A-MOP: An Antipsychotic Medication Optimization Program for Long Term Care Fiona Sudbury, RN, Director of Care Duncan Robertson, Chief of Medical Staff The Lodge at Broadmead Victoria, B.C., Canada

The Lodge at Broadmead

Population served Many Veterans 65% male Average age 88 50% admitted from hospital ALOS ~ 18 mos ~80% mod - severe dementia

Medication Optimization Program Admission & regular review of medication Beer’s list audits Staff education and good practice guidelines Policy development

Antipsychotic Concerns!

A-MOP Project Framework Baseline descriptive statistics Audit and clinical review Make recommendations to prescriber Develop new policy and procedure for antipsychotic drug use Staff education and support Ongoing quality monitoring

Atypical Antipsychotic Use - June 2011 – Time 1 Lodge Residents Regular Order Regular & PRN Order PRN OnlyTotal % 9%14%10%33% 23%

Average Daily Dose MedicationRisperidoneQuetiapineOlanzapine # residents21255 Average daily dose 0.49 mg44.50 mg6.75 mg Upper limit rec’d/day 1.5 mg200 mg10 mg

Audit Form & Clinical Review RN audit: diagnosis, drug, dosage and frequency Reason for use - behaviour of concern Non-pharmacological strategies in care plan Antipsychotic medication history 3 month’s documentation of behaviour of concern Review with Medical Coordinator or Geriatric Psychiatrist Recommendation to primary care physician

Results - Time 1 Audits (N=62) Indication for use:  73% - Dementia (AD, VaD, Mixed)  27% - Other psychiatric diagnoses Rationale documented for 83% of residents Most common reason - aggression and/or risk to self or others Care plan review  57% had non-pharmacological strategies identified Medication history  50% started lower than current dose

Impact of Recommendations to Physicians 14 residents - drug discontinued  Of these, 7 prescribed PRN dose 9 residents - dose reduced 4 residents – no change advised 3 residents - dose increased advised 6 residents died before review completed

Comparison of Atypical Antipsychotic Use: T1 - T2 T %6%17%6%29% 23% Time Residents Regular Order Regular & PRN Order PRN OnlyTotal T % 9%14%10%33% 23%

Project Successes Clearer picture of atypical antipsychotic drug use in this care home Increased team awareness of the risks and good practice principles for use of atypical antipsychotics Pride in our apparently lower use than other care homes in our region

New Policy & Procedure Prior to initiation:  Behaviour assessment  Treat causes of BPSD i.e. Pain, infection, depression  Care plan non-pharmacological interventions On initiation:  Clear identification of behaviour of concern  Information and consent with family  Lowest effective dose Ongoing monitoring:  Monitoring for effect and adverse effects  Review every 3 months  If no behaviour of concern, trial of dose reduction/withdrawal Auto stop for PRN antipsychotics not used in 3 months Quality monitoring of antipsychotic use Q 6 months

Final thoughts