Consultants Forum

Monitoring Tips for Psychotropic Drug Classes

Behavioral monitoring in long-term care can be confusing. Which medications to monitor, which need target behaviors, how often to monitor, who should monitor-these issues are perpetual topics of in-service programs in the homes I serve. I have found a concise and easily understandable way to break it all down and help nursing staff make sense of the confusion. Here is the condensed version of what I teach during in-service programs.

Four basic types of psychotropic agents require monitoring: antidepressant agents, sedative-hypnotic medications, antianxiety agents, and antipsychotic drugs. Each has its own set of criteria for monitoring and must be treated differently. I provide a list of common medications in each category during the in-service as a handout. The following information is conveyed orally.

Antidepressant medications require the least amount of monitoring. The patient must have a diagnosis of depression. The staff must monitor for side effects as with any medication, and the findings should be in the nursing notes or another appropriate area of the resident's chart. If the resident does not have a diagnosis of depression, contact the consultant pharmacist or prescriber.

Sedative-hypnotic agents require monitoring only if used as a routine medication. With p.r.n. use, nursing staff must document the reason for use (generally insomnia), any side effects, and the clinical outcomes on the back of the medication administration record each time the drug is administered. If a sedative-hypnotic is prescribed as a scheduled medication and the prescriber will not allow a change to p.r.n. status, then the resident must be diagnosed as having insomnia, nursing staff must complete a behavioral sheet to monitor side effects, and insomnia should be monitored as a target behavior. However, most physicians will change the medication to p.r.n. if asked, and the consultant pharmacist can help with appropriate communications. Incidentally, the manufacturers of this drug class do not recommend daily use beyond 10 days, and state surveyors usually will accept this as the standard to be met.

Antianxiety medications fall into the same category as above if used p.r.n. No additional monitoring is required beyond what is normally provided for as-needed drugs. If the medication is used routinely, the resident only need be diagnosed as having an anxiety or panic disorder. With these, side effects should be charted on the behavior monitoring sheet. Without an appropriate diagnosis, a target behavior must be charted. I recommend using anxiety as the target behavior; no one can argue that an antianxiety medication is being used inappropriately if it is being given for anxiety.

Antipsychotic drugs are the most regulated group. I recommend they not be used p.r.n. unless used in conjunction with a scheduled dose of the same, or a similar, medication. An example would be Haldol 1 mg t.i.d. and a p.r.n. order of Haldol 1 mg I.M. p.r.n. for hallucinations. I provide a list of the OBRA-approved diagnoses as well as the names of commonly prescribed antipsychotics and appropriate versus inappropriate target behaviors as a handout. If the resident has an acceptable diagnosis, nursing must only chart side effects-a target behavior is not needed. I recommend the standard behavior monitoring sheet be used to chart side effects in this instance. If the resident does not have an approved diagnosis, nursing staff must chart side effects and a target behavior. The choice of a target behavior is important because use of an inappropriate behavior could lead to a chemical restraint deficiency. I review a list of acceptable and unacceptable target behaviors at this point.

I then provide attendees with a copy of a behavior monitoring sheet. If a target behavior is not required, the nurse fills out the bottom half for side effects only.

To use the system, I instruct the nursing staff to first determine the class of psychotropic agent the medication falls into. Then the above guidelines for the class should be followed. I wrap up by going over some examples using the behavior monitoring sheet and having participants fill it in with me.

I have had very little trouble with my cooperative homes following and complying with OBRA guidelines using this system. It is easy to follow, leading to better compliance and less need for repeat in-service programs. Once the homes begin a consistent monitoring program, a wealth of information is generated with which consultant pharmacists can assess dosage-reduction appropriateness, as well as side effects the residents may be experiencing.

Chris Caronna, RPh, FASCP
1520 West Waterview St.
Portland, TX 78374