Mental disorders are present in a large percentage of the nursing home population.Antipsychotics, benzodiazepines and antidepressants are among the medications most commonly used to manage problem behaviors.1 Historically, antipsychotics and benzodiazepines have been used excessively (and without appropriate diagnosis or monitoring for side effects) in nursing home residents, often solely for the convenience of staff.

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Antidepressant drugs are typically underutilized in nursing homes.

Tricyclic antidepressants have many side effects and thus are not preferred medications in elderly patients.

Because treatment with psychotropic medications is indicated only to maintain or improve functional status, diagnoses and specific target symptoms or behaviors must be documented, and the effectiveness of drug therapy must be monitored.

Specific dosage limits must be observed, and periodic dosage reductions or drug discontinuations must be undertaken. of Health and Human Services, 1990OBRA restricts the use of antipsychotic drugs only in patients with dementia.

A recent review11 found that specific guidelines (on appropriate diagnosis, target symptom documentation and reasonable dosage level) were widely followed, with compliance rates ranging from 70 to 90 percent.

Less specific guidelines (on attempts to use nonpharmacologic interventions and the monitoring of drug efficacy and safety) were less well followed, with compliance rates below 55 percent.

Of particular concern are excessive sedation, anticholinergic effects (dry mouth, constipation, urinary retention, blurred near vision, tachycardia and confusion), orthostatic hypotension and electrocardiographic changes.

In elderly patients, it is better to use tricyclic antidepressants that cause less severe anticholinergic effects and orthostatic hypotension, such as nortriptyline and desipramine (Norpramin).

Studies have found that most residents of long-term care facilities receive at least one psychotropic medication. of Health and Human Services, 1990All psychotropic drugs (antidepressants, anxiolytics, sedative-hypnotics and antipsychotics) are subject to the “unnecessary drug” regulation of OBRA.