Sex in Nursing Homes: A Survey of Nursing Home Policies Governing Resident Sexual Activity.

OBJECTIVE: To identify nursing home (NH) standards related to sexual activity and sexual relationships for residents through a nationwide survey of directors of nursing (DONs). METHODS: A national survey was distributed online and was completed by 366 DONs of skilled nursing facilities. The DONs answered questions concerning policies and experiences related to sexual activities of their residents including types of resident sexual activity they have encountered, perceptions about residents with dementia engaging in sexual activity, and policies pertaining to sexual activity including masturbation. RESULTS: The results of the survey demonstrated that the vast majority (71.2%) indicated that there had been issues regarding residents' sexual activities in their facilities with over one-half (58%) of the DONs reporting situations of resident with resident sexual activity and 60% with situations of resident masturbation. More than one-half (56.6%) require a family or designated representative to approve sexual activity for a cognitively impaired resident. For a cognitively intact resident, 12.4% of facilities still require family or designated representative to approve sexual activity. However, despite the prevalence of sexual activity, the majority of NHs (63.4%) actually do not have policies dealing with resident sexual activity. Of the NHs with policies, 58.6% have written policies in place, with 11.2% requiring a physician order to allow sexual activity and 9.5% requiring a physician order to restrict sexual activity. CONCLUSIONS: Issues related to sexual activity in NH residents are quite prevalent, however, the rates of policies related to sexual activity are low and the policies and restrictions are not uniform. Our study suggests nursing homes should have a clear policy addressing resident sexual activity. It would be beneficial for such a policy to be communicated to residents and their families as part of an admission package instead of waiting for sexual interest to be noticed. This would enable residents to engage in sexual activity with understanding and support rather than hiding.

Antipsychotic drug use since the FDA black box warning: survey of nursing home policies.

OBJECTIVES: To use a nationwide survey to assess changes in antipsychotic utilization patterns and usage policies in nursing homes (NHs) in the United States since the introduction of the black box warning by the FDA. DESIGN/SETTING/PARTICIPANTS: A survey was distributed online and was completed by 250 directors of nursing of NH. The directors of nursing answered questions concerning policies about and use of antipsychotic medications. MEASUREMENTS/RESULTS: The most commonly reported intervention to manage symptoms in residents with dementia since the black box warning was to lower doses of antipsychotics. Over half of facilities report obtaining more frequent psychiatry/psychology consults. One-hundred seven facilities have a policy regarding informing family members of residents about the black box warning. Most facilities (63.6%) with a policy require family to sign consent. In the NH setting, the presence or absence of a policy did not correlate with the reported change in use of antipsychotics or types of alternative interventions. CONCLUSION: Notably, a large number of NH facilities have policies regarding informed consent on the use of antipsychotics. However, in our study, the rate of use of antipsychotics did not change in many facilities since the black box warning. In addition, having a policy did not correlate with decreased antipsychotic use or with use of alternate agents or nonpharmacologic methods to address symptoms. The results of this survey suggest that NH administrators should worry less about the legal exposure of using antipsychotics and focus on actions that result in improved patient care.

Smoking rates in dementia patients in the outpatient setting.

The purpose of this study is to determine the prevalence of tobacco use in patients diagnosed with dementia or cognitive impairment in an outpatient setting as they may be unsafe smokers and present safety risks to themselves and others. We conducted a retrospective chart review of new patients between 1/06 and 8/07 who were diagnosed with dementia or cognitive impairment in a geriatric outpatient practice. The data collected included age, gender, tobacco use patterns and mini-mental state examination (MMSE) score. Data was analyzed using SAS 9.1 for Windows (SAS Institute, Cary, NC). Former tobacco use rates in our study were similar to nationwide published rates for elderly over 65 (39.9% vs. 39.5%, respectively, p=0.99). However, only two patients in our study (1.32%, 95%CI=0.16-4.70) were current tobacco users compared with published census data that 10.2% of those over 65 are current smokers nationwide (p<0.001). Our study revealed a much lower rate of current tobacco use in our series of cognitively impaired patients. Further research is needed to explore the reasons for decreased smoking in those with cognitive impairment and its clinical implications.

Antipsychotic treatments for the elderly: efficacy and safety of aripiprazole.

Delusions, hallucinations and other psychotic symptoms can accompany a number of conditions in late life. As such, elderly patients are commonly prescribed antipsychotic medications for the treatment of psychosis in both acute and chronic conditions. Those conditions include schizophrenia, bipolar disorder, depression and dementia. Elderly patients are at an increased risk of adverse events from antipsychotic medications because of age-related pharmacodynamic and pharmacokinetic changes as well as polypharmacy. Drug selection should be individualized to the patient's previous history of antipsychotic use, current medical conditions, potential drug interactions, and potential side effects of the antipsychotic. Specifically, metabolic side effects should be closely monitored in this population. This paper provides a review of aripiprazole, a newer second generation antipsychotic agent, for its use in a variety of psychiatric disorders in the elderly including schizophrenia, bipolar disorder, dementia, Parkinson's disease and depression. We will review the pharmacokinetics and pharmacodynamics of aripiprazole as well as dosing, diagnostic indications, efficacy studies, and tolerability including its metabolic profile. We will also detail patient focused perspectives including quality of life, patient satisfaction and adherence.

Rapidly worsening hypertriglyceridemia during treatment with risperidone.

To report a case of rapidly worsening hypertriglyceridemia in a geriatric patient that occurred 2 weeks after treatment with risperidone. The patient is a 70-year-old morbidly obese woman admitted to an inpatient psychiatric unit for exacerbation of schizophrenia. She had a pre-existing metabolic syndrome at baseline with a baseline triglyceride level of 188 mg/dL (>150 mg/dL), high-density lipoprotein of 34 mg/dL (<50 mg/dL), and fasting blood glucose of 100 mg/dL. She was started on risperidone and rapidly developed worsening hypertriglyceridemia after 2 weeks of being on the medication without any associated weight gain. Two weeks after admission, a repeat fasting lipid profile revealed serum triglycerides of 395 mg/dL with a direct low-density lipoprotein of 79 mg/dL, high-density lipoprotein of 21 mg/dL, and total serum cholesterol of 155 mg/dL. The hypertriglyceridemia improved when the medication was stopped. We postulate that the worsening hypertriglyceridemia was due to the effects of risperidone. An objective causality assessment revealed that the adverse drug event was probable. There have been numerous reports in the literature of hypertriglyceridemia without weight gain associated with atypical antipsychotics. None of the published cases had reported a rapidly occurring hypertriglyceridemia within 2 weeks of starting an atypical antipsychotic. It is possible that baseline obesity and baseline metabolic disorder may be risk factors for worsening hypertriglyceridemia in patients started on atypical antipsychotics. Clinicians treating elderly patients with risperidone should be aware of the potential for rapidly developing hypertriglyceridemia and monitor such patients accordingly. We caution clinicians to be aware that hypertriglyceridemia can worsen rapidly after initiation of atypical antipsychotics even in the first 2 weeks of treatment. Further studies are needed to see whether pre-existing metabolic syndrome is a possible risk factor for developing rapid hypertriglyceridemia in patients started on atypical antipsychotic drugs.

Nursing home policies on items brought in from the outside for facility residents.

OBJECTIVE: To identify nursing home standards related to items brought in from the community for residents through a nationwide survey of directors of nursing. Specifically we examined the policies with regard to food, cigarettes, alcoholic beverages, and over-the-counter medications. METHODS: A national survey was distributed online and was completed by 299 directors of nursing of skilled nursing facilities. The directors of nursing were asked about policies regarding whether family and friends of residents are permitted to bring in items such as food, cigarettes, alcohol, and over-the-counter medications. Specifically, questions were related to monitoring, staff involvement, safety precautions, and policy implementation. RESULTS: The results of the survey demonstrated a consistent policy practiced among facilities. Items commonly restricted for all residents included over-the-counter medications, alcohol, and cigarettes. On the other hand, food was significantly less likely to be restricted. CONCLUSION: Despite overall strict policies regarding the monitoring of access to over-the-counter medications, alcohol, and cigarettes by nursing home residents, ingestion of outside food remains fairly unrestricted. This is especially concerning given the growing number of residents with end-stage congestive heart failure, diabetes, dysphagia, or food allergies where access to outside food could result in an adverse event. Perhaps, facilities need to identify at-risk residents and better communicate to residents and their families regarding dietary restrictions on outside food.

Central sleep apnea in a geriatric patient treated with aripiprazole.

We report a case of central sleep apnea in a geriatric patient that was associated with treatment with aripiprazole for an episode of major depressive disorder with psychotic features. The patient was a 72-year-old man who was started on aripiprazole and developed central sleep apnea that improved significantly when the medication was stopped. A rechallenge with aripiprazole led to a worsening of the central sleep apnea, which again improved off the aripiprazole. We postulate that the central sleep apnea was due to aripiprazole. There have been numerous case reports in the literature of obstructive sleep apnea associated with atypical antipsychotics. To our knowledge, this is the first published case of central sleep apnea. We caution clinicians to be aware that there is potential risk of atypical antipsychotics like aripiprazole inducing or exacerbating central sleep apnea.

Increases in C-reactive protein may predict recurrence of clozapine-induced fever.

OBJECTIVE: To report a case of recurrent clozapine-induced fever that was associated with a rise in C-reactive protein (CRP). CASE SUMMARY: A 73-year-old man with Lewy Body dementia was admitted for psychosis. He was treated with clozapine (initial dose 12.5 mg/day, titrated to 75 mg/day over 15 days). On day 15 of clozapine therapy, he developed a benign fever (maximum 38.4 degrees C) that was associated with a rise in the CRP level (3.96 mg/dL). The level normalized when clozapine was discontinued. However, when the patient was rechallenged with clozapine, the CRP level became elevated (4.36 mg/dL) after 3 days of therapy, with a subsequent recurrence of fever (38.7 degrees C). DISCUSSION: We postulate that the elevation in CRP levels and the subsequent fever were caused by the effects of clozapine on the cytokine system via interleukin-6 and tumor necrosis factor-alpha, resulting in an inflammatory response with an acute phase reaction. This case is unique, as it is the first reported in the literature associating a recurrence of clozapine-induced fever with the known immunomodulatory effects of clozapine on cytokines and CRP level. According to the Naranjo probability scale, this adverse effect is probably associated with clozapine. CONCLUSIONS: Clozapine-related fever is generally benign but difficult to assess and manage, as it can be confused with much more serious conditions. Further research is needed to study whether CRP is a useful tool in predicting and managing clozapine fever.

Quetiapine-associated dysphagia.

We report a case of quetiapine-induced dysphagia in a geriatric patient which improved with discontinuation of the antipsychotic. The patient had developed dysphagia while being treated with antipsychotics for bipolar disorder. The patient's dysphagia showed significant improvement when she was taken off quetiapine. We review the available literature on antipsychotic-related dysphagia and suggest that clinicians need to be aware of the potential for this syndrome even with lower potency antipsychotics.

Antipsychotic-induced hyponatremia: case report and literature review.

We report a case of hyponatremia in a patient that occurred 3 days after initiation of treatment with aripiprazole. The patient was a 50-year-old man admitted to an inpatient psychiatric unit for exacerbation of schizophrenia. He was started on aripiprazole and developed hyponatremia that resolved when the medication was stopped. We postulate that the hyponatremia was due to an aripiprazole-induced syndrome of inappropriate secretion of antidiuretic hormone. There have been numerous case reports in the literature of hyponatremia in the literature associated with atypical antipsychotics. We caution clinicians to be aware that the potential hyponatremic-inducing effects of atypical antipsychotics can occur rapidly after initiation of the medications.

Bitemporal electroconvulsive therapy for depression in a Parkinson disease patient with a deep-brain stimulator.

We report the successful treatment of an episode of major depression with psychotic features with electroconvulsive therapy (ECT) in a 78-year-old woman with advanced Parkinson disease who had a left subthalamic nucleus deep-brain stimulator (DBS) in place. Electroconvulsive therapy effectively and safely treated the patient's depression without harming the patient or damaging the DBS hardware. We offer additional evidence about the safety and efficacy of electroconvulsive therapy in patients with DBS.

Rapidly developing hyperglycemia during treatment with olanzapine.

OBJECTIVE: To report a case of rapidly occurring hyperglycemia that occurred in a geriatric patient 3 days after treatment with olanzapine. CASE SUMMARY: An 89-year-old man was admitted for dementia with behavioral disturbance and psychosis and was started on olanzapine 2.5 mg twice daily. Due to paranoia and agitation, the dose was increased to 5 mg twice daily after 2 days. Subsequently, he developed hyperglycemia (fasting blood glucose 138 mg/dL) that resolved when olanzapine was stopped and recurred (fasting blood glucose 150 mg/dL) after 2 days of rechallenge with olanzapine 2.5 mg twice daily. In addition, his overall medical status worsened, as he developed concurrent acute renal failure and became more confused and lethargic. The hyperglycemia once again resolved with discontinuation of the drug. DISCUSSION: We postulate that the rapid onset of hyperglycemia and the resulting medical sequelae were due to olanzapine. An objective causality assessment revealed that the adverse drug event was probable. There have been numerous case reports of hyperglycemia with olanzapine in the literature, but none reported hyperglycemia within days of initiation of the medication. Although weight gain often coincides with hyperglycemia in patients taking atypical antipsychotics, it does not seem to be a necessary causal factor. Recent data in animal studies have indicated that olanzapine and clozapine rapidly impair whole-body insulin sensitivity in a dose-dependent manner. CONCLUSIONS: Clinicians treating elderly patients with olanzapine should be aware of the potential for rapidly developing hyperglycemia and monitor such patients accordingly.

Smoking in the nursing home: a case report and literature review.

We report a case of second- and third-degree burns in an elderly nursing home resident with dementia who was smoking in her room. This case highlights the risks of smoking by residents in long-term care settings. It also raises awareness to the issues involving smoking cessation and restriction of smoking privileges in the long-term care setting.

Nursing home resident smoking policies.

OBJECTIVE: To identify nursing home standards related to resident smoking through a nation wide survey of directors of nursing. METHODS: A national survey was distributed online and was completed by 248 directors of nursing. The directors of nurses answered questions concerning resident smoking including the criteria utilized to determine an unsafe resident smoker. For those residents identified as unsafe, the questions asked were specifically related to monitoring, staff involvement, safety precautions and policy. RESULTS: The results of the survey demonstrated a consistent policy practiced among facilities across the United States. The monitoring of nursing home residents is based on a resident's mental acuity, physical restrictions and equipment requirements. Once a resident was identified as a smoker at risk of harm to self or others, staff involvement ranged from distributing cigarettes to direct supervision. In addition, the majority of facilities required residents to wear fire resistant aprons and provided a fire extinguisher in smoking areas. CONCLUSION: Monitoring policies of nursing home residents who smoke starts with identifying those residents at risk based on an assessment of mental acuity, physical restrictions and equipment requirements. Those that are identified as being at risk smokers have their cigarettes controlled and distributed by nursing staff and are supervised by facility staff when smoking. This policy is implemented through written policy as well as staff education. Despite some discrepancies in the actual implementation of policies to supervise residents who smoke, the policies for assessment for at-risk smokers requiring monitoring is consistent on a national basis.

Serotonin syndrome in elderly patients treated for psychotic depression with atypical antipsychotics and antidepressants: two case reports.

We report two cases of serotonin syndrome in elderly patients during treatment of psychotic depression with atypical antipsychotics and antidepressants. The first case is a 69-year-old man who was admitted for depression with psychosis and treated with trazodone, risperidone, and sertraline. Subsequently, he developed myoclonus, tremor, cogwheel rigidity, and diaphoresis. The second case is a 72-year-old female initially admitted to a medical inpatient unit for a change in mental status that presented as increased confusion, lethargy, slurred speech, and a fever of 101.5 degrees. She had been on phenelzine and quetiapine. In both cases, all symptoms resolved within 24 hours of the psychotropics being stopped. In both cases, we believe that serotonin syndrome was produced by a combination of an antidepressant and an atypical antipsychotic. There have been several case reports of serotonin syndrome from similar combinations of antidepressant and atypical antipsychotic treatment. Clinicians treating elderly patients with a combination of serotonergic antidepressants and atypical antipsychotics for psychotic depression should be aware of the potential for serotonin syndrome.