A sedating

Side effects (of antipsychotics, in particular) must be monitored. of Health and Human Services, 1990In accordance with regulations relating to the Omnibus Budget Reconciliation Act of 1987, drugs listed in this table are not to be used unless started before admission to a nursing home, given as a single dose for a medical or dental procedure or used for the treatment of seizures (phenobarbital)Information from Health Care Financing Administration. None of the OBRA dosage restrictions or monitoring requirements apply in patients with psychotic disorders (e.g., schizophrenia). Because facilities that do not meet HCFA's legislated requirements may be denied Medicare reimbursement,7 physicians who prescribe medications for nursing home residents must document the medical necessity of noncompliance with regulations (e.g., drug prescriptions in excess of OBRA-mandated dosages).

Barbiturates and certain other older tranquilizers may not be prescribed unless they were being used successfully before a patient was admitted to a long-term care facility In accordance with regulations relating to the Omnibus Budget Reconciliation Act of 1987, drugs listed in this table are not to be used unless started before admission to a nursing home, given as a single dose for a medical or dental procedure or used for the treatment of seizures (phenobarbital)Information from Health Care Financing Administration. Survey procedures and interpretive guidelines for skilled nursing facilities and intermediate care facilities. As a resource for physicians and facilities, a local consultant pharmacist reviews all charts monthly and assists with compliance.

Sertraline (Zoloft) and its metabolite have considerably shorter half-lives (25 and 66 hours, respectively).

Paroxetine (Paxil), which has no active metabolite, also has a considerably shorter half-life (24 hours) than fluoxetine.1213Most SSRIs are associated with significant drug interactions.

Newer antipsychotic drugs are less often associated with these side effects, but they should be used only for specific diagnoses and when behavioral and environmental measures are unsuccessful.

To combat this problem, the federal government passed nursing home reform legislation, the Omnibus Budget Reconciliation Act (OBRA) of 1987.3 This legislation is directed at protecting residents of long-term care facilities from medically unnecessary “physical or chemical restraints imposed for purposes of discipline or convenience.”3The Health Care Financing Administration (HCFA), an agency responsible for regulating nursing homes participating in the Medicare and Medicaid programs, developed interpretive guidelines for fulfilling OBRA requirements.4 These guidelines were implemented nationally in 1990 and remain in force5 Information from Health Care Financing Administration. Survey procedures and interpretive guidelines for skilled nursing facilities and intermediate care facilities. The remaining regulations apply to anxiolytic, sedative-hypnotic and antipsychotic drugs only.

Survey procedures and interpretive guidelines for skilled nursing facilities and intermediate care facilities. Medical, environmental and psychosocial causes of behavioral problems must be ruled out, and nonpharmacologic management must be attempted before psychotropic drugs are prescribed to nursing home residents.

Prescribed judiciously, psychotropic drugs can enhance the physical and psychologic well-being of the elderly.

However, altered drug disposition makes this age group particularly sensitive to undesirable side effects, which can lead to a decline in medical and functional status or the use of additional prescriptions and an increased risk of drug interactions.

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