Psychotropic Medication Guidelines for Assisted Living Facilities: When to Contact Psychiatry vs. Emergency Services
Understanding Our Role: We Are NOT Crisis Workers
Psychiatric consultation services manage chronic behavioral symptoms and medication optimization over weeks to months—we do not provide emergency crisis intervention, which requires immediate ER evaluation. 1
Contact Psychiatry for:
- Chronic agitation or behavioral symptoms developing gradually over days to weeks that have not responded to non-pharmacological interventions 1
- Medication optimization for depression, anxiety, or chronic behavioral symptoms in dementia patients 1
- Routine medication reviews and deprescribing of psychotropic medications 2
- Scheduled follow-up for patients already established in psychiatric care 2
Send to Emergency Room for:
- Acute, severe agitation with imminent risk of harm to self or others requiring immediate sedation 2, 1
- New-onset confusion or delirium with acute medical instability (fever, hypoxia, severe metabolic derangement) 2
- Suicidal ideation with plan or intent 2
- Acute psychosis with dangerous behaviors that cannot be safely managed in the facility 2
- Suspected medication overdose or severe adverse drug reactions 2
- Any medical emergency requiring immediate physician evaluation (chest pain, respiratory distress, stroke symptoms, severe falls with injury) 2
Critical Timing Expectations: Psychiatric Medications Work SLOWLY
SSRIs require 4-8 weeks at adequate dosing to achieve full therapeutic effect for depression and chronic agitation. 1 Expecting rapid improvement within days is unrealistic and leads to inappropriate medication changes.
Realistic Timelines:
- SSRIs (citalopram, sertraline): 4-8 weeks for full effect on depression and chronic agitation 1
- Antipsychotics for chronic agitation: 2-4 weeks to assess response 1
- Mood stabilizers (divalproex): 2-4 weeks to reach therapeutic levels and assess efficacy 1
- Trazodone: 2-4 weeks for full anxiolytic/sedative effects 1
Do not contact psychiatry requesting medication changes before allowing adequate trial duration—premature adjustments prevent proper assessment of efficacy. 1
PRN Psychotropic Medications in Elderly Residents: Critical Safety Guidelines
PRN Benzodiazepines: AVOID in Elderly Patients
Benzodiazepines should NOT be used as first-line PRN medications for agitation in elderly residents except for alcohol or benzodiazepine withdrawal. 2, 1
Why Benzodiazepines Are Dangerous:
- Increase delirium incidence and duration 2, 1
- Cause paradoxical agitation in approximately 10% of elderly patients 1, 3
- Significantly increase fall risk (30% in real-world studies) 1
- Cause respiratory depression, especially when combined with opioids 3
- Lead to tolerance, addiction, and cognitive impairment 1
- Worsen cognitive function in dementia patients 1
Lorazepam Specific Warnings:
- Maximum initial dose: 2 mg in elderly/debilitated patients 3
- Elderly patients are more susceptible to sedative effects 3
- Risk of paradoxical reactions in elderly populations 3
- Can worsen hepatic encephalopathy 3
- Requires careful dose adjustment and frequent monitoring 3
The FDA explicitly warns that elderly or debilitated patients should have initial doses not exceeding 2 mg and require frequent monitoring with careful dose adjustment. 3
PRN Antipsychotics: Use Only for Severe, Dangerous Agitation
Antipsychotics as PRN medications should be reserved exclusively for severe agitation with imminent risk of harm to self or others after behavioral interventions have failed. 2, 1
Appropriate PRN Antipsychotic Use:
- Haloperidol 0.5-1 mg orally or subcutaneously is the preferred PRN antipsychotic for acute severe agitation 2, 1
- Maximum 5 mg daily in elderly patients 2, 1
- Use only when patient is severely agitated, threatening substantial harm, and behavioral interventions have failed 1
- Requires daily in-person evaluation to assess ongoing need 1
Critical Safety Warnings for Antipsychotics:
- Increased mortality risk 1.6-1.7 times higher than placebo in elderly dementia patients 1
- Risk of QT prolongation, sudden death, dysrhythmias, and hypotension 1
- Increased stroke risk, particularly with risperidone and olanzapine 1
- Significantly increased fall risk 2
- Extrapyramidal symptoms (tremor, rigidity, bradykinesia) 1
- Patients over 75 years respond less well to antipsychotics, particularly olanzapine 1
Approximately 47% of patients continue receiving antipsychotics after discharge without clear indication—inadvertent chronic use must be avoided through regular reassessment. 1
Medication Review and Fall Prevention
Particular attention to medication reduction should be given to residents taking four or more medications and those taking psychotropic medications, as polypharmacy significantly increases fall risk. 2
High-Risk Medications for Falls:
- All benzodiazepines (lorazepam, diazepam, alprazolam) 2, 1
- All antipsychotics (haloperidol, risperidone, quetiapine, olanzapine) 2, 1
- Anticholinergic medications (diphenhydramine, hydroxyzine, oxybutynin) 1, 4
- Pregabalin and gabapentin 5
- Hydroxyzine (sedative and anticholinergic effects persist into next day) 4
Medication Review Protocol:
- Review and modify medications, especially psychotropic medications, in long-term care settings as part of multifactorial fall prevention 2
- Reduction of medications was a prominent component of effective fall-reducing interventions 2
- Consider alternatives when possible for patients at high fall risk 5, 4
- Assess baseline fall risk before prescribing any psychotropic medication 5
Non-Pharmacological Interventions MUST Come First
Behavioral interventions must be attempted and documented as failed or impossible before initiating or adjusting psychotropic medications. 1
Systematic Investigation of Reversible Causes:
- Pain assessment and management (major contributor to behavioral disturbances) 2, 1
- Infections: urinary tract infections, pneumonia 2, 1
- Metabolic disturbances: dehydration, electrolyte abnormalities, hypoxia 2, 1
- Constipation and urinary retention 2, 1
- Medication side effects: review for anticholinergic medications worsening agitation 1
- Sensory impairments: hearing aids, glasses 1
Environmental and Communication Strategies:
- Use calm tones, simple one-step commands, gentle touch for reassurance 2, 1
- Ensure adequate lighting and reduce excessive noise 2, 1
- Provide predictable daily routines and structured activities 1
- Allow adequate time for patient to process information 1
- Use orientation aids (calendars, clocks, clear labels) 2, 1
- Maintain consistency of caregivers and minimize relocations 2, 1
Staff education programs in long-term care settings are effective components of multifactorial interventions for fall prevention and behavioral management. 2
When Medications Are Necessary: Preferred Options
For Chronic Agitation Without Psychotic Features:
SSRIs are first-line pharmacological treatment: 1
- Citalopram: Start 10 mg/day, maximum 40 mg/day 1
- Sertraline: Start 25-50 mg/day, maximum 200 mg/day 1
- Assess response after 4 weeks at adequate dose 1
- If no clinically significant response after 4 weeks, taper and withdraw 1
For Severe Agitation With Psychotic Features:
Risperidone is preferred over other antipsychotics: 1
- Start 0.25 mg once daily at bedtime 1
- Target dose 0.5-1.25 mg daily 1
- Use lowest effective dose for shortest duration 1
- Attempt taper within 3-6 months 1
Alternative Options:
- Quetiapine: Start 12.5 mg twice daily, maximum 200 mg twice daily (more sedating, risk of orthostatic hypotension) 1
- Trazodone: Start 25 mg/day, maximum 200-400 mg/day (use caution with cardiac history) 1
Medications to AVOID in Elderly Residents
The following medications should NOT be prescribed or continued in elderly assisted living residents: 1, 6
Absolutely Avoid:
- Typical antipsychotics as first-line (haloperidol, fluphenazine, thiothixene): 50% risk of tardive dyskinesia after 2 years 1
- Benzodiazepines for routine agitation management (except alcohol/benzodiazepine withdrawal) 1
- Anticholinergic medications: diphenhydramine, hydroxyzine, oxybutynin, cyclobenzaprine (worsen confusion and agitation) 1, 4
- Propoxyphene 6
- Ticlopidine 6
Required Documentation Before Psychiatric Consultation
To facilitate efficient consultation, provide the following information:
Current Situation:
- Specific description of behavioral symptoms (not just "agitated"—describe exact behaviors) 1
- ABC charting: Antecedent-Behavior-Consequence over several days 1
- Timing and triggers of symptoms 1
- Duration of current symptoms (days vs. weeks vs. months) 1
Medical Workup Completed:
- Recent vital signs including orthostatic blood pressure 2
- Recent labs (CBC, CMP, urinalysis) to rule out infection and metabolic causes 2, 1
- Pain assessment and current pain management 1
- Bowel and bladder function status 2, 1
Non-Pharmacological Interventions Attempted:
- Specific environmental modifications tried 1
- Communication strategies implemented 1
- Duration of behavioral intervention trial 1
Current Medications:
- Complete medication list with doses and frequencies 1
- Duration of current psychotropic medications 1
- Recent medication changes 1
- PRN medication use frequency over past week 1
Monitoring Requirements for Residents on Psychotropic Medications
Facilities must monitor residents on psychotropic medications for the following:
Regular Assessments:
- Falls risk assessment at each visit 5, 4
- Gait and balance evaluation 5, 4
- Orthostatic vital signs 2, 4
- Extrapyramidal symptoms (tremor, rigidity, bradykinesia) 1
- Cognitive function changes 1
- Sedation level 1
Medication-Specific Monitoring:
- Antipsychotics: ECG for QTc prolongation, metabolic changes (weight, glucose, lipids), movement disorders 1
- SSRIs: Hyponatremia risk, GI symptoms, sleep disturbances 1
- Benzodiazepines (if unavoidable): Respiratory rate, sedation level, paradoxical agitation 3