Psychoactive Medications for Residents With Dementia in California Care Homes

Medications that act on mood, thinking or behavior are called psychoactive or psychotropic. They include antipsychotics, anti-anxiety drugs, sleep aids and antidepressants. This page is about the rules around them in a care home. Whether any drug is right for your parent is a question for the prescribing doctor and the pharmacist.

The Alzheimer's Association states that non-drug approaches should always be tried first, and that medication may be considered when those approaches have not worked after being used consistently, mainly for severe symptoms or a risk of harm. It reports that antipsychotics are associated with an increased risk of stroke and death in older adults with dementia, and that the Food and Drug Administration requires a boxed warning on them about those risks.

Its position is direct: antipsychotic medications should not be used to sedate or restrain persons with dementia. It describes their use as appropriate only in limited situations, such as when symptoms are due to mania or psychosis, present a danger to the person or others, or cause inconsolable distress.

Not the care home. Assisted living communities and board and care homes are licensed in California as residential care facilities for the elderly (RCFEs), and they are non-medical. Title 22, section 87465, has the home assist residents with self-administered medications. A physician or other prescriber orders the drug. Our guide to medication management in assisted living explains assistance, storage and records.

The decision to accept a medication belongs to the resident. The personal rights regulation gives every resident the right to receive or reject medical care. When a person can no longer make that decision, who decides for them depends on documents such as an advance health care directive or a conservatorship. That is a legal matter, and an elder law attorney or the Long-Term Care Ombudsman can explain it for your family's situation.

What the home owes the doctor is accurate information. When staff see behavior that could cause harm, the reappraisal rule requires them to record what happened just before it and to use the least restrictive intervention. A prescriber who hears only "she was agitated" has less to work with than one who hears what set it off. See sundowning and behavior changes.

This is where assisted living differs from a nursing home, and where families are often given the wrong answer.

California does have a detailed consent law for these drugs. Health and Safety Code section 1599.15 requires the prescriber to personally examine the resident and obtain informed written consent from the resident or the resident's representative before prescribing a psychotherapeutic drug. The prescriber must explain non-drug approaches, any boxed warning, and whether the use is approved by the Food and Drug Administration. But that section defines a resident as a person in a skilled nursing facility or an intermediate care facility. It does not cover RCFEs.

The RCFE rules we read protect the resident in other ways: the right to refuse, the ban on forcing or hiding medication, the physician's order needed for every as-needed dose, staff training, and the abuse law described below. So in assisted living, ask the prescriber, not only the home, to tell you before a new medication is started, and put that request in writing.

Yes. Title 22, section 87465, says that assisting with self-administration does not include forcing a resident to take medication, hiding or camouflaging medication in other substances without the resident's knowledge and consent, or otherwise infringing on the resident's right to refuse to take a medication.

The regulation makes no exception for a resident with dementia. A refusal is also information the doctor needs. Ask a home what its caregivers do, in practice, when a resident says no, and how soon the prescriber and the family hear about it.

More on residents' rights in general is in RCFE resident rights in California.

California's elder abuse law draws the line. Welfare and Institutions Code section 15610.63 defines physical abuse to include the use of a physical or chemical restraint or psychotropic medication in any of these conditions:

• For punishment.
• For a period beyond that for which the medication was ordered by a California-licensed physician who is providing the person's medical care.
• For any purpose not authorized by the physician.

As-needed medications deserve a close look, because they are given at the moment of a behavior. Title 22 requires a physician's signed, dated order for each one, stating the specific symptoms, the exact dose, the minimum hours between doses and the maximum doses in 24 hours. When a resident can neither judge the need nor describe symptoms clearly, staff must contact the physician before each dose.

If you believe a resident is being drugged for convenience or punishment and is in immediate danger, call 911. Complaints about a licensed home go to California's Community Care Licensing Division, which takes them by phone, email and online.

California law names the subject more than once. Every direct care worker's training must cover dementia care, including the use and misuse of antipsychotics and the adverse effects of psychotropic drugs used to control the behavior of persons with dementia, along with non-drug, person-centered approaches. The dementia regulation, section 87705, adds training in recognizing the effects of medications commonly used to reduce behavior.

Staff who assist with medications have separate training under Health and Safety Code section 1569.69. Its required topics include the adverse effects of psychotropic drugs used to control behavior in dementia and the increased risk of death when older residents with dementia are given antipsychotic medications. The wider set of rules is in California's dementia care rules.

Bring the current medication list to every conversation, and ask for a copy whenever it changes. Then ask:

• To the home: what do you try before you call the doctor about a behavior?
• To the home: who do you call, and will you call me at the same time?
• To the home: may I see the record of as-needed doses and what led to each one?
• To the home: what do your caregivers do when a resident refuses a pill?
• To the doctor: what is this medication for, and is that use approved?
• To the doctor: does it carry a boxed warning, and what should we watch for?
• To the doctor: when will you review whether it is still needed?

Hamssa Benrekia is a senior living placement specialist in Torrance with a background in hospice, palliative care and home health, and she holds an RCFE Administrator Certificate. She helps families in the South Bay and Harbor area of Los Angeles County compare licensed homes and asks about medication practices on tours. She does not give medical advice. To talk about memory care placement, contact Hamssa. The California Assisted Living Placement Guide covers the other steps.