Commentary

Psychotropic drugs should be used with care in the elderly because of adverse side effects including sedation, and undesirable interactions with medications for physical ilnesses. SMPA treatment guidelines for prescribing psychotropic drugs in the demented elderly were distributed in 1994 to all Swedish physicians, recommending minimal use of antipsychotics, certain benzodiazepines, and tricyclic antidepressants with anticholinergic properties. Schmidt et al examine the effect of the guidelines, thus extending various uncontrolled studies of psychotropic drug use in NHs in the US.¹

The authors had to contend with different sizes of NH facilities and changes in residents. Firstly, despite randomisation, experimental NHs were smaller than control NHs (mean 51 v 80 beds). Even where staff:resident ratios are equivalent, if all staff members care for all residents then home size necessarily affects the quality of social interactions. Such psychosocial factors contribute to behavioural and mental health problems. Secondly, there was a 10.2% reduction in experimental NH residents by 12 months compared with a 1.2% increase in control NH residents. Death rate or endpoint data by diagnostic category or functional status were not provided. Resident turnover may affect prescribing practice because those who died or moved home could also be those maintained on the older, non-recommended drugs; deaths can upset staff and residents, potentially increasing behavioural or mental health problems; and new residents may have been admitted because of behavioural or mental health problems.²

Education and support are necessary for NH staff members to implement non-medication interventions for behavioural and mental health problems,³ and passive dissemination of guidelines tends not to change professional practice.⁴ Schmidt et al show that externally facilitated casereviews involving a pharmacist trained in communication skills, problem solving, and staff support are more successful than written guidelines alone.