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Reducing Medications in Persons with Dementia
Helping to Brighten Someone’s Day!!
Session W24AMDA Annual Symposium
March 7, 2003
Alva S. “Buzz” Baker, MD, CMDArthur Riley, MS, PD
2
Why Medications are Used in Persons with Dementiatreatment of the dementing
disease processtreatment of the side effects or
consequences of the dementing illness
treatment of medical co-morbidities
6
Institutional Philosophy of Medication Use in Dementia“tie ‘em up or drug ‘em down”
– low tolerance for• the “un-cooperative” or hard-to-handle
resident• the wandering resident• crying out
– zero tolerance for resident-to-resident negative interactions
“attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident”
F490CFR §483.75
7
Institutional Philosophy of Medication Use in Dementia“tie ‘em up or drug ‘em down”
– lack of knowledge or understanding of dementia syndromes as an illness
– lack of knowledge and skills in how to manage behavioral issues in persons with cognitive impairment
– it takes less staff time and effort to use this approach as opposed to making every effort to optimize abilities
“attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident”
F490CFR §483.75
8
Institutional Philosophy of Medication Use in Dementia“But, these people need these
medicines, don’t they?”– the Hospice experience: enter a near-
dead dementia patient into Hospice• (all) medicines stopped• patient improves – 10 - 20% to where they
no longer meet Hospice criteria (at least for a while…)
• subsequent care not an issue for caregivers
“attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident”
F490CFR §483.75
9
Medication reduction
Basic Questions– Do all persons with dementia need all the
medications they are receiving?• benefits of medication use:
– ethical quality-of-life issues– bothersome (to resident) symptom control
• burdens of medication use:– deterioration in overall health status– decreased quality of life– medication side-effects, drug interactions– possible earlier death
10
Medication reduction program
process: medical directorprocess: working to achieve
reductioneducation
– medical staff– nursing staff– residents and families
14
Benefits of medication reduction program
to residents/familiesto caregiversto facility
18
Medication Reduction Program: Example in actiondesign program, do educationdo resident reviewsconference: pharmacist and
medical director, develop recommendations
present recommendations to attending physician
monitor results
19
Results
resident profilemedication use in this cohortrecommendations made and how
received by attending physiciansmedication reduction
– accomplished– failed
examples
20
Resident profile
Item Mean Range Comment
Age (yrs) 82 69-92 excl. 4 <65 (80)
MMSE 3 0-10 excl. 2 >20 (4)
Gender: male – 16% female – 84%
21
Resident profile: dementia diagnosis
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
Per
ce
nt
of
Re
sid
en
ts
AD VAD other mixed
22
Medication use in this cohort
Mean # of Rx’s: 7.29Least # of Rx: 1 Highest # of Rx: 15
number of rx's per resident
number of rx's per resident
1514131210987654321
Fre
qu
en
cy
10
8
6
4
2
0
23
Classes of medications in use and ID’d
Class/use
# of Rx’s # ID’d
Parkinson’s
15 5
Gut 33 18
Brain 121 17
CVS 80 20
Arthritis 19 5
Diabetes 13 0
Anticoags 14 0
Other 106 19
24
“Brain” drugs
Type # of Rx’s(# of Res.)
# ID’d
CNI 21 (20) 10
neuroleptic
26 (21) 0
anti-depr 51 (38) 6
benzo 22 (18) 1
hypnotic 1 0
25
CVS drugs
Type # of Rx’s
(# of Res.)
# ID’d
HTN 17 (16) 5
‘cardiac’ 35 (24) 5
diuretic 15 (14) 0
hyperlipidemia
13 (13) 10
26
Program at work: reduction
Item Number
Per Res.
Comment
Residents 56 --
Rx’s 401 7.29
ID’d forReduction
82 meds(44 Res.)
1.9 (per Res. ID’d)
20% of total Rx’s
Rx Reduced 15 meds(14 Res.)
.34 Rx (per Res. ID’d)
18% of ID’d Rx’s
4% of total Rx’s
$$ Reduced 1,079.00
19.27
27
Medications reduced, by class
Class/use # of Rx’s
# ID’d
# DC’d
Parkinson’s 15 5 1
Gut 33 18 1
Brain 121 17 1
CVS 80 20 8*
Arthritis 19 5 1
Diabetes 13 0 0
Anticoags 14 0 0
Other 106 19 3* 7 = lipid lowering agents
28
Reason for medication not being changed (82% of ID’d)
2% 6%6%
18%
2%66%
Insurance mandated therapy Physician agrees, no order Family refusal
Neuropsychiatry control Physician opinion Physician refusal/history
29
Discussion
Considering the ethical, economic and operational aspects of a comprehensive medication-reduction program: Is it worth it?
30
Think about it: maybe
YOUcould brighten someone’s
day!
Thank You!!