Challenges to Psychoactive Dose Reductions: A Consultant Pharmacist’s Perspective

Janice Hoffman, PharmD, CGP, FASCPAssociate Professor of Pharmacy Practice and Administration Western University of Health SciencesCollege of Pharmacy August 21, 2013

Mental illness treatment should parallel Diabetes or High Blood Pressure

• Should insulin be tapered to none in an Insulin-dependent patient with Diabetes ?

• A patient has high BP: would you treat with medication?

• “Clinically contraindicated” is a dilemma for pharmacists • When a gradual dose reduction is due :

• No thorough assessment is done to determine if clinically contraindicated in a chronic disease state

Mental illness treatment should parallel Diabetes or High Blood Pressure

• So why is it ok to withdraw antidepressants from a patient with chronic Dementia with Depression ??

• Or in a patient with a chronic diagnosis of Dementia with Psychosis, we are willing to deny antipsychotic therapy?

• Diagnosed mental disorders are true disease states that need to be treated as such • Nondrug intervention and lifestyle modifications• Drug therapy when indicated

Pharmacist/Physician Issues Transition of care issues –

New patient to physician – Came into SNF on medication and not sure

what the behaviors are - history a mystery Physician more reluctant to change Pattern of signing consent form on

admission by fax (so medication can be continued prior to first physician visit) may promote signing forms without consent ever occurring

More need for thorough assessment Past Mental Health disorders is commonly

under-assessed by acute hospitals/Nursing Homes

Pharmacist/Physician Issues

• Psychiatrist refusal to reduce or change- as the expert prescriber • Some psychiatrists are unaware of the

guidelines for antipsychotics and for dose reductions

• The physician may not know the pharmacist and note-based communication may be less effective

• Attending physicians nonresponsive to pharmacists note requesting for reduction

Pharmacist/Physician Issues

• Medication Reconciliation • May not be done at the time of admission• New starts on Psychoactive Meds not

appreciated• The indication for a new psychoactive medicine

commonly is not clearly identified in the transfer records or admission orders

• Medicare Part D plans restricted Antipsychotic use – trying to recoup money if the only diagnosis is dementia• Prior authorization may not be completed

correctly by attending physician

SNF Facility Issues • Pharmacist not invited or not allowed to attend

IDT behavior management team meetings due to cost or time• IDT needs to place high value on pharmacist’s

recommendation• Need strong Director of Nursing support• Need for rapid cycle Admissions patient care

conference within 48 hours of admission to address psychoactive medication issues as a team is likely a best practice

• May need Psychiatrist to attend IDT or psychotropic rounds since most attending physicians do not want to manage psychoactives

• Social Services Designee to run meeting if psychiatrist is not available

SNF Facility Issues

• Accuracy of assessment and documentation of behaviors by nursing

• Staffing issues for nondrug intervention• Optimal patient centered activities programs

will likely require more resources

• Nursing perception to keep patients calm as a high value, rather then focusing on optimal patient functioning.

SNF Facility Issues

• “Patients doing well” , assuming patients will do worse if GDR attempted, rather then may do

• • Families do not want reduction attempts- fear

of return of behaviors of their loved one• Poor communication with families about

gradual dose reductions• Most families will consent to reduce if

explained the risk vs. benefits

Differential Depression, Delirium and Dementia

Table 1. Characteristics of depression, delirium and dementia

Depression Delirium Dementia

Onset Weeks to months Hours to days Months to years

Mood Low/apathetic Fluctuates Fluctuates

Course Chronic; responds to treatment.

Acute; responds to treatment

Chronic, with deterioration over time

Self-Awareness Likely to be concerned about memory impairment

May be aware of changes in cognition; fluctuates

Likely to hide or be unaware of cognitive deficits

Activities of Daily Living (ADLs)

May neglect basic self-care

May be intact or impaired

May be intact early, impaired as disease progresses

Instrumental Activities of Daily Living (IADLs)

May be intact or impaired

May be intact or impaired

May be intact early, impaired before ADLs as disease progresses

Jane P. Gagliardi, MD” Differentiating among Depression, Delirium, and Dementia in Elderly Patients” Virtual Mentor. June 2008, Volume 10, Number 6: 383-388.

Pharmacist Interventions• Continue to write notes to physician• Provide education for all staff • Attend behavior/psychotropic team– most

effective • Helpful for Quality Assurance • Issue- cost – some facilities may not be willing

to pay the time and likewise some pharmacists are not willing to attend if they are not paid

• Recommend alternative interventions • Recommend alternative training for staff

• Communication training• Non-drug intervention training (ex. “Bathing

without Battles”)

“Quality of Life—not Quantity”• If someone is hallucinating and it is not

disturbing, should we treat with medication ?

• If a patient is hallucinating and it is disturbing and creates aggressive behavior verbal or physical should we treat with medication? • Have non-pharmacologic approaches been

identified and implemented?

• If a patient is depressed and not eating, should we treat with medication?

Summary • Mental Illness needs to be treated similar to other

chronic disease states • Transition of care is an issue especially when the

patient is new to the physician and facility • Behavior Management IDT is the most effective

with physician, pharmacist and strong DON support

• Pharmacist can be utilized more for alternative therapy recommendations

• Quality of life is more important than quantity