Expert: Mary Gordon - 2/8/2008

Question
You spoke to this issue in a response to a "Jackie" in 2006. Is it possible that my father, in late stage AD, should need up to .5 mg adivan to be agreeable to nursing home staff? Approx. two months ago he was on .25 mg, and at this time we found it relatively easy to shave him and cut his nails, as we were doing ourselves. He was of medium stature was emaciated upon his arrival to the home. His weight gain with artificial nutrition was not significant.  Family visits randomly almost every day, even as early as 7am. He is not awake at any time.  Two days ago we met with his doctor, whom we convinced to change his order from daily automatic dosing to "hold meds if already sedated." As of yet the staff has not attempted to follow this order, claiming combativeness.  Prior to the increase we had been having quality visits, with him pointing to things he found interesting, answering our yes/no questions, and even saying a few words.  You suggested Zoloft or Respiridol as alternatives. Are there now any others that I should bring to the doctor's attention?  Has anyone had any success with herbal or homeopathic remedies? Other than this issue, he has no pain, a strong heart, and his only additional medicine is commonly prescribed Parkinson's pill.
Thank you.

Answer
Hi Shannon,

Sounds to me like staff at the facility may be using a tranquilizer as a form of "chemical restraint" - in other words, for convenience.

The use of Ativan should not be daily and ongoing to the point he's a zombie. A drug like this should be used short term, with specific goals in mind. Your dad should be monitored closely and re-assessed regularly to ensure that side effects of medication are not interfering with participation in daily activities - which is clearly NOT what is happening at the moment, given that he is very sleepy all the time, which may be increasing his risk of falls if he is still ambulatory.  It is not acceptable that the doctor has indicated the drug be given only when needed, and the facility continuing to dose him daily, effectively saying its ALWAYS needed.   

If your father is indeed getting agitated during certain activities or times of the day, the staff absolutely has a duty to be documenting his behaviors and what strategies they are trying to use to manage it i.e. the tranquilizer should only be in use when nothing else is working. They also should be able to give you specifics so family members can arrange to be present to witness the behavior that is of concern.  In other words, they owe it to you to demonstrate what they are doing is necessary and appropriate and that other approaches are not working.

One of the most successful strategies for dealing with difficult behaviours, without using restraints, is to use the problem-solving approach.
i.e. Identify the problem: Take a step back and objectively pinpoint the problem.
Analyze the problem: Is the person trying to communicate something? What factors might be contributing to the person's reaction? What is happening and why? Could the person be reacting to something or someone in the environment?
List possible strategies: Think of all the ways to possibly solve the problem.
Choose a strategy: Weigh the pros and cons of each strategy. Select one.
Take action: Put the chosen strategy into effect.
Assess the results: Did the chosen strategy work? If not, why not? Should another strategy be tried?

I would call a care conference, if that is possible, with the doctor in attendance and someone familiar with your father from the facility, and have a discussion about your concerns. I would ask the doctor about weaning him off the ativan entirely, and reassessing him.  

Here is the American Geriatrics Society position statement on restraint use, including chemical restraints.

http://www.americangeriatrics.org/products/positionpapers/restraintsupdate.shtml

Here is a nursing education discussion of the issues
http://yenoh93.medceu.com/index/courses/restraints.htm

Hope this helps

Mary G.