Post by norbert1 on Jul 11, 2006 8:11:26 GMT -5
Use of benzodiazepines is scrutinized closely in nursing homes. You might want to read the following (exerpted) ----
www.alzbrain.org/quicklinks/practguide/anxiety.htm
A Short Practical Guide to Psychotropic Medications for Dementia Patients
Treatment of Anxiety
F329B pg 116 Guide to Surveyors – LTC Facilities (State Nursing home inspectors)
Prescription of anxiolytic/sedative drugs for the purpose other than sleep induction should occur only when:
1. Other possible reasons for resident distress are excluded.
2. Maintenance or improvement of function is documented.
3. Daily use is less than four continuous months unless an attempt at gradual dose reduction is unsuccessful and
4. Patient has diagnosis of: a) generalized anxiety disorder, b) organic mental syndrome with special symptoms, c) panic disorder, or d) anxiety produced by other psychiatric disorders, e.g., depression.
“A gradual dose should be attempted at least twice within one year before one can conclude that a gradual dose reduction is clinically contraindicated”
The use of long-acting benzodiazepines is STRONGLY DISCOURAGED by federal survey guidelines. Benzodiazepines with long half-lifes, e.g., 18 hours or greater, tend to accumulate in the elderly patients and these elevated blood levels produce intoxication.
Note--
---- Here, they are refering to Xanax. A mean half-life of alprazolam (Xanax) of 16.3 hours has been observed in healthy elderly subjects (range: 9.0-26.9 hours, n = 16) compared to 11.0 hours (range: 6.3-15.8 hours, n = 16) in healthy adult subjects.
In an obese group of subjects the half-life of alprazolam ranged between 9.9 and 40.4 hours (mean = 21.8 hours, n = 12)----
Benzodiazepine usage is associated with increased falls, increased gastroesophageal reflex, more confusion and deterioration of ADL function in elderly patients. These drugs are particularly toxic in demented patients. The OBRA guidelines require that skilled nursing facilities (SNF’s) attempt dose reductions after four months of continuous benzodiazepine use unless the resident has a diagnosis that allows continuous use, e.g., generalized anxiety disorder. A gradual dose reduction is needed to avoid withdrawal or increased anxiety, e.g., weeks to months. Excessively sedated patients should have a more rapid taper until alert, e.g., days to several weeks. A second dose reduction should be attempted for patients who fail to tolerate the first dose reduction.
Patients receiving long-term benzodiazepine therapy usually develop tolerance to the medication and these individuals may develop symptoms of withdrawal during dose reduction. Aprazolam, i.e., Xanax is particularly problematic for withdrawal symptoms. The treatment team must decide between dose reduction or medication continuation. Patients who have terminal illness with short life expectancy, e.g., less than 12 months, are best left on the medication with a note that justifies the usage for palliative care. Elders with a long life expectancy, e.g., two to three years, should be considered for gradual dose reduction. Benzodiazepine therapy is a legitimate component to palliative care for patients with terminal disease and these medications are commonly prescribed during the dying process. Careful use of benzodiazepines in conjunction with narcotics for the dying patient may ease the distress of dying, while not hastening the patient’s demise.
Benzodiazepine Dose Reductions
Benzodiazepine therapy is indicated for treatment of anxiety disorders that are disabling or unresponsive to psychological and behavioral interventions. Medication should improve or
sustain function. Federal regulations require attempts at dose reduction following four continuous months of therapy. Doses should be gradually tapered to avoid withdrawal symptoms. Regulations outline recommended maximum benzodiazepine doses for elderly patients (See Table 7-1). The prescription of doses that exceed OBRA recommendations require physician documentation in the medical records to justify the higher levels.
The present OBRA guidelines mandate dose reductions for sedatives and hypnotics. Antihistamines, such as Vistaril and Benadryl, can be discontinued without a taper and have no antipsychotic or hypnotic effect. Patients receiving long-term, i.e., over 2 months, benzodiazepine therapy, i.e., Xanax, Valium and Librium, should have dose reductions over weeks or months, depending on the initial dosage by reducing doses 10% per month. The symptoms of benzodiazepine withdrawal resemble alcohol withdrawal and are treated by re-institutions of benzodiazepines. When necessary, maintenance dosing of benzodiazepines for an elderly patient, should be as low as possible; e.g., Ativan - .25mg tid or qid. Brief benzodiazepine therapy (less than one month) can be tapered over several days to weeks.
www.alzbrain.org/quicklinks/practguide/anxiety.htm
A Short Practical Guide to Psychotropic Medications for Dementia Patients
Treatment of Anxiety
F329B pg 116 Guide to Surveyors – LTC Facilities (State Nursing home inspectors)
Prescription of anxiolytic/sedative drugs for the purpose other than sleep induction should occur only when:
1. Other possible reasons for resident distress are excluded.
2. Maintenance or improvement of function is documented.
3. Daily use is less than four continuous months unless an attempt at gradual dose reduction is unsuccessful and
4. Patient has diagnosis of: a) generalized anxiety disorder, b) organic mental syndrome with special symptoms, c) panic disorder, or d) anxiety produced by other psychiatric disorders, e.g., depression.
“A gradual dose should be attempted at least twice within one year before one can conclude that a gradual dose reduction is clinically contraindicated”
The use of long-acting benzodiazepines is STRONGLY DISCOURAGED by federal survey guidelines. Benzodiazepines with long half-lifes, e.g., 18 hours or greater, tend to accumulate in the elderly patients and these elevated blood levels produce intoxication.
Note--
---- Here, they are refering to Xanax. A mean half-life of alprazolam (Xanax) of 16.3 hours has been observed in healthy elderly subjects (range: 9.0-26.9 hours, n = 16) compared to 11.0 hours (range: 6.3-15.8 hours, n = 16) in healthy adult subjects.
In an obese group of subjects the half-life of alprazolam ranged between 9.9 and 40.4 hours (mean = 21.8 hours, n = 12)----
Benzodiazepine usage is associated with increased falls, increased gastroesophageal reflex, more confusion and deterioration of ADL function in elderly patients. These drugs are particularly toxic in demented patients. The OBRA guidelines require that skilled nursing facilities (SNF’s) attempt dose reductions after four months of continuous benzodiazepine use unless the resident has a diagnosis that allows continuous use, e.g., generalized anxiety disorder. A gradual dose reduction is needed to avoid withdrawal or increased anxiety, e.g., weeks to months. Excessively sedated patients should have a more rapid taper until alert, e.g., days to several weeks. A second dose reduction should be attempted for patients who fail to tolerate the first dose reduction.
Patients receiving long-term benzodiazepine therapy usually develop tolerance to the medication and these individuals may develop symptoms of withdrawal during dose reduction. Aprazolam, i.e., Xanax is particularly problematic for withdrawal symptoms. The treatment team must decide between dose reduction or medication continuation. Patients who have terminal illness with short life expectancy, e.g., less than 12 months, are best left on the medication with a note that justifies the usage for palliative care. Elders with a long life expectancy, e.g., two to three years, should be considered for gradual dose reduction. Benzodiazepine therapy is a legitimate component to palliative care for patients with terminal disease and these medications are commonly prescribed during the dying process. Careful use of benzodiazepines in conjunction with narcotics for the dying patient may ease the distress of dying, while not hastening the patient’s demise.
Benzodiazepine Dose Reductions
Benzodiazepine therapy is indicated for treatment of anxiety disorders that are disabling or unresponsive to psychological and behavioral interventions. Medication should improve or
sustain function. Federal regulations require attempts at dose reduction following four continuous months of therapy. Doses should be gradually tapered to avoid withdrawal symptoms. Regulations outline recommended maximum benzodiazepine doses for elderly patients (See Table 7-1). The prescription of doses that exceed OBRA recommendations require physician documentation in the medical records to justify the higher levels.
The present OBRA guidelines mandate dose reductions for sedatives and hypnotics. Antihistamines, such as Vistaril and Benadryl, can be discontinued without a taper and have no antipsychotic or hypnotic effect. Patients receiving long-term, i.e., over 2 months, benzodiazepine therapy, i.e., Xanax, Valium and Librium, should have dose reductions over weeks or months, depending on the initial dosage by reducing doses 10% per month. The symptoms of benzodiazepine withdrawal resemble alcohol withdrawal and are treated by re-institutions of benzodiazepines. When necessary, maintenance dosing of benzodiazepines for an elderly patient, should be as low as possible; e.g., Ativan - .25mg tid or qid. Brief benzodiazepine therapy (less than one month) can be tapered over several days to weeks.
I am no longer able to hold your hand my beloved but I cherish the remembrance of your hand in mine...and the wonderful person that touched so many lives with joy. : ) 
..alice