Medications prescribed by specialists in nursing homes.

The existence of specialty prescribers is challenging. Multiple prescribers have been identified as a risk factor for treatment with medications considered to be “inappropriate.” The use of “inappropriate” medications, in turn, has been associated with adverse outcomes such as hospitalization and death. In my experience, specialty prescribed medications include muscle relaxants for spasticity induced by upper motor neuron lesions (tizanidine, baclofen, and dantrolene), antiseizure medications (phenobarbital, carbamazepine, phenytoin), and the anti-arrhythmic (amiodarone). Other examples include immunomodulating agents for rheumatoid arthritis and psychiatric medications. Primary physicians may be uncomfortable determining if these “specialty” medications are indicated or the lowest effective dose. Unfortunately, office-based specialty consultants may not be aware of the “big picture.” The urology consultant may focus on a single problem such as urge incontinence and give little attention to systemic anticholinergic effects. The neurology consultant may advance the dose of medications for Parkinson’s disease in an effort to maintain ambulation without awareness of hallucinations and agitation triggered by the medications. Psychiatry consultants vary considerably in training, experience, and approach to frail residents with multiple medical problems. A psychiatrist with an outpatient practice managing major psychiatric illness will have difficulty projecting outpatient approaches to nursing home residents. Behaviors such as crying, apathy, fear, anger, or hallucinations are often triggered by delirium, focal brain disease, and/or dementia rather than major psychiatric illness such as depression or schizophrenia. The psychiatrist is often consulted to manage agitation (shouting, aggression). Psychiatrists who practice in multidisciplinary settings are expected to prescribe medications. Unfortunately, there are no Food and Drug Administration (FDA)-approved medications for this indication. The beststudied medications, the atypical antipsychotics, have limited efficacy and are associated with greater mortality.