Letters

Behaviour problems are underdocumented

No data are provided on the extent of behaviour problems among the patients studied. Previous research in similar settings suggests that a high prevalence of behaviour problems can be anticipated.^{2 3} Neuroleptic use may seem inappropriate in many cases because the behaviour had already been modified by treatment, but the nature of the study does not permit elucidation of this point.

The American legislation allows for deviation from the guidelines on antipsychotics if the prescriber can present a rationale for their use.⁴ This requires that the nature and severity of behaviour problems and response to drug treatment are carefully recorded. Although the management of disturbed behaviour is a routine part of the care process in most long term care settings, documentation of this important area is often poor.

Using a rating scale⁵ which is quick and simple to perform we assessed the prevalence and severity of behaviour disturbance in 104 patients aged 65-98 (mean 82) years in long term geriatric medical care and recorded the use of psychotropics in this group. In 52 of 76 patients tested the abbreviated mental test score was less than 6 out of 10, consistent with moderate to severe cognitive impairment. Twenty eight patients could not be scored because of severe deafness or dysphasia. Only 10 patients had no behaviour disturbance. The commonest problems identified were agitation (57 (55%) patients), nocturnal restlessness (51 (49%)), irritability (50 (48%)), and noisiness or verbal aggression (49 (47%)). Physical aggression occurred in 29 (28%) patients. In all, 46 patients (44%) were receiving one or more psychotropic medications (31 neuroleptics, 9 temazepam, 4 diazepam, 2 chlormethiazole). Of 64 patients whose behaviour disturbance was considered severe enough to cause appreciable distress to themselves, other patients, or staff, only 31 (48%) were receiving psychotropics. The use of neuroleptics was therefore higher than that found by McGrath and Jackson, but given the extent of behaviour problems identified this was not felt to be inappropriate. Indeed, some clinicians suggested that given the high prevalence of untreated behaviour disturbance there may have been underuse of psychotropics.

Documentation of behaviour problems and response to treatment in long term care settings should be routine. Without this information it is impossible to assess whether the prescription of psychotropic drugs in the nursing homes documented by McGrath and Jackson is appropriate or inappropriate.

Senior registrar in geriatric medicine Gartnavel General Hospital, Glasgow G12 0YN

Heather Cameron 

1. McGrath AM, Jackson GA. Survey of neuroleptic prescribing in residents of nursing homes in Glasgow. BMJ 1996;312:611-2. (9 March.) [Free Full Text]
2. Rovner BW, Kafonek S, Filipp L, Lucas MJ, Folstein MF. Prevalence of mental illness in a community nursing home. Am J Psychiatry 1986;143:1446-9. [Abstract/Free Full Text]
3. Chandler JD, Chandler JE. The prevalence of neuropsychiatric disorders in a nursing home population. J Geriatr Psychiat Neurol 1988;1:71-6.
4. Elon R, Pawlson LG. The impact of OBRA on medical practice within nursing facilities. J Am Geriatr Soc 1992;40:958-63. [Medline]
5. Connelly PJ. An audit of the use of antipsychotics in a geriatric psychiatry continuing care unit in Scotland. Int J Geriatr Psychiatry 1992;7:447-53.