@Copyright 2014, Jennifer Hardesty.
All right reserved. 1
Medications: Friend or Foe?
The role of medications in both caus...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 2
Objectives
To identify various medications that can
contribute t...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 3
Organic Causes of Cognitive/Behavior Changes
Medical Conditions:...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 4
Psychiatric Disorders
Depression
• Symptoms include
either a dep...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 5
Iatrogenic Causes
From outside influences
Alcohol/drug
intoxicat...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 6
Preventable Adverse Drug Events
Incidence of ADRs in high risk s...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 7
Prevalence of Delirium in the Elderly
Common in hospitalized old...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 8
Dementia, Depression, and Delirium
Depression Dementia Delirium
...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 9
Case Study: AD
AD is an 89 year old woman residing in your SNF f...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 10
Can you name any medications that may
cause cognition or behavi...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 11
Anti-Parkinsonian Drugs
Anti-Parkinson’s drugs, besides causing...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 12
Urinary Incontinence Agents
oxybutnin, tolterodine, trospium, e...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 13
Medications with anti-cholinergic properties
Antidepressants
Am...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 14
Emptying Drugs (GI Drugs)
GI antispasmodics
• Dicyclomine
• Hyo...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 15
H-2 Receptor Blockers
Cimetidine is most common offender
• Conf...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 16
NSAIDs
Aspirin toxicity:
Delirium is the major manifestation
In...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 17
Anxiolytics
Long-acting benzodiazepines (diazepam, chlordiazepo...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 18
1st Generation Antihistamines (diphenhydramine, brompheniramine...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 19
Untreated pain itself can cause delirium
Narcotics
Drugs
• Mepe...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 20
All anticonvulsants can affect cognition, even in the
presence ...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 21
Medication-Related Problems Can Occur at ANY Time!
When Are Med...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 22
What medications could contribute to her confusion?
HCTZ 25mg Q...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 23
Managing Cognitive and Behavioral Problems
Investigating the Ca...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 24
When control is needed to prevent harm and to allowWhen control...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 25
Acute Situations/Emergency
“Acute onset or exacerbation of symp...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 26
Pharmacological Management
When control is needed to prevent ha...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 27
Inadequate Indications for Antipsychotic Use:
• Wandering
• Poo...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 28
Investigator’s Review of Medication Management
Surveyors are in...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 29
CMS State Operations Manual: Medication Management
Medication M...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 30
Adverse Consequences: Identification
Medication review should b...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 31
Your Pharmacy Provider Service Team
• Pharmacists
• Technicians...
@Copyright 2014, Jennifer Hardesty.
All right reserved. 32
Bowen JD, Larson EB. Drug-induced cognitive impairment. Definin...
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Medication Friend or Foe - Jennifer Hardesty

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Presentation made May 6, 2014 by Jennifer Hardesty at live webinar:
http://worldeventsforum.blogspot.com/p/mel-ive-event-to-be-held-tuesday-may-6.html

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Medication Friend or Foe - Jennifer Hardesty

  1. 1. @Copyright 2014, Jennifer Hardesty. All right reserved. 1 Medications: Friend or Foe? The role of medications in both causing and curing behavior and cognition problems Jennifer Hardesty, PharmD, FASCP Director of Clinical Services, Remedi SeniorCare Jennifer.Hardesty@RemediRx.com Could These Behaviors Be a Result of a Medication?  Altered Cognition  Confusion  Aggression  Negative Behaviors
  2. 2. @Copyright 2014, Jennifer Hardesty. All right reserved. 2 Objectives To identify various medications that can contribute to cognitive impairment and behavioral symptoms in the older individual. To educate on appropriate interventions to address behavioral/cognitive problems in the elderly. To review the implications these medications and resultant behaviors have in relation to regulatory guidance. Risk vs. Benefits of Medications Medications can cause problems, even if used correctly! MEDICATION BENEFITS • When used correctly, medications can lead to: • Better life quality • Healthier life • Longer life MEDICATION RISKS • Unwanted or unexpected effects may occur • Mild adverse effect: • upset stomach • dry mouth, nausea • Serious adverse effects: • organ damage • coma • CNS adverse effects: • Sedation • Confusion • Agitation/aggression • Psychosis
  3. 3. @Copyright 2014, Jennifer Hardesty. All right reserved. 3 Organic Causes of Cognitive/Behavior Changes Medical Conditions: • Infections: • UTI • Pneumonia • Sepsis • Stroke, hemorrhage • Metabolic derangements: • electrolytes • dehydration • hyper/hypoglycemia • hyper/hypothyroid • hypoxia • CV disease: • hypotension • MI • hypertensive crisis Psychiatric Disorders • Dementia • Depression • Anxiety • Schizophrenia • Psychosis DementiaDementia is progressive deterioration in Intellectual function Memory/Recognition Language Executive function/skilled motor activities Visuospatial ability  leading to a decline in the ability to perform activities of daily living. Changes in Behavior & Activity Level • Isolation/ social withdrawal/ Decreased interest • Difficulty with decision making • Problems concentrating • Unexplained anger • Anxiety • Aggression/Agitation • Sleep difficulties • Changes in appetite
  4. 4. @Copyright 2014, Jennifer Hardesty. All right reserved. 4 Psychiatric Disorders Depression • Symptoms include either a depressed mood or loss of interest, PLUS: • Weight Changes, sleep changes • Behavior that is agitated or slowed down. • Fatigue • Thoughts of worthlessness or extreme guilt • Problems concentrating or making decisions • Thoughts of death or suicide • The person's symptoms are a cause of great distress or difficulty in functioning at home, work, or other important areas. Anxiety • Excessive anxiety and worry about a variety of events and situations. • Struggle to gain control, relax, or cope with the anxiety and worry • Feeling wound-up, tense, or restless • Easily fatigued or worn-out • Concentration problems • Irritability • The symptoms cause "clinically significant distress" or problems functioning in daily life. Schizophrenia • Delusions • Hallucinations • Disorganized speech • Grossly disorganized or catatonic behavior • Negative symptoms: • low levels of interest • motivation • mental activity • social drive • speech Psychosis • Psychosis can be a symptom of mental illness, but it is not a mental illness in its own right • hallucinations or delusional beliefs • personality changes • disorganized thinking • unusual or bizarre behavior • impairment in activities of daily living Causes of Cognitive Changes OrganicCauses Dementia Psychiatric Disorders Depression Anxiety Schizophrenia IatrogenicCauses Predictable drug side effects Alcohol or illicit drug intoxication Medications-Adverse Drug event
  5. 5. @Copyright 2014, Jennifer Hardesty. All right reserved. 5 Iatrogenic Causes From outside influences Alcohol/drug intoxication or withdraw Poisons Anesthesia • Sedation • Confusion • Agitation Sensory deprivation/E nvironment Medications • Numerous CNS side effects Adverse Drug Reactions Any noxious, unintended, and undesired effect of a drug which occurs at doses used in humans for prophylaxis, diagnosis or therapy Adverse Drug Reactions (ADRs) 36% of all reported adverse drug events involve an elderly patient Elderly are at Greater Risk for ADR’s: • Multiple chronic diseases • Multiple prescribers • Multiple medications • Types of medications prescribed • Under-representation in clinical trials, particularly those over age 75
  6. 6. @Copyright 2014, Jennifer Hardesty. All right reserved. 6 Preventable Adverse Drug Events Incidence of ADRs in high risk seniors (=>5 Rxs) • 35% experienced ADR • 95% of ADRs were predictable • 63% required MD intervention • 11% required hospitalization Psychoactive drugs and anticoagulants are the most common medications associated with preventable adverse drug events -oversedation, confusion, hallucinations, delirium, falls and bleeds Signs / Symptoms of Delirium: • Restlessness, agitation • Memory deficit • Drowsiness, poor attention span • Wandering • “Picking” at the air/clothes... • Hallucinations Types of delirium: • Hyperactive delirium: agitation, anxiety state • Hypoactive delirium: lethargy, excess somnolence, sluggish • Mixed delirium: symptoms of both Medications = Most common causes of delirium 22-39% of all cases Drug-Induced Delirium A clinical state characterized by an acute, fluctuating change in mental status, with inattention and altered levels of consciousness.
  7. 7. @Copyright 2014, Jennifer Hardesty. All right reserved. 7 Prevalence of Delirium in the Elderly Common in hospitalized older adults: Emergency 10% - 30% Post-operatively up to 50% Cardiac Surgery 17 - 73% Post Hip Fracture 35% - 65% General Medicine 11% - 26% Known Dementia 32% - 89% Course: Can be quite variable Prevalence: Typical: 10-12 days Range: 1-8 weeks Lasting > 30 days: 15% Increased Risk: Longer LOS, LTC Risk factors for Delirium Risk factors include: • Advanced old age • Underlying dementia • Functional impairment • Multiple medical problems • Polypharmacy • Renal impairment
  8. 8. @Copyright 2014, Jennifer Hardesty. All right reserved. 8 Dementia, Depression, and Delirium Depression Dementia Delirium Onset Usually within a period of weeks Slow, insidious, over a period of months/years Abrupt, may be within hours or days Symptoms Pervasive sadness or loss of pleasure, plus somatic signs Gradual decline in functioning, including recent memory loss and word finding difficulty Fluctuation in consciousness and attention Possible hallucinations, delusions, disorientation Course Episodic, treatable, resolvable Progressive, manageable Treatable, usually resolvable Facility Staff Nurse Family Pharmacist MD/NP Resident Consultant TEAMWORK is needed to help identify and resolve cognitive and behavioral problems!
  9. 9. @Copyright 2014, Jennifer Hardesty. All right reserved. 9 Case Study: AD AD is an 89 year old woman residing in your SNF for 2 weeks. She is recovering from knee replacement surgery. Two days ago she was not communicating as clearly as usual with nursing staff, and after further investigation was found to have a UTI. PMH: • Mild dementia • DM Type 2 • HTN, CHF • Osteoporosis • S/P knee replacement Current medications include: • HCTZ 25mg QD • Digoxin 0.25mg QD • Lisinopril 20mg QD • Metoprolol XL 50mg QD • Tolterodine LA 4mg QD • Amitriptyline 25mg HS for restless legs • Cipro 500 mg BID x 10 days • Metformin 500mg BID • Zolpidem 5mg HS prn sleep • Diphenhydramine 50mg PRN itchy rash Today she is acting very confused and does not recognize her son who visits in the morning. She does claim to see her husband and speaks with him while she is in her room, although he had passed away several years ago. Can you assess this situation? Drugs Associated with Adverse Cognitive Effects “Medicine sometimes snatches away health, sometimes gives it.” ~Ovid, Tristia "Any symptom in an elderly patient should be considered a drug side effect until proved otherwise.” J Gurwitz, M Monane, S Monane, J Avorn Brown University Long-term Care Quality Letter 1995
  10. 10. @Copyright 2014, Jennifer Hardesty. All right reserved. 10 Can you name any medications that may cause cognition or behavior problems? Medications Associated with Cognitive Impairment ‘ACUTE CHANGE IN MS’ Initial Drug Class A Antiparkinsonian drugs C Cardiovascular drugs U Urinary incontinence drugs T Theophylline E Emptying drugs C Corticosteroids H H2-blockers A Antimicrobials N NSAIDs G Geropsychiatric drugs E ENT drugs I Insomnia drugs N Narcotics M Muscle relaxants S Seizure drugs
  11. 11. @Copyright 2014, Jennifer Hardesty. All right reserved. 11 Anti-Parkinsonian Drugs Anti-Parkinson’s drugs, besides causing psychotic symptoms, have also been linked to mood symptoms, even at therapeutic doses. Levodopa: About 5% of patients develop delirium from the use of this drug Cognitive symptoms occur in up to 60% of patients • Isolated hallucinations while maintaining a clear state of consciousness • Abnormal dreaming and sleep disturbances may be early signs Selegiline, dopamine agonists, amantadine: Visual hallucinations, delusions, depression Anticholinergics: (eg, trihexyphenidyl, benztropine): confusion and delirium Cardiovascular Drugs Antiarrhythmics Disopyramide : Fatigue, nervousness, confusion Digoxin Confusion, delirium, hallucinations, anxiety Antihypertensives: (5-10% incidence in normal population) Beta-Blockers: Depression, delirium, confusion, psychosis Clonidine: Depression, delirium, psychosis, hallucinations Methyldopa: May exacerbate depression or anxiety in elderly patients Amiodarone: long half-life may promote prolonged confusion or memory problems Diuretics: can cause fluid and/or acid- base imbalances, which can result in confusion, especially in the postoperative patient
  12. 12. @Copyright 2014, Jennifer Hardesty. All right reserved. 12 Urinary Incontinence Agents oxybutnin, tolterodine, trospium, etc. Elderly have increased sensitivity to anticholinergic effects, resulting in: • Confusion/Delirium • Xerostomia • Constipation • Urinary Retention Anticholinergic drugs have been linked to memory impairment, changes in consciousness, and even decreases in ADLs/IADLs Anticholinergic Drugs • Total burden of anticholinergic drugs may determine the development of delirium, rather than any single agent. • The total burden of anticholinergic medications is the sum of the anticholinergic activity of all the drugs a patient is consuming.
  13. 13. @Copyright 2014, Jennifer Hardesty. All right reserved. 13 Medications with anti-cholinergic properties Antidepressants Amitriptyline Desipramine/Imi pramine Doxepin Antipsychotics Olanzapine Clozapine Antihistamines Diphenhydramin e Hydroxyzine Meclizine OTC antihistamines Prochlorperazin e Scopolamine Narcotics Urinary Incontinence Oxybutynin Toleterodine Muscle Relaxants Cyclobenzaprine Carisoprodol Others Ipatropium Captopril Furosemide Nifedipine Cimetidine/Ranit idine Theophylline Warfarin Glycopyrrolate Theophylline Adverse effects usually occur in high dose or overdose situations: • Insomnia • Anxiety • Agitation
  14. 14. @Copyright 2014, Jennifer Hardesty. All right reserved. 14 Emptying Drugs (GI Drugs) GI antispasmodics • Dicyclomine • Hyoscyamine Metoclopramide Confusion, lethargy, delirium, hallucinations (rare) High risk of cognitive toxicity due to: • High anticholinergic activity • Dopaminergic activity Symptoms occur in approximately 18% of patients on high doses of corticosteroids Corticosteroids can induce mental status changes Corticosteroids Risks include: • Use of high-dose steroids (> 80 mg/day of prednisone) • Long duration of use • Abrupt discontinuation Appear as a variety of mental status changes: • depressive symptoms • manic symptoms • paranoid-hallucinations • psychosis
  15. 15. @Copyright 2014, Jennifer Hardesty. All right reserved. 15 H-2 Receptor Blockers Cimetidine is most common offender • Confusion • Depression • Delusions/Psychosis • Aggression or Mania Predisposing factors include: • High doses, older age • Pre-existing psychiatric illness • Poor renal function • Simultaneous treatment with psychotropic medications Cimetidine, ranitidine, famotidine Risk factors include sepsis, renal impairment, high doses Antimicrobials Cephalosporins/Penicillins: • Delusions,hallucinations, agitation, confusion Aminoglycosides: • Confusion, hallucinations Fluoroquinolones • Confusion, agitation, depression, hallucinations, paranoia,
  16. 16. @Copyright 2014, Jennifer Hardesty. All right reserved. 16 NSAIDs Aspirin toxicity: Delirium is the major manifestation Indomethacin: Depression and delirium Naproxen/Ibuprofen: Disturbances in memory and concentration (low risk; usually occurs at high doses). Celecoxib: Confusion, anxiety Geropsychiatric Drugs Antidepressants • Tricyclic Antidepressants: (Amitriptyline, Imipramine) • Delirium, disorientation, and memory impairment • Highly anticholinergic properties • Fluoxetine • Long half-life of drug • Anxiety, sleep disturbances, and increasing agitation • Venlafaxine • Nervousness, Agitation Antidepressant Medication Anticholinergic Activity Amitriptyline 4 Trimipramine 4 Doxepin 3 Imipramine 3 Nortriptyline 2 Phenelzine 2 Tranylcypromine 2 Selegiline 2 Desipramine 1 Paroxetine 1 Duloxetine 1 Venlafaxine 1 Mirtazapine 1 Citalopram 0 Escitalopram 0 Fluoxetine 0 Fluvoxamine 0 Sertraline 0 Bupropion 0 Trazodone 0 Lexicomp Drug Information Handbook, 2008
  17. 17. @Copyright 2014, Jennifer Hardesty. All right reserved. 17 Anxiolytics Long-acting benzodiazepines (diazepam, chlordiazepoxide, flurazepam, chlordiazepoxide) • Long half-life in elderly patients (often several days) • Produce prolonged sedation and increase risk of falls and fractures Short- and intermediate-acting benzodiazepines preferred All benzodiazepines have been associated with: • impaired learning of verbal and visual information • immediate and delayed memory • psychomotor performance Geropsychiatric Drugs Antipsychotics • Sedation • Confusion • Delusions • Personality Changes • Traditional and some newer antipsychotics possess anticholinergic properties Lithium • May impair memory and psychomotor performance • Sedation and confusion • Associated with the development of delirium at high serum levels Geropsychiatric Drugs
  18. 18. @Copyright 2014, Jennifer Hardesty. All right reserved. 18 1st Generation Antihistamines (diphenhydramine, brompheniramine ) • Potent anticholinergic effects • Sedation • Constipation • Confusion Anticholinergic OTC Medications: • Cough/cold products with antihistamines • Sleep aids Oral Decongestants (pseudoephedrine, phenylephrine) • Anxiety, nervousness, hallucinations ENT Drugs Insomnia drugs Sedative-hypnotics (zolpidem/zaleplon) • Confusion • Abnormal thinking • Behavior changes • Aggression/agitation • Hallucinations Barbiturates (secobarbital, pentobarbital) • Confusion, agitation, hallucinations • Cause more adverse effects than other sedative or hypnotic drugs Tylenol-PM (diphenhydramine)
  19. 19. @Copyright 2014, Jennifer Hardesty. All right reserved. 19 Untreated pain itself can cause delirium Narcotics Drugs • Meperidine: – Accumulation of normeperidine, a neurotoxic substance – fluctuations in levels of awareness, confusion, disorientation, hallucinations, delusions • Pentazocine: – Causes confusion and hallucinations more commonly than other narcotic drugs • Opioids – Probably the most important cause of delirium in postoperative patients – Renal impairment = accumulation of metabolites Withdraw effects Muscle Relaxants Muscle Relaxants • Cyclobenzaprine, methocarbamol, carisoprodol metaxalone Anticholinergic adverse effects: • Sedation • Confusion • Weakness • Hallucinations
  20. 20. @Copyright 2014, Jennifer Hardesty. All right reserved. 20 All anticonvulsants can affect cognition, even in the presence of therapeutic drug levels Seizure Drugs Phenytoin • Confusion, mood changes, lethargy at high serum levels • In elderly patients with low albumin, a therapeutic level of phenytoin may also be toxic. Carbamazepine • Sedation • Confusion Valproic Acid: • Nervousness, • Confusion, abnormal thinking Topiramate: • Memory impairment and confusion • Cognitive and motor slowing Others Diabetes medications • Reversible and irreversible brain damage secondary to hypoglycemia • Chlorpropamide- long half-life in elderly patients and could cause prolonged hypoglycemia Herbal Products • St. John's Wort  mania, anxiety • Melatonin confusion, sedation
  21. 21. @Copyright 2014, Jennifer Hardesty. All right reserved. 21 Medication-Related Problems Can Occur at ANY Time! When Are Medication-Related Problems Most Likely to Occur? • New drug is added • Change of dose (higher or lower) • Drug discontinued • With alcohol or illicit drugs • Taking multiple sedating drugs or CNS active drugs Case Study: AD AD is an 89 year old woman residing in your SNF for 2 weeks. She is recovering from knee replacement surgery. Two days ago she was not communicating as clearly as usual with nursing staff, and after further investigation was found to have a UTI. PMH: • Mild dementia • DM Type 2 • HTN, CHF • Osteoporosis • S/P knee replacement Current medications include: • HCTZ 25mg QD • Digoxin 0.25mg QD • Lisinopril 20mg QD • Metoprolol XL 50mg QD • Tolterodine LA 4mg QD • Amitriptyline 25mg HS for restless legs • Cipro 500 mg BID x 10 days • Metformin 500mg BID • Zolpidem 5mg HS prn sleep • Diphenhydramine 50mg PRN itchy rash Today she is acting very confused and does not recognize her son who visits in the morning. She does claim to see her husband and speaks with him while she is in her room, although he had passed away several years ago. What Medications Could be Contributing?
  22. 22. @Copyright 2014, Jennifer Hardesty. All right reserved. 22 What medications could contribute to her confusion? HCTZ 25mg QD Digoxin 0.25mg QD Lisinopril 20mg QD Metoprolol XL 50mg QD Tolterodine LA 4mg QD Amitriptyline 25mg HS for restless legs Cipro 500 mg BID x 10 days Metformin 500mg BID Zolpidem 5mg HS prn sleep Diphenhydramine 50mg PRN itchy rash Resource for Appropriate and ‘Inappropriate’ Medication Therapy http://www.cms.hhs.gov/manuals/downloads/som107ap_pp_guidelines_ltcf.pdf F329: Unnecessary Drugs TABLE I: MEDICATION ISSUES OF PARTICULAR RELEVANCE
  23. 23. @Copyright 2014, Jennifer Hardesty. All right reserved. 23 Managing Cognitive and Behavioral Problems Investigating the Cause! Organic Disorders • Dementia • Psychiatric Disorders • Depression • Anxiety • Schizophrenia • Psychosis Iatrogenic Problems • Adverse Drug Events • Delirium Managing Drug-Related Delirium & CNS- Related Adverse Drug Events Basic principles: – Identifying and treating/removing acute precipitants – Supportive and restorative care – Controlling disruptive behaviors with a minimum of chemical or physical restraint Non-pharmacological Management Provide general supportive measures: • Avoid restraints • Encourage familiar faces for reassurance • Low stimulation - avoid excessive noise • Provide orientation (calendar, clock)
  24. 24. @Copyright 2014, Jennifer Hardesty. All right reserved. 24 When control is needed to prevent harm and to allowWhen control is needed to prevent harm and to allow evaluation and treatment, psychotropic medications may be required. Pharmacological Management Indications for pharmacologic treatment: • Aggression • Risk of harm to self or others • Hallucinations • Inconsolable or Persistent Distress (e.g., fear, continuously yelling, screaming, end-of-life distress, or crying); • Significant decline in function Must seek the underlying cause of distressed behavior before or while treating the symptom Pharmacological Management Prescribing Principles: • Use a SINGLE medication • Start with a low dose. • Choose a drug with low anticholinergic activity • Stop the medication as soon as possible • Continue to use Non-Pharmacological interventions
  25. 25. @Copyright 2014, Jennifer Hardesty. All right reserved. 25 Acute Situations/Emergency “Acute onset or exacerbation of symptoms, or immediate threat to health or safety of resident or others” • Acute treatment period limited to 7 days • Clinician and IDT must reevaluate and document situation within 7 days, and define continuing need • Non-drug therapies are attempted beyond the emergency period http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and- Regions-Items/Survey-and-Cert-Letter-13-35.html Part of all medication treatment = Non-pharmacological approaches Non-Drug Therapy Requirements Examples of non-pharmacological interventions may include: • Identifying, addressing, and eliminating or reducing underlying causes of distressed behavior • Developing interventions that are specific to resident’s interests, abilities, strengths and needs • Minimize distractions or overstimulated environment • Using sleep hygiene techniques and individualized sleep routines • ↑ exercise or therapy • Massage, hot/warm or cold compresses • Enhancing the taste and presentation of food • Music therapy
  26. 26. @Copyright 2014, Jennifer Hardesty. All right reserved. 26 Pharmacological Management When control is needed to prevent harm and to allow evaluation and treatment, psychotropic medications may be required. Indications for pharmacologic treatment: • Aggression • Agitation • Risk of harm to self or others • Hallucinations • Inconsolable or Persistent Distress (e.g., fear, continuously yelling, screaming, distress associated with end-of-life, or crying); • Significant decline in function Must seek the underlying cause of distressed behavior before or while treating the symptom. Behavioral symptoms must be reevaluated periodically to determine the effectiveness of the antipsychotic and the potential for reducing or discontinuing Requirements for Enduring Use of Antipsychotics Target behavior must be clearly and specifically identified and monitored objectively and qualitatively Ensure the behavioral symptoms are:  A. Not due to a medical condition or problem that can be expected to improve or resolve  B. Persistent or likely to reoccur without continued treatment; and  C. Not sufficiently relieved by non-pharmacological interventions; and  D. Not due to environmental stressors that can be addressed to improve the psychotic symptoms or maintain safety  E. Not due to psychological stressors or anxiety or fear stemming from misunderstanding related to his or her cognitive impairment
  27. 27. @Copyright 2014, Jennifer Hardesty. All right reserved. 27 Inadequate Indications for Antipsychotic Use: • Wandering • Poor self-care • Restlessness • Impaired memory • Mild anxiety • Insomnia • Unsociability • Inattention or indifference to surroundings • Fidgeting/Nervousness • Uncooperativeness; • Verbal expressions or behavior that do not represent a danger to the resident or others CMS State Operations Manual: Antipsychotics Usage New Admissions to Skilled Nursing Facility When a resident is admitted to a SNF from hospital/ community and are already on an antipsychotic: • Facility must re-evaluate antipsychotic medication at the time of admission and/or within two weeks of admission • PASRR screening (F285) - evaluation for mental illness and/or intellectual disability
  28. 28. @Copyright 2014, Jennifer Hardesty. All right reserved. 28 Investigator’s Review of Medication Management Surveyors are instructed to review the clinical record to determine if it reflects the following elements: • Indication • Non-pharmacological interventions • Dose • Duration • Tapering/Gradual Dose Reduction documentation • Monitoring and reporting for efficacy and adverse consequences • Adverse consequence identification, evaluation, and actions by physician and facility Surveyor Investigation- Areas of Focus • PRN orders for antipsychotic medications • Describe how the facility provides individualized care and services for residents with dementia • Provide policies related to the use of antipsychotic medications in residents with dementia • Resident/families/representatives involvement • Identify and document specific target behaviors • Communicate consistently
  29. 29. @Copyright 2014, Jennifer Hardesty. All right reserved. 29 CMS State Operations Manual: Medication Management Medication Management Process: • All drugs implicated! • Enhanced focus on : • Medications as cause for change in condition • Need for Medication Reviews in response to changes in condition • Enhanced interdisciplinary teamwork • Enhanced care process • Personal responsibility • Need to document process Medication Management Medication management should support and promote: 1. Evaluating resident for underlying causes of signs/symptoms 2. Use of non-drug interventions 3. Selection of medications based on benefits vs. risk for individual residents 4. Selection and use of medication in doses and duration individual resident 5. Monitoring of medications for efficacy and adverse consequences*.
  30. 30. @Copyright 2014, Jennifer Hardesty. All right reserved. 30 Adverse Consequences: Identification Medication review should be performed if resident has experienced a change in condition: Weight loss or gain Behavioral changes/ mental status changes Bleeding or bruising Bowel dysfunction Dehydration/electrolyte imbalance Dysphagia GI bleed Headaches or non-specific pain Rash or itching Respiratory changes Sedation, insomnia, sleep changes Seizures Urinary retention or incontinence How Can I Remember All of This?
  31. 31. @Copyright 2014, Jennifer Hardesty. All right reserved. 31 Your Pharmacy Provider Service Team • Pharmacists • Technicians • Nurses • Consultant Pharmacists • Account Managers Facility Staff Nurse Family Pharmacist MD/NP Resident Consultant TEAMWORK is needed to help identify and resolve cognitive and behavioral problems!
  32. 32. @Copyright 2014, Jennifer Hardesty. All right reserved. 32 Bowen JD, Larson EB. Drug-induced cognitive impairment. Defining the problem and finding the solutions. Drugs Aging 1993; 3 (4): 349-57. Cole MG, McCusker J., Dendukuri N, Han L. Symptoms of delirium among elderly medical inpatients with or without dementia. J. Neuropsychiatry Clin Neurosci 2002; 14(2):167-75. Drug-Induced Delirium: Diagnosis, Management, and Prevention. Drug Ther Perspect 10(3):5-9, 1997 Evidence-Based Interventions for Nursing Psychiatric Clinics of North America - Volume 28, Issue 4 Home Residents with Dementia-Related Behavioral Symptoms (December 2005) Flaherty JH. Commonly prescribed and OTC medications: causes of confusion. Clin Geriatr Med 1998;14:101-127. Francis J. Martin D, Kkapoor WN. A prospective study of delirium in hospitalized elderly. JAMA 1990;263(8):1097-101. Gleason, OC. Am Fam Phys.67(5):1027-1034. 2003 Inouye SK. The dilemma of delirium: Clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. AM J Med 1994;97(3):278-88. Inouye, SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990; 113(12):941-8. Inouye SK, Charpentier PA, Precipitating Factors for Delirium in Hospitalized Elderly Persons. JAMA. 1996;275:852-857. Liang, BA. Diagnosis and Management of Delirium in the Elderly. Hosp Phys June 199:34-52. Lisi, D. Definition of Drug-Induced Cognitive Impairment in the Elderly Donna Medscape Pharmacotherapy 2(1), 2000. Pompei P, Foreman M, Rudberg MA, Inouye SK, Braund V, Cassel CK. Delirium in hospitalized older persons: Outcomes and predictors. J Am Geriatr Soc 1994; 2(8):809-15. State Operations Manual: Appendix- Medications of Particular Relavence. http://www.cms.hhs.gov/manuals/downloads/som107ap_pp_guidelines_ltcf.pdf pp. 299-339 References Jennifer Hardesty, PharmD, FASCP Director of Clinical Services, Remedi SeniorCare Jennifer.Hardesty@RemediRx.com Q & A

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