10/22/21 1 2021 Annual Meeting & Exhibition November 4-7, 2021 | San Diego, California Treatment of Neuropsychiatric Symptoms in Older Adults Presentation by: Erin M. Foti, PharmD, BCGP and Rebecca L. Salbu, PharmD, BCGP November 4, 2021 1 2021 Annual Meeting & Exhibition November 4-7, 2021 | San Diego, California Meet the Speakers Erin M. Foti, PharmD, BCGP Erin M. Foti, PharmD, BCGP is currently the National Director of Consultant Services for Remedi SeniorCare Pharmacy. She has been a clinical consultant pharmacist for Remedi for nine years but has been in long-term care for fourteen years. She graduated from the University of Toledo College of Pharmacy in 2007 with her Doctorate of Pharmacy degree. She is an active member of ASCP, and is on the board of directors for Ohio ASCP. She has been a board certified geriatric pharmacist since 2012. She is currently based outside of Cleveland, Ohio. Rebecca L. Salbu, PharmD, BCGP Rebecca L. Salbu, PharmD, BCGP is currently the Director of Talent Development, Training and Oversight for Guardian Consulting Services, Inc. She has been a clinical consultant pharmacist with Guardian for 6 years and has worked with the Geriatric population in various pharmacy and academic settings for thirteen years. She graduated from St. John’s University College of Pharmacy and Allied Health Professions in 2008 and completed a Residency with an emphasis in Geriatrics from The James J. Peters VA Medical Center in Bronx, NY. She is an active member of ASCP and has been a board certified geriatric pharmacist since 2011. She is currently based in Queens, New York. 2
Transcript
10/22/21
1
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
Treatment of Neuropsychiatric Symptoms in Older Adults
Presentation by: Erin M. Foti, PharmD, BCGP and Rebecca L. Salbu, PharmD, BCGP
November 4, 2021
1
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
Meet the Speakers
Erin M. Foti, PharmD, BCGPErin M. Foti, PharmD, BCGP is currently the National Director of Consultant Services for Remedi SeniorCare Pharmacy. She has been a clinical consultant pharmacist for Remedi for nine years but has been in long-term care for fourteen years.
She graduated from the University of Toledo College of Pharmacy in 2007 with her Doctorate of Pharmacy degree.
She is an active member of ASCP, and is on the board of directors for Ohio ASCP. She has been a board certified geriatric pharmacist since 2012. She is currently based outside of Cleveland, Ohio.
Rebecca L. Salbu, PharmD, BCGPRebecca L. Salbu, PharmD, BCGP is currently the Director of Talent Development, Training and Oversight for Guardian Consulting Services, Inc. She has been a clinical consultant pharmacist with Guardian for 6 years and has worked with the Geriatric population in various pharmacy and academic settings for thirteen years.She graduated from St. John’s University College of Pharmacy and Allied Health Professions in 2008 and completed a Residency with an emphasis in Geriatrics from The James J. Peters VA Medical Center in Bronx, NY.She is an active member of ASCP and has been a board certified geriatric pharmacist since 2011. She is currently based in Queens, New York.
2
10/22/21
2
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
Disclosure
• Erin M. Foti, PharmD, BCGP is employed by Remedi SeniorCarePharmacy• Contact Information: [email protected]
• Rebecca L. Salbu, PharmD, BCGP is employed by Guardian Consulting Services, Inc.• Contact Information: [email protected]
3
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
7
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
Drug Regimen Reviews: Regulatory
F756 Drug Regimen Review
F757 Unnecessary Drugs-General
F758 Psychotropic Medications
F761 Storage and Labeling
8
10/22/21
5
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
9
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
Psychotropic Classes
10
10/22/21
6
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
Antipsychotics• Common classes
• First generation antipsychotics• Haloperidol, chlorpromazine, prochlorperazine, etc.
• Second generation antipsychotics• Aripiprazole, quetiapine, risperidone, olanzapine, etc.
• Approved diagnoses• Schizophrenia and related disorders• Bipolar Disorder and related diagnoses• Depression - adjunct• Huntington’s Disease; Tourette’s Syndrome
• Other diagnoses – evaluate for gradual dose reduction (GDR)• psychosis, delirium, mood disorder
• Use in dementia: not approved!
11
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
Antipsychotics• First Generation adverse effects:
• Extrapyramidal side effects (EPS) including rigidity, bradykinesia, dystonias, tremor, and akathisia, tardive dyskinesia (TD), neuroleptic malignant syndrome (NMS)
• Second Generation adverse effects: • Metabolic syndrome (Weight gain, diabetes, and dyslipidemia)• Anticholinergic effects (dry mouth, constipation, blurred vision, urinary retention, dizziness,
falls)• Cardiovascular events (QTC prolongation, orthostatic hypotension, myocarditis)• EPS, TD, falls, etc.
12
10/22/21
7
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
Antipsychotics
• BLACK BOX WARNING:• Elderly patients with dementia-related psychosis treated
with atypical antipsychotic drugs are at an increased risk of death compared to placebo.• Observational studies suggest that, similar to atypical
antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality
13
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
Antipsychotics
• Target Behavior documentation and improvement• Rule out underlying conditions causing psychotic symptoms• Infection?• Drugs?• Environment?
• DOCUMENTATION
14
10/22/21
8
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
• Consider:• Duration of order• Environmental factors• Sleep hygiene
• Adverse effects:• Sedation, daytime drowsiness and falls
15
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
Anxiolytics
• Most common classes:• Antidepressants (First line)• Benzodiazepines • Buspirone (PRN use??)
• Current diagnosis and duplicate therapy• Long-acting vs. shorter acting benzodiazepines• All have increased risk of delirium, cognitive impairment, falls, fractures
• Duration and rationale for PRN orders, non-pharmacological interventions
16
10/22/21
9
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
• Areas to watch - weight, blood pressure, sodium levels, seizure implications, GI bleed• Take 4-6 weeks for effect
17
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
Gradual Dose Reductions (GDRs)• §483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility
must ensure that–• §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless
the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;
• §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;
• §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and
• §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in • §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate
for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident’s medical record and indicate the duration for the PRN order.
• §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
18
10/22/21
10
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
Gradual Dose Reductions (GDRs)• Documentation, the devil is always in the details!• Indication for use• Dose, Duration, Frequency• Nursing Notes• Progress Notes• Psychiatry Notes• MAR Documentation
• Is the resident on the lowest, effective dose?• Timelines and Diagnoses
19
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
You are now the surveyor: Scope/Severity ?
Immediate Jeopardy - “A situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.”
20
10/22/21
11
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
F 758 – Psychotropic Drugs Immediate Jeopardy• Admit from home on hospice à within 2 weeks, seen
by psych, ordered Haldol 0.25 mg bid x 14 days (no indication in the record) à using EHR, nursing inputs Haldol 20 mg bid à dispensed à 4 doses àhospitalization (ADR / overdose)• Federal CMP: $ 98,455.00.
21
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
22
10/22/21
12
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
23
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
Resident Centered Approach to Deprescribing
Assess Resident
Discuss and Define Overall
Goals of Therapy
Identify Medications with
Potential Risks
Actively Stop or Reduce Dose
Communicate Actions
Monitor regularly for adjustments
24
10/22/21
13
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
Key Recommendations for Practice
Identify priority medications to discontinue
Develop follow up plan
Before Starting NEW medications, consider underlying causes, prescribing cascade, non-pharmacologic interventions, risk vs benefit
If a new medication is added, consider it a trial and review ongoing
25
2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California
How to identify a change in condition
• Clinical deviation from a resident’s baseline in physical, cognitive, behavioral, or functional domains• Identify the time frame• ALWAYS BLAME THE DRUGS FIRST• Types of change in condition
![Neuropsychiatric symptoms in a patient with Dyke–Davidoff ... · ipsilateral hyperpneumatization of sinuses [2]. Clinical features such as hemiplegia/hemiparesis, facial asym-metry,](https://static.documents.pub/doc/80x56/6090d5af66fffe37783bd3e5/neuropsychiatric-symptoms-in-a-patient-with-dykeadavidoff-ipsilateral-hyperpneumatization.jpg)
