Dys Sarah, Carder Paula
School of Public Health, Oregon Health and Science University-Portland State University, Portland, Oregon, USA.
Institute on Aging, College of Urban and Public Affairs, Portland State University, Portland, Oregon, USA.
Innov Aging. 2022 Aug 17;6(6):igac052. doi: 10.1093/geroni/igac052. eCollection 2022.
As-needed (PRN) antipsychotic medication use (APU) among assisted living/residential care (AL/RC) residents is a controversial health policy issue. AL/RC care staff, families, clinicians, researchers, and policymakers disagree about PRN APU to manage behavioral expressions associated with residents' dementia or cognitive impairment.
Semistructured interviews among eleven direct care staff ( = 3), licensed nurses ( = 2), administrators/executive directors ( = 4), and consultant pharmacists ( = 2) currently working in Oregon AL/RC. Using situational analysis, we identify, describe, and visualize positions and ideologies by job role to theorize PRN APU decision-making.
Three broad processes underlie APU to manage residents' behavioral expressions: justifying PRN APU, moralizing APU, and balancing local practices (eg, managing behavioral expressions, respecting individuals) with nonlocal practices (eg, professional authority). People involved in the situation of APU in AL/RC describe positive and negative justifications, and personal moral positions that frame PRN antipsychotics or nonpharmaceutical interventions as "right" or "wrong," driving various approaches to behavior management. Participants described a converse orientation between perceived level of agency within and proximity to the situation of APU. Those most closely involved, or local, to the situation of passing medications (eg, direct care staff and nurses) expressed less agency compared with nonlocal physicians and policymakers, who are not involved in the day-to-day practices within AL/RC.
This study raises practice and policy implications regarding APU in AL/RC settings. Care staff roles, ethical considerations, and perceived agency inform decision-making on whether to use antipsychotic medications. Participants described costs and benefits associated with both PRN APU and nonpharmaceutical interventions when responding to AL/RC residents' behavioral expressions. Participants' experiences emphasize the interactions across multiple levels of care. Balancing regulatory goals with resident-centered practices underscores the need for a system-level perspective, extending beyond direct care staff passing antipsychotic medications to residents.
辅助生活/寄宿护理（AL/RC）机构居民按需使用抗精神病药物（APU）是一个存在争议的卫生政策问题。AL/RC护理人员、家属、临床医生、研究人员和政策制定者对于使用PRN APU来管理与居民痴呆或认知障碍相关的行为表现存在分歧。
对目前在俄勒冈州AL/RC机构工作的11名直接护理人员（n = 3）、执业护士（n = 2）、管理人员/执行董事（n = 4）和顾问药剂师（n = 2）进行半结构化访谈。运用情境分析，我们按工作角色识别、描述并直观呈现立场和意识形态，以构建PRN APU决策的理论。
APU用于管理居民行为表现有三个主要过程：为PRN APU辩护、将APU道德化，以及平衡本地做法（如管理行为表现、尊重个体）与非本地做法（如专业权威）。参与AL/RC中APU情境的人描述了积极和消极的理由，以及将PRN抗精神病药物或非药物干预视为“正确”或“错误”的个人道德立场，这推动了各种行为管理方法。参与者描述了在APU情境中感知到的能动性水平与接近程度之间的相反取向。与不参与AL/RC日常工作的非本地医生和政策制定者相比，那些最密切参与给药情境（如直接护理人员和护士）或本地人员表现出的能动性较低。
本研究提出了关于AL/RC环境中APU的实践和政策启示。护理人员角色、伦理考量和感知到的能动性为是否使用抗精神病药物的决策提供了信息。参与者在应对AL/RC居民的行为表现时描述了PRN APU和非药物干预的成本与收益。参与者的经历强调了多层次护理之间的相互作用。在监管目标与以居民为中心的做法之间取得平衡凸显了从系统层面看待问题的必要性，这不仅限于直接护理人员给居民使用抗精神病药物。
