Journal of Gerontological Nursing

MANAGING DISRUPTIVE BEHAVIORS WITH NEUROLEPTICS: Treatment Options for Older Adults in Nursing Homes

Philippe Voyer, PhD, RN; René Verreault, MD, PhD; Pamphile Nkogho Mengue, MSc; Danielle Laurin, PhD; Louis Rochette, MSc; Lori Schindel Martin, MSc, RN

Abstract

ABSTRACT

Disruptive behaviors are frequent among elderly individuals in long-term care centers. Neuroleptics remain the most common pharmacological treatment for controlling these challenging behavioral manifestations. However, their effectiveness is a subject of controversy and it is unclear what specific behaviors are more likely to be managed with neuroleptic medications. The objective of this study was to identify the types of disruptive behaviors for which neuroleptics are given to elderly individuals in long-term care facilities and determine if the frequency of these behaviors increases the risk of being prescribed neuroleptics. A cross-sectional study was conducted with 2,332 participants ages 65 or older living in 28 long-term care facilities. Among them, 27.8% had taken at least one neuroleptic drug in the prior week. The administration of neuroleptics was not linked to the presence of any one specific disruptive behavior. However, a significant finding was that the greater the frequency of disruptive behavior exhibited by an elderly individual, the greater the risk of them being administered a neuroleptic medication. A multi-dimensional approach to the assessment of disruptive behaviors is recommended to facilitate the identification of the underlying causes of those behaviors. Accordingly, it is suggested that non-pharmacological treatment plans be adapted to each situation and then implemented to potentially reduce the use of neuroleptics.

Abstract

ABSTRACT

Disruptive behaviors are frequent among elderly individuals in long-term care centers. Neuroleptics remain the most common pharmacological treatment for controlling these challenging behavioral manifestations. However, their effectiveness is a subject of controversy and it is unclear what specific behaviors are more likely to be managed with neuroleptic medications. The objective of this study was to identify the types of disruptive behaviors for which neuroleptics are given to elderly individuals in long-term care facilities and determine if the frequency of these behaviors increases the risk of being prescribed neuroleptics. A cross-sectional study was conducted with 2,332 participants ages 65 or older living in 28 long-term care facilities. Among them, 27.8% had taken at least one neuroleptic drug in the prior week. The administration of neuroleptics was not linked to the presence of any one specific disruptive behavior. However, a significant finding was that the greater the frequency of disruptive behavior exhibited by an elderly individual, the greater the risk of them being administered a neuroleptic medication. A multi-dimensional approach to the assessment of disruptive behaviors is recommended to facilitate the identification of the underlying causes of those behaviors. Accordingly, it is suggested that non-pharmacological treatment plans be adapted to each situation and then implemented to potentially reduce the use of neuroleptics.

Elderly individuals suffering from cognitive impairments (e.g., Alzheimer's disease, Lewy Body Disease, fronto-temporal dementia) or residing in longterm care facilities often manifest disruptive behavior, such as agitation, wandering, vocalization, and aggressiveness. The frequency of these disruptive behaviors varies from 43% to 93% in nursing homes (Beck & Shue, 1994; Forbes, 1998; Landreville, Bordes, Dicaire, & Verreault, 1998; Taft & Cronin-Stubbs, 1995; Tariot, Porsteinsson, Teri, & Weiner, 1996). These disruptive behaviors can result in negative labeling, isolation, staff withdrawal, and a decrease in the quality of life for the elderly individual. In addition, disruptive behaviors are typically managed by physical restraint and neuroleptic administration, the use of which is associated with falls and other negative sequelae, such as movement disorders, irreversible tardive dyskinesia, and orthostatic hypotension (Castle, 1999). Among health care professionals, they can lead to burnout, absenteeism, injuries, and a high rate of employee turnover. Finally, the disruptive behaviors have a considerable effect on health care systems in terms of cost and use of resources (Beck & Shue, 1994; Ellgring, 1999; Hagen & Armstrong-Esther, 1999; O'Brien, Shomphe, & Caro, 2000; Ostbye & Crosse, 1994). These behaviors, therefore, have major consequences for the health of elderly individuals and the caregivers.

BACKGROUND

Neuroleptic drugs, also called antipsychotic drugs, include conventional neuroleptics (e.g., haloperidol, thioridazine, chlorpromazine) and atypical neuroleptics (e.g., risperidone, olanzapine, clozapine). These medications are the cornerstone drug therapy for psychiatric disorders (Lehne, Moore, Crosby, & Hamilton, 2001) and are used in the pharmacological management of the behavioral syndromes associated with dementia, such as agitation, aggression, hallucinations, delusions, and delirium (Kapur & Seeman, 1998). These drugs block the receptors of neurotransmitters such as dopamine, acetylecholine, histamine, serotonin, and norepinephrine. They are thought to work on disruptive behaviors by muting the impact of dopamine (particularly dopamine receptors of D2, D3, D4) and serotonin, two of the brain's key chemical neurotransmitters. However, much more research is needed to understand clearly their mechanism of action (Lanctôt, Herrmann, & Mazzotta, 2001; Lehne et al., 2001; Seeman, 2002; Strange, 2001).

Neuroleptic medication is the most common pharmacological response in controlling disruptive behavior among elderly individuals in long-term care (Beck & Shue, 1994; Buckwalter, Stolley, & Farran, 1999; Devanand et al., 1998; Forbes, 1998; Giménez, Brazier, Calop, Dine, & Tchiakpé, 2000; Sweet & Pollock, 1995). Yet it is suggested that neuroleptics should be used only as a last resort, because of their significant secondary effects and their limited effectiveness in treating disruptive behaviors (Beck & Shue, 1994; Gerdner & Buckwalter, 1994; Hagen & Armstrong-Esther, 1999; Leroi, Steele, & Lyketsos, 1999; Nilsson, Palmertierna, & Wistedt, 1998). A review of pharmacological use patterns led the U.S. Congress to enact a law called Omnibus Budget Reconciliation Act (OBRA-87) (Shorr, Fought, & Ray, 1994). The OBRA-87 act requires quantitative documentation of the disruptive behavior, trial of alternative interventions, and gradual dose reductions after 6 months of drug therapy. Neuroleptic drug use in nursing homes in the United States decreased after the enforcement of the law (Shorr et al., 1994). However, a recent U.S. study (Castle, 1999) reported a slight increase in the use of neuroleptics among nursing home residents (n = 268 facilities). Unfortunately, at the present time in Canada, there is no regulation, law, or policy controlling the proper use of neuroleptics in nursing homes.

Caution is required when resorting to neuroleptics because of their frequent side effects and their limited level of effectiveness to treat disruptive behaviors. Among the side effects, the most significant are extrapyramidal symptoms (e.g., dystonia, akathisia, rigidity and shaking, akinesia, dysphagia) and anticholinergic effects (e.g., dryness of mouth, tachycardia, hypotension, constipation, urinary retention) (Hagen & Armstrong-Esther, 1999; Lehne et al., 2001; Leroi et al., 1999). In elderly individuals, the aging process increases the risk of being affected by the side effects of neuroleptics. An estimated 50% of elderly individuals are particularly vulnerable to anticholinergic effects (Falsetti, 2000). One study showed that upon examination 50% of elderly individuals using neuroleptics exhibited the side effects of these medications (Koopmans et al., 1996; Sultzer, Gray, Gunay, Berisford, & Mahler, 1997). Researchers reported that tardive dyskinesia appeared in 25% of elderly individuals after 1 year of treatment and in 50% after 3 years (Hagen & Armstrong-Esther, 1999). These side effects have been reported in several clinical trials (Chan et al., 2001; Nygaard, Fuglum, & Eigen, 1992; Sultzer et al., 1997). Depending on the clinical trial, 15% to 50% of the participants experienced extra pyramidal side effects (De Deyn et al, 1999; Devanand et al., 1998; Katz et al., 1999), and up to 60% experienced at least one adverse event (Allain et al., 2000; Katz et al., 1999). Unfortunately, the authors of these clinical trials rarely give the characteristics of these participants, which would have provided essential data for clinical decision-making (Lonergan, Luxenberg, & Colford, 2002).

CONFLICTING FINDINGS IN THE LITERATURE

The scientific literature reports conflicting results when it comes to neuroleptics' capacity to reduce the frequency of disruptive behaviors. Despite that these formulations have been used for several years, only 20 or so clinical trials were explicitly targeted to assess the effectiveness of neuroleptics in the treatment of disruptive behaviors among elderly individuals. In fact, Lanctôt et al. (1998), who undertook a recent meta-analysis on the effectiveness of neuroleptics, were able to identify only 16 clinical trials that fit stringent review criteria. The researchers at the Cochrane Library (Lonergan et al., 2002), who undertook a meta-analysis specifically of the effectiveness of haloperidol in controlling agitation among elderly individuals suffering from dementia, included only five clinical trials because the others did not meet methodological criteria for inclusion in the review.

The effectiveness of neuroleptics is debatable because several clinical trials produced opposite results. For example, some researchers (Allain et al., 2000; Katz et al., 1999) report that neuroleptics are effective in the treatment of agitation, while others maintain the contrary (Cummings, Street, Masterman, & Clark, 2002; Devanand et al., 1998; Lonergan et al., 2002). Unlike Devanand et al. (1998), Katz et al. (1999) show that neuroleptics are effective in the treatment of psychoses. Cummings et al. (2002) indicated that olanzapine is not effective in the treatment of hallucinations at the level of a 10 mg dose, while research by Street et al. (2000) showed that olanzapine is effective in treating these symptoms at 10 mg dose. The current body of knowledge, therefore, does not offer significant scientific evidence to assist with clinical decision-making related to administration of neuroleptics as part of the management plan for disruptive behaviors (Kindermann, Dolder, Baily, Katz, & Jeste, 2002). At best, the evidence would suggest that the effectiveness of neuroleptics varies according to the types of disruptive behavior.

This corroborates the results of three meta-analyses on the effectiveness of neuroleptics. One reported a reduction in disruptive behaviors in only 18% of cases (Schneider, Pollock, & Lyness, 1990), the other in 26% of cases (Lanctôt et al., 1998) compared to a placebo. Lonergan et al. (2002) report that haloperidol is not more effective than a placebo in controlling agitation among elderly individuals suffering from dementia. This, therefore, signifies that neuroleptics are not useful in most cases. It is plausible that their effectiveness would be greater if researchers could determine which disruptive behaviors respond best to them. However, at the present time, researchers do not know which types of disruptive behavior are more likely to result in the administration of neuroleptics.

In addition, these authors have found no clinical trial that has assessed the effectiveness of neuroleptics according to the frequency of disruptive behaviors, which would make it possible to answer clinical questions such as, "Are neuroleptics more effective for reducing the frequency of aggressive behaviors among elderly individuals who manifest them during all health care treatments?" Or, "Are neuroleptics more effective for controlling physical aggressiveness that occurs only during daily bathing and grooming activities?" In short, no study seems to have specifically examined for which types of disruptive behaviors neuroleptics are used, just as no study has assessed if the frequency of disruptive behaviors increases the risk that neuroleptics will be administered as a behavioral control. Yet, this data could be very important for nursing practice in long-term health care, because nurses often influence the prescribing patterns of physicians (Simonson, 1984; Stevenson, Kellogg, Ernst, & Whinney, 1989; Voyer & Martin, 2003). Consequently, it is important that nurses have this knowledge to assist the clinical team to discriminate between those behaviors that are most amenable to treatment with neuroleptic medications and those that are not. Nurses need to include this knowledge in interdisciplinary decision-making.

Table

TABLE 1CHARACTERISTICS OF THE STUDY POPULATION (n = 2332)

TABLE 1

CHARACTERISTICS OF THE STUDY POPULATION (n = 2332)

It is essential to know for which disruptive behaviors neuroleptics are used most often, to assess if the state of scientific knowledge justifies their use. Similarly, it is crucial to determine if the frequency of disruptive behaviors influences recourse to neuroleptics and if scientific knowledge justifies this.

STUDY GOALS

The goal of this descriptive study is to identify the types of disruptive behaviors for which neuroleptics are administered to elderly individuals in nursing homes and to determine if the frequency of these behaviors increases the chance that neuroleptics will be administered. Finally, the authors will view the results in the context of the current state of knowledge concerning the effectiveness of neuroleptics in the treatment of disruptive behaviors.

METHOD

Population

A cross-sectional study was conducted with a group of elderly individuals (N = 2,332) living in 28 long-term care facilities in the Quebec City region, in 1996. Public facilities in Quebec generally house elderly individuals having significant physical and mental conditions (Auger, Durand, Mercier, & Paré, 1989; Ministère de la santé et des services sociaux, du Québec, 2001). Admission to these facilities is managed by a single central committee that evaluates requests related to medical diagnoses, the seriousness of the loss of functional autonomy, and the extent of health care needs (Bernard, 1999). Individuals were eligible for the study if they were ages 65 or older and living in a long-term care facility. All participants with previous or concurrent diagnosis of a psychiatric condition were excluded to prevent over-estimation of the use of neuroleptics in this population.

Data Collection

Data came from two sources of information - first, from structured and simultaneous interviews with two nurses who knew the residents of the health care unit well, and second, from a systematic review of the medical files.

Variables Measured During the Interview with the Nurses. Information on disruptive behaviors during the 2 weeks prior to data collection was collected using a modified version of the Cohen Mansfield Agitation Inventory (CMAI) (Bélanger, 1993; Cohen-Mansfield, Marx, & Rosenthal, 1989). For every unit, the charge nurse assigned two staff nurses who knew the residents well to estimate the frequency of disruptive behaviors for each resident in collaboration with the research assistant. The research assistant explained all items of the CMAI and supported the staff nurses during the completion of the instrument to clarify any items when requested. The CMAI measures 29 disruptive behaviors classified into four groups:

* Aggressive physical behavior.

* Non-aggressive physical behavior.

* Aggressive verbal behavior.

* Non-aggressive verbal behavior.

Each behavior is measured on a scale of 5 points defined as follows:

* 1, never.

* 2, rarely (1 time a day or less).

* 3, sometimes (2 times a day or 8 to 14 times per week).

* 4, often (3 times a day or 15 to 21 times per week).

* 5, very often (4 times a day or more than 22 times per week).

The validity and the reliability of the French version of the CMAI showed good interrater reliability (r = .72; ? < .05), temporal stability (r = .72; ? < .05), internal consistency (Cronbach's alpha varying between .75 and .77; ? < .05), concomitant reliability (r = .74;^ < .05) and construct validity (Deslauriers, Landreville, & Verreault, 2001; Durand et al., 2000).

Variables Measured by a Medical File Review. A structured questionnaire was used to collect information on sociodemographic characteristics of participants (e.g., age, gender, length of stay in the care unit), presence of a prescription for neuroleptic drugs to be taken regularly, and the occasional use of a neuroleptic drug during the week prior to data collection. For a participant to be considered as a neuroleptic user, they either had to have a regular neuroleptic prescription or have consumed pro re nata (PRN) neuroleptic drugs in the past week. The medication was coded according to the Anatomic, Therapeutic, Chemical classification system (ATC classification) (World Health Organization Collaborating Center for Drug Statistics Methodology, 2000). Neuroleptics are coded N05A in this system.

This study was reviewed and approved by a research ethics committee.

Analysis of Data. The characteristics of the population in the study are described using the proportions for the categorial variables (consumption of neuroleptics and gender) and mean for the continuous variables (age and length of stay in the health care unit).

The items associated with each of four types of behavior measured by the CMAI have been described by proportions. Each of these items was dichotomized as follows: absence of disruptive behaviors for a score of 1 and presence of disruptive behaviors for scores varying from 2 to 5.

The items constituting each type of disruptive behavior were grouped to create four composite variables:

* All disruptive behaviors of a physical type, with aggressiveness.

* All disruptive behaviors of a physical type, without aggressiveness.

* All disruptive behaviors of a verbal type, with aggressiveness.

* All disruptive behaviors of a verbal type, without aggressiveness.

These composite variables present three values - never, if no disruptive behavior has been observed on the part of the elderly individual; sometimes, if the elderly individuals manifested at least one disruptive behavior between 1 and 3 times a day; and often, if they manifested at least one disruptive behavior 4 times a day or more.

Given the multicollinearity among the various disruptive behaviors, raw score ratios (RCb) have been calculated to measure the association between each overall type of disruptive behavior and consumption of neuroleptics among the elderly individuals. All of the analyses were performed using Statistical Analysis System (SAS) software, version 8.0 (SAS Institute Inc., Cary, NC).

Table

TABLE 2CONSUMPTION OF NEUROLEPTICS ACCORDING TO BEHAVIORS OF A PHYSICAL TYPE, WITH AGGRESSIVENESS (N = 2332)

TABLE 2

CONSUMPTION OF NEUROLEPTICS ACCORDING TO BEHAVIORS OF A PHYSICAL TYPE, WITH AGGRESSIVENESS (N = 2332)

RESULTS

The characteristics of the participants are described in Table 1. Participants' average age was 83.1 years (SD = 8.1), and the average length of stay in the long-term care facility was 64.7 months (SD = 83.1). Women represent 75.4% of the sample. Among the 2,332 participants in the study, 649 (27.8%) took at least one neuroleptic, almost exclusively a conventional neuroleptic. The most frequent formulations used were two conventional neuroleptics: haloperidol (60.6%) and thioridazine (18.5%) (Table 2). The low prevalence of atypical neuroleptic consumption is probably explained by the fact that these formulations (e.g., risperidone and olanzapine) had appeared only recently on the Canadian market at the time of the study.

Globally, among the users of neuroleptics, 82.7% displayed at least one disruptive behavior in the previous 2 weeks in comparison to 61.9% in the non-user group. More specifically, neuroleptic administration in elderly individuals was associated with all behavioral manifestations of a physical type in combination with aggression with the exception of hurting oneself and intentional falling (Table 2).

In comparison to non-users, neuroleptic drug users more frequently displayed such behaviors as hitting, pushing, biting, spitting, kicking, scratching, and throwing things. The neuroleptic ordering patterns for elderly residents was linked with several behaviors of the physical type in the absence of aggression, except those who ate or drank inappropriate substances, those who made physical sexual advances, and those who hoarded things (Table 3). Neuroleptic administration was associated with all behavioral manifestations of the verbal type when occurring in combination with aggression (e.g., cursing, negativism, screaming) (Table 4). Complaining or whining and verbal sexual advances were the two types of non-aggressive verbal behaviors with which neuroleptic administration was not associated (Table 5), as opposed to repetitive sentences and making strange noises.

The ratios of raw scores presented in Table 6 indicate that the risk of taking neuroleptics increases significantly with the frequency of disruptive behaviors. For example, for disruptive behaviors of a physical type with aggressiveness, the risk of taking neuroleptics is two to three times greater if the elderly individual manifests disruptive behaviors sometimes or often compared to never.

Table

TABLE 3CONSUMPTION OF NEUROLEPTICS ACCORDING TO BEHAVIORS OF A PHYSICAL TYPE, WITHOUT AGGRESSIVENESS (N = 2332)

TABLE 3

CONSUMPTION OF NEUROLEPTICS ACCORDING TO BEHAVIORS OF A PHYSICAL TYPE, WITHOUT AGGRESSIVENESS (N = 2332)

Table

TABLE 4CONSUMPTION OF NEUROLEPTICS ACCORDING TO BEHAVIORS OF A VERBAL TYPE, WITH AGGRESSIVENESS (N = 2332)

TABLE 4

CONSUMPTION OF NEUROLEPTICS ACCORDING TO BEHAVIORS OF A VERBAL TYPE, WITH AGGRESSIVENESS (N = 2332)

DISCUSSION AND IMPLICATIONS

The results suggest there is not one specific behavioral entity or CMAI behavioral category for which neuroleptics are exclusively used among elderly individuals in nursing homes. Several behaviors, of a physical or verbal type, with or without aggressiveness, seem to be linked to administration of neuroleptics. These results possibly reflect knowledge based on clinical trials that do not yet make it possible to determine for which types of disruptive behavior neuroleptics are the most effective.

The results indicate that the more an elderly individual displays disruptive behaviors, the greater the risk that they will be administered neuroleptics. This leads one to wonder about the effectiveness of neuroleptics for elderly individuals who manifest different profiles of disruptive behavior. Do neuroleptics act like benzodiazepines for sleep ? That is to say, do they lose their effectiveness after being taken for a certain period of time? Or do they work like normothymics for bipolar depression? In other words, is there a therapeutic dosage? Or again, do they work like antihypertensives for hypertension where the dosage must be adjusted according to the degree of severity, and other formulations added for resistant hypertension? With the current state of knowledge, one cannot answer these questions. Answers to these various questions would contribute to a more evidence-based approach to the use of neuroleptics in treating the problem of disruptive behaviors among elderly individuals in long-term care.

Table

TABLE 5CONSUMPTION OF NEUROLEPTICS ACCORDING TO BEHAVIORS OF A VERBAL TYPE, WITH AGGRESSIVENESS (N = 2332)

TABLE 5

CONSUMPTION OF NEUROLEPTICS ACCORDING TO BEHAVIORS OF A VERBAL TYPE, WITH AGGRESSIVENESS (N = 2332)

Because the risk of being administered neuroleptics increases with the frequency of disruptive behaviors, it seems plausible that these more frequent behaviors disrupt the caregivers' routine. So, to manage them, it is probable that nurses ask physicians to prescribe neuroleptics to restore order in a task-oriented work culture. Neuroleptics, therefore, are used as a chemical restraint (Beck & Shue, 1994; Bradley & Dufton, 1995; Buckwalter et al., 1999; Taft & Cronin-Stubbs, 1995). In the present study, the disruptive behaviors not associated with neuroleptic administration may be less disruptive for caregivers (e.g., eating or drinking inappropriate substances, making physical sexual advances or exposing genitals, hoarding things, verbal sexual advances, self-mutilation, intentional falls).

The lack of specific association between disruptive behaviors and neuroleptics, therefore, leads to a discussion of the clinical trials related to using neuroleptics to control disruptive behaviors among elderly individuals. However, the results of clinical trials are not conclusive. Under these circumstances, one cannot establish evidence-based clinical practice guidelines for the prescription and administration of neuroleptics to treat disruptive behaviors.

Greater Prudence in Neuroleptic Use

The authors suggest greater prudence in the use of neuroleptics for disruptive behavior. Even if prescribing medication is the physician's responsibility, it is important that nurses be aware of the strengths and limitations of the effectiveness of neuroleptics. Knowledgeable nurses can, therefore, position themselves to play an important role as gatekeeper and advocate for elderly individuals in nursing homes with respect to neuroleptic use.

Placebo Effect. The first argument to suggest greater prudence in the use of neuroleptics relates to the placebo effect. In the clinical trials comparing various neuroleptics (Carlyle, Ancill, & Sheldon, 1993; Chan et al., 2001; Nygaard et al., 1992; Sultzer et al., 1997) the results indicate that no single neuroleptic appears to be more effective than another. According to the U.S. Food and Drug Administration (FDA), it is difficult to prove the effectiveness of a neuroleptics other than in the context of a clinical trial controlled with a placebo (Enserink, 2000). In clinical trials of neuroleptics, it is frequently noted that the condition of participants in the placebo group improves in 30% to 50% of cases (Allain et al., 2000; Beecher, 1955; Devanand et al., 1998; Enserink, 2000; Katz et al., 1999). Furthermore, these improvements are superior to those obtained in the three meta-analyses on the effectiveness of neuroleptics (Lanctôt et al., 1998; Lonergan et al., 2002; Schneider et al., 1990). Because of the high incidence of the placebo effect, one must be very prudent when it comes to deciding that a neuroleptic is effective (Enserink, 2000; Shukla &McAuley,2001).

Study Group Heterogeneity. The second argument refers to the heterogeneity of the groups studied. In most cases, the study group included participants suffering from a type of dementia, such as Alzheimer's disease, vascular dementia, frontotemporal dementia, or mixed dementia (Carlyle et al., 1993; Chan et al., 2001; De Deyn et al., 1999; Katz et al., 1999; Street et al., 2000). But, no analysis has been made in function of these various types of dementia. Certain studies also report results obtained either from elderly individuals living at home (Devanand et al., 1998; Laks et al., 2001), from those living in an institution (Carlyle et al., 1993, De Deyn et al., 1999; Edell & Tunis, 2001; Katz et al., 1999; Sultzer et al., 1997), or both (Chan et al., 2001). Simultaneously assessing the effectiveness of neuroleptics comparing different groups living in different settings greatly limits the capacity to interpret the results in terms of the effectiveness of neuroleptics.

Table

TABLE 6ALL DISRUPTIVE BEHAVIORS ACCORDING TO CONSUMPTION OF NEUROLEPTICS: FREQUENCY AND MEASUREMENT OF RAW ASSOCIATION (N = 2332)

TABLE 6

ALL DISRUPTIVE BEHAVIORS ACCORDING TO CONSUMPTION OF NEUROLEPTICS: FREQUENCY AND MEASUREMENT OF RAW ASSOCIATION (N = 2332)

Sample Size. The third argument concerns the size of the sample groups. The clinical trials report results for groups of 28 participants (Sultzer et al., 1997), 29 participants (Cummings et al., 2002), 40 participants (Carlyle et al., 1993), and 58 participants (Chan et al., 2001). The limited sample size in each of these studies does not support generalizing results to a broader population of elderly individuals living in long-term care.

Measuring Instrument Consistency. The fourth argument refers to a lack of consistency in the choice of measuring instruments. The disruptive behaviors in the clinical trials were measured with more than 30 scales. Examples of scales used to measure behavior include the Behavior Pathology in Alzheimer's Disease Rating Scale (De Deyn et al., 1999; Katz et al., 1999), the Cohen-Mansfield Agitation Inventory (Chan et al., 2001; De Deyn et al., 1999; Sultzer et al, 1 997), the Clinical Global Impression Scale (Allain et al., 2000; Laks et al., 2001), the Multidimensional Observation Scale for the Elderly Participants (Allain et al., 2000), the Psychogeriatric Dependency Rating Scale (Edell & Tunis, 2001), the Brief Psychiatric Rating Scale (Cummings et al., 2002; Street et al., 2001), the Schedule for Affective Disorders and Schizophrenia (Devanand et al., 1998), the Neuropsychiatrie Inventory/Nursing Home (Cummings et al., 2002; Street et al., 2001), and the Behavioral and Emotional Activities Manifested in Dementia Scale (Laks et al., 2001). In addition to the lack of uniformity among the studies, several studies used instruments that were not standardized for the groups being studied. Finally, these instruments were often too general to adequately assess specific behaviors (Scottish Intercollegiate Guidelines Network, 1998). It would be desirable to increase the harmonization of measurements to facilitate comparison of the studies, and thereby of the different neuroleptic formulations (Lonergan et al., 2002).

Study Duration. The fifth argument refers to the duration of the studies. The length of treatment for these clinical trials varied between 3 (Allain et al., 2000) and 18 weeks (Street et al., 2001), with an average of 10 weeks (Chan et al., 2001; De Deyn et al., 1999; Devanand et al., 1998; Katz et al., 1999; Lanctôt et al., 1998; Sultzer et al., 1997). However, the duration of neuroleptic use in institutional environments is generally longer (Van Dijk, de Vries, van den Berg, Brouwers, & de Jong-van den Berg, 2000). Koopmans et al. (1996) have shown that neuroleptic use in long-term care can be as long as 22 weeks. Yet, the therapeutic qualities of these formulations and their undesirable effects beyond the time period of the experimental studies are unknown. Therefore, the current state of knowledge does not justify long-term use of neuroleptics for patients living in institutional environments (Lonergan et al., 2002).

These arguments show the importance of continuing experimental research on the effectiveness of neuroleptics given the gap between the use of neuroleptics and knowledge related to their effectiveness. These results show that neuroleptics are given to elderly individuals to treat all types of disruptive behavior, when scientific knowledge offers no indication that this is appropriate. Until their effectiveness has been well established in the control of disruptive behaviors, one can only repeat the importance of making more use of non-pharmacological interventions in long-term treatment facilities (Rovner, Steele, Shmuely, & Folstein, 1996).

Non- Pharmacological Options

The authors agree with the definition of the concept of disruptive behaviors proposed by Algase et al. (1996) that disruptive behaviors can be avoided or corrected without using neuroleptics as a first treatment. Algase et al. (1996) propose the concept of needed-driven dementia compromised behavior. This concept of disruptive behaviors has several implications, such as the behavior being the symptom of a compromised need, and therefore, modifiable. In addition, it implies that the behavior does not stem only from the cognitive impairment. Thus, certain researchers (Beck & Shue, 1994; Landreville et al., 1998; Lehninger, Ravindran, & Stewart, 1998) suggest encouraging non-pharmacological interventions aimed at different etiologies, such as the environment (e.g., light intensity, white noise) and the individual (e.g., exercise program, music therapy, zootherapy, leisure activities) along with specific behavioral techniques to avoid or eliminate one particular disruptive behavior (e.g., light therapy for sundowning syndrome, cognitive stimulation and comfort intervention for vocalization). However, so far clinical trials need to be performed for many of the non-pharmacological interventions (Forbes, 1998).

Limits of the Study

The present study has two main limitations. The first is that the neuroleptics used by the patients were almost exclusively conventional formulations that are currently being abandoned in favor of atypical neuroleptics. These conventional formulations lead to undesirable effects in nearly all consumers (Kapur & Seeman, 1998). Nevertheless, undesirable effects of atypical neuroleptics should not be underestimated, and no scientific evidence has established their superior therapeutic value in the treatment of disruptive behaviors (Falsetti, 2000; Lanctôt et al., 1998). The second limitation stems from the fact that this was a crosssectional study; that is, these factors were measured simultaneously with the use of neuroleptics, thus making it difficult to determine a cause-andeffect relationship.

CONCLUSION

This study shows that neuroleptic medication is frequently used in long-term care of elderly individuals presenting disruptive behaviors. Information on the effectiveness of neuroleptics in the control of these disruptive behaviors is not sufficiently conclusive to justify their use as a first-line therapeutic strategy in controlling disruptive behaviors overall. In addition, the undesirable anticholinergic and extra-pyramidal effects of these medications are well known. The aging process also increases the risk of being afflicted with these undesirable effects. Therefore, prudence is required in the use of these medications among elderly individuals. Nurses' close monitoring of the effectiveness of these drugs in nursing homes should be part of the routine care and assessment protocols.

Disruptive behaviors may be symptoms of an underlying problem and constitute a means of expression for patients with cognitive impairments. This leads to the suggestion that health care professionals must adopt a multi-dimensional approach based mainly on observing and analyzing the behavior, seeking underlying causes, and establishing a treatment plan adapted to each situation.

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TABLE 1

CHARACTERISTICS OF THE STUDY POPULATION (n = 2332)

TABLE 2

CONSUMPTION OF NEUROLEPTICS ACCORDING TO BEHAVIORS OF A PHYSICAL TYPE, WITH AGGRESSIVENESS (N = 2332)

TABLE 3

CONSUMPTION OF NEUROLEPTICS ACCORDING TO BEHAVIORS OF A PHYSICAL TYPE, WITHOUT AGGRESSIVENESS (N = 2332)

TABLE 4

CONSUMPTION OF NEUROLEPTICS ACCORDING TO BEHAVIORS OF A VERBAL TYPE, WITH AGGRESSIVENESS (N = 2332)

TABLE 5

CONSUMPTION OF NEUROLEPTICS ACCORDING TO BEHAVIORS OF A VERBAL TYPE, WITH AGGRESSIVENESS (N = 2332)

TABLE 6

ALL DISRUPTIVE BEHAVIORS ACCORDING TO CONSUMPTION OF NEUROLEPTICS: FREQUENCY AND MEASUREMENT OF RAW ASSOCIATION (N = 2332)

10.3928/0098-9134-20051101-11

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