lester finished by calling on nursing homes to confront the sexuality of their residents more directly. "Sexuality and intimacy needs of nursing home residents are frequently taboo and ignored," she said.
Dr. Kohen, Dr. Lester, and Dr. Martin all reported that they had no financial interests or affiliations that affected their presentations.