strategies for reducing aps a consultant pharmacist ......0-40 -30 -20 -10 0 10 20 30 months before...

9/13/2010

Revised May 18, 2012 1

© 2015 Remedi SeniorCare™1 |

Strategies for Reducing APs: A Consultant Pharmacist Perspective

Derek Sanders, D.Ph.Remedi SeniorCare of Oklahoma

Lead Consultant Pharmacist SW Region


CASE STUDY


92 Year Old Female

•Diagnoses • Dementia • Depression• HTN• Hypothyroidism • History of falls • Hard of hearing

9/13/2010



Nursing Note: June 17, 2010

• “Increased confusion today …. bed and chair alarms on due to fall risk … despite alarms resident found on floor in bathroom with stool in diaper … states she is getting ready to go to a wedding”

• MD contacted and gave the following orders:• Stools x 3 for C diff (why?)• Flagyl x 10 days (why? … see above?)• Haldol 5 mg now and q 12 hours PRN


June 17, 2010

• PRN order placed into the record

• 9 PM: Haldol 5 mg administered

• 10:30 PM: Resident sleeping


June 23, 2010 at 10 PM( 6 days after the order for PRN Haldol)

• Nursing Note:• “ Resident expressed that she wanted to go to

Kmart to buy nylons and a raincoat for roommate … calm but confused … PRN Haldol given … effective, resident stopped preparing to go to Kmart”

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July 19, 2010 at 12:10 AM(~ 1 month post order)

• Nursing Note:• “PRN Haldol given for agitation [not described]

… effective results noted”


July 20, 2010

• Pharmacist medication regimen review:

• “No irregularities noted”


August 2, 2010 at 1:30 AM(~ 6 weeks post order)

• Nursing Note:• “Resident agitated [not described]

… PRN Haldol given … resident now sleeping”

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August 2, 2010 at 4:45 PM(~ 6 weeks post order)

• Nursing Note:• “ Nursing assistant reported that resident was

packing up her room to go home … resident requested shopping bag to give pictures on window sill to the person they belong to … PRN Haldol given … effective, resident no longer wants to go home … “

2nd dose of Haldol 5 mg administered < 24 hours


August 2, 2010 at 6:30 PM(~ 2 hrs after 2nd dose)

• Nursing Note:

• “Resident noted with muscle spasms of neck and clenching of teeth intermittently … this is a new finding …”


“Any symptom in an elderly patient should be considered a drug side effect until proved otherwise.”

Gurwitz et al. Long-Term Care Quality Letter, Brown University, 1995

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August 2, 2010 at 6:30 PM

(~ 2 hrs after 2nd dose)• Nursing Note:

• “Resident noted with muscle spasms of neck and clenching of teeth intermittently … this is a new finding … MD called, Haldol discontinued … give Benadryl 25 mg x 1 dose for possible dyskinesia ..”


August 3, 2010(~ 6 weeks post order)

• Seen by MD, ordered Cogentin 1 mg bid for “cogwheeling and dyskinesia”

• Symptoms resolved within 24 hours


Lets Review: “Indication” for Haldol

• June 17: Confused, fall in bathroom, wanted to go to a wedding

• June 23: Wanted to go to Kmart

• July 19: Agitation (not described)

• August 2: Agitation (not described)

• August 2: Wanted to go home

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Actual Deficiencies Cited

• F 281 (Professional Standards of Practice) • Nurses knew or should have known Haldol was not

indicated

• F 329 (Unnecessary Drugs) = Actual Harm • Without adequate indication for use• Excessive dose

• F 385 (Physician Services)

• F 428 (Drug Regimen Review)• Failure to note and act upon a drug irregularity


Sanctions

• Directed plan of correction

• Civil money penalty ($10,000.00)


Could some or all aspects of this case

happen in your facility?

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DEFINING THE ISSUE: CONDITION • Behavioral and Psychological Symptoms of

Dementia (BPSD)• Agitation• Aberrant motor behavior• Anxiety• Elation• Irritability• Depression• Apathy• Disinhibition• Delusions• Hallucinations• Sleep or appetite changes


How many of you are parents?


PROGRESSION: ALZHEIMER'S

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PEAK FREQUENCY OF BEHAVIORAL SYMPTOMS AS AD PROGRESSES

100

80

60

40

20

0

-40 -30 -20 -10 0 10 20 30

Months before diagnosis

Pre

vale

nce

(% o

f pa

tient

s)

Months after diagnosis

Sexually inappropriate behaviorSuicidalideation

Agitation

Diurnal rhythm

Irritability

Wandering Aggression

Hallucinations

DelusionsAccusatorybehavior

Paranoia

Depression

AnxietySocial withdrawal Mood

change

Socially unacceptable behavior

Jost BC, Grossberg GT. J Am Geriatr Soc. 1996;44:1078-1081.


DEFINING THE ISSUE: CONDITION


DEFINING THE ISSUE: DRUGS

• Drug Class: Antipsychotics• Seroquel• Risperdal• Zyprexa • Abilify• Haldol• Clozaril• Geodon

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The lower the number, the riskier a drug. A University of Michigan analysis finds that 1 in 26 older patients would be expected to die within six months of starting Haldol for symptoms of dementia.JAMA Psychiatry

Source: Risks Run High When Antipsychotics Are Prescribed For Dementia – NPR: March 18,2015

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DEFINING THE ISSUE: DRUGS • Adverse Effects – Antipsychotics

• Drowsiness• Dizziness• Restlessness• Weight gain • Dry mouth

• Constipation• Nausea• Vomiting• Blurred vision• Low blood pressure

• Uncontrollable movements• Seizures• Decreased WBC • Rigidity• Persistent muscle spasms• Tremors

• Restlessnesssource NIH http://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml#part_149866



“Clinicians should generally limit the use of antipsychotic medications to cases where non-pharmacologic measures have failed and the patients’ symptoms may create a threat to themselves or others.”

- American Psychiatric Association

“The therapeutic goal of the use of antipsychotic medications is to treat patients who present an imminent threat of harm to self or others, or are in extreme distress–not to treat nonspecific agitation or other forms of lesser distress.”

- AMDA – The Society for Post-Acute and Long-Term Care Medicine

“Don’t use antipsychotics as the first choice to treat behavioral and psychological symptoms of dementia.”

- American Geriatrics Society

Identifying and addressing causes of behavior change can make drug treatment unnecessary.

- American Academy of Family Physicians


CMS NURSING HOME REGULATIONS

Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and

Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

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STAFF RESPONSIBILITIES

Who can report behaviors?? Who’s responsibility is it??



What Information do we need about a Behavior??

1. Time of Day?2. Location in the facility where the observed

behavior took place?3. Residents or Staff members present during

behavior?4. Any environmental issues noticed that could have

contributed to behavior?



5. Has Nursing staff completed a physical assessment of the resident??

Gather data and present to IDT for potential behavioral interventions.

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Interdisciplinary Team Responsibilities

1. Reviewing reported behaviors and developing behavioral intervention plans

• Encourage family/POA participation• Resident History (e.g. Career, Hobbies, etc.)

2. Reviewing newly admitted residents to the facility that have current antipsychotic therapy.

• Encourage family/POA participation• Was resident on this medication prior to hospitalization?


Nonpharmacologic Interventions for Agitation and Aggression in Dementia Executive Summary | AHRQ Effective Health Care Program


Tips for Discontinuing Antipsychotics1. Wean off medications instead of

“Cold Turkey” approach.2. If antipsychotics are discontinued

and not weaned appropriately it could cause withdrawal issues with behavioral outburst and the antipsychotic possibly would be re-started.

3. Go slow it is a marathon not a sprint. Goal is discontinuation it doesn’t matter if it takes 3 to 4 weeks.

4. Don’t be afraid to question why a antipsychotic was started??

5. Keep your Medical Director and Physicians involved with your goals of reducing and discontinuing antipsychotic medications.

9/13/2010



THANK YOU

strategies for reducing aps a consultant pharmacist ......0-40 -30 -20 -10 0 10 20 30 months before...

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