Antipsychotic medication reduction and appropriate use

Hello everyone,

 The use of psychotropic drugs for people with dementia living in long term care facilities is common, but research continues to show that their risks often far outweigh their benefits, and they are effective for a limited number of symptoms. The Centers for Medicare and Medicaid Services’ national initiative to improve behavioral health and decrease antipsychotic use among nursing home residents with dementia has prompted the education of interdisciplinary healthcare teams, patients and their families about the use of psychotropic drugs and effective alternatives to them. Attached is a helpful tool developed by the American Medical Directors Association that you and your team can use to assess a dementia patient’s antipsychotic use.

 While research has shown short-term effectiveness of psychotropic drugs in the treatment of those with psychotic symptoms (hallucinations, delusions) and significant physical aggression, there is little evidence of efficacy of these drugs with restlessness, verbal outbursts and resistance to care. Rather, these issues can be better addressed through behavioral interventions, which we will discuss in next week’s tidbit.

 Risks of antipsychotic medications include:

  • Falls & fractures
  • Sedation, delirium, functional decline
  • Extrapyramidal symptoms
  • Anticholinergic side effects, e.g. orthostasis, constipation, blurry vision
  • Hyperglycemia
  • Hyperlipidemia
  • Drug interaction potential
  • Pneumonia
  • Cardiovascular risks
  • Death—morbidity is highest in first 30 to 40 days

 Psychotropic drugs, especially antipsychotic drugs, are often prescribed too often and for too long. Evidence has shown that psychotropic drugs can be safely discontinued in many cases. Consider this 5-step approach when determining the appropriateness of a psychotropic drug for a patient, and when it is time to reduce dosage.

 A Five-Step Approach to Antipsychotic Reduction & Appropriate Use

  1. Assess facility policies, environment and culture, and baseline data: what are your beliefs about antipsychotics? Is there adequate staff to support non-pharmacologic approaches? Are current activities appropriate and effective? Can the environment be altered to decrease symptoms? What is rewarded…i.e. is quiet and sleeping rewarded more than functional and moving?
  2. Staff and family education: Do family and staff understand the limits of the efficacy of the drugs, along with their risks? Are they aware of non-pharmacologic interventions and their benefits?
  3. Interdisciplinary team of champions: Partner with consultants; not just about filling out tracking forms; staff should communicate regularly with drug prescribers to help determine when it’s time for a gradual dose reduction
  4. Start with “low hanging fruit”: Start with a patient whose medication is not effective, or has negative side effects, or who is already on a low dose of a medication or PRN, with no clear history of aggressive behavior or psychosis, and no GDR in 6 months. Go slow, develop strategies with clinician prescribers, reassess, be mindful that this may not be successful, involve family and put a non-pharmacological plan in place.
  5. Ongoing motivation and mentoring: Assess for change in target symptom, evidence of adverse effects or functional decline; gradual dosage reduction should be considered in 3-6 months once symptoms have been effectively treated OR if adverse effects outweigh benefits.

 Next week, we’ll discuss non-pharmacological approaches to use in place of psychotropic medications to address behavioral and psychological symptoms of dementia.

Link to this document to assess antipsychotic medication use in persons with dementia- Multidisciplinary_Medication_Management

Have a great week!

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