Challenges to Psychoactive Dose Reductions: A Consultant Pharmacist’s Perspective Janice Hoffman, PharmD, CGP, FASCP Associate Professor of Pharmacy Practice and Administration Western University of Health Sciences College 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

Prevalence of Current Depression* Among Persons Aged ≥12 Years, by Age Group and Sex — United States, National Health and Nutrition Examination Survey, 2007–2010 (NHANES) * Current depression was determined based on responses to the Patient Health Questionnaire, which asks about symptoms of depression during the preceding 2 weeks. Depression was defined by a score of ≥10 out of a possible total score of 27.

Depression with other common disease states Depression is common following stroke An estimated percent of poststroke patients meeting criteria for major depressive disorder ++ Other medical problems have also been associated with a higher incidence of depression.++ Parkinson’s disease Coronary artery disease Cancer Other ***Humility is needed. Evidence for efficacy of antidepressants in Dementia is very limited with only positive literature for Sertraline and Mirtazapine ++Evans DL, Charney DS, Lewis L, et al. Mood disorders in the medically ill: scientific review and recommendations. Biol Psychiatry. 2005;58(3): )

Differential Depression, Delirium and Dementia Table 1. Characteristics of depression, delirium and dementia DepressionDeliriumDementia OnsetWeeks to monthsHours to daysMonths to years MoodLow/apatheticFluctuates 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 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: June 2008

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