Effective and Appropriate Use of Psych

Effective and Appropriate Use of Psych

Effective and Appropriate Use of Psychoactive Medications in Long Term Care Residents Dr. Cynthia Hadfield, Pharm.D. Director of Pharmacy for Employee, LTC & Retail Pharmacies Lead Clinical Pharmacist, Geriatric Specialist Citizens Memorial Healthcare Faculty Disclosure Dr. Hadfield has no financial, other relationship or other support from the pharmaceutical industry Dr. Hadfield will be discussing off-label use of Psychoactive medications and other medications Off-label Medication Use

Prescribing of a medication for a condition other than its FDA approved indication Common practice allowed by FDA and Medical boards and often appropriate and beneficial FDA approval expensive >50% Cancer Drugs used off label All Anti-psychotic use for Behavioral and psychological Symptoms of Dementia (BPSD) in USA is off-label Risperdal is approved in Canada OIG report 201183% Antipsychotic use off label Objectives Outline CMS Regulations and initiatives related to use of Antipsychotics Understand how Antipsychotics work and why they

can cause serious side effects Understand how Anti-anxiety and Hypnotic medications work and related side effects Understand effects and side effects of Antidepressants and Anticonvulsants Understand how analgesics and other main classes of medications affect cognition and behaviors Strategies to ensure safe and effective use of Psychoactive medications in Long Term Care and how to reduce Psychoactive medication use rates Some Good News CMS reports by late 2014 nursing homes in the US had achieved a 19.4% reduction in Antipsychotic use >30,000 fewer residents on Antipsychotics

All but 8 states have met or exceeded 15% reduction target Missouri Antipsychotic rate was25.5% in 2nd quarter of 2011 but rose to 26.1% in 4th Quarter of 2011, then dropped to to 20.7% in the 4th Quarter of 2014 5.43% percentage point decrease, which translates to a 20.8 % change Excludes individuals with Schizophrenia, Tourettes and Huntingtons disease CMH LTC overall rate is13% (11% if Schizophrenia, Tourettes and Huntingtons Excluded) Focus on Antipsychotic Reduction Will Continue ! CMS and national organizations that are actively participating in the Partnership, recently announced an updated goal to achieve 30% reduction in the use of Antipsychotic medications nationally, no later than the end of CY2016

Feb 2015 CMS added two measures of Antipsychotic use (one for long stay residents and one for short stay) to the algorithm that is used to calculate each nursing homes Five Star Rating System on CMS Nursing Home Compare website Antipsychotics Chlorpromazine (Thorazine)

Fluphenazine Haloperidol (Haldol) Loxapine Mesoridazine Molindone Perphenazine Promazine Thioridazine (Mellaril) Thiothixine Trifluperazine Triflupromazine Typical (first generation / conventional)

Asenapine (Saphris) Aripiprazole (Abilify) Clozapine (Clozaril) Iloperidone (Fanapt) Lurasidone (Latuda) Olanzepine (Zyprexa) Paliperidone(Invega) Quetiapine (Seroquel) Riperidone(Risperdal) Ziprasidone(Geodon) Atypical (second generation) How Antipsychotics work

Psychotic symptoms (hallucinations, delusions) linked to abnormal dopamine release and function in the brain Antipsychotic Medications block Dopamine receptors in the brain causing dopamine to have less effect Older Antipsychotics (Typical) not particularly selective and also block dopamine receptors in other areas of the brain including the nigrostriatal pathway responsible for movement Newer Antipsychotics (Atypical) developed to be more selective but still have the same side effects also affect serotonin receptors Side Effects of Antipsychotics The why behind all of the regulations! General: anticholinergic effects , falls, sedation Cardiovascular: arrhythmias, orthostatic hypotension Perform orthostatic blood pressures every shift for the first

week and again with dose increases ECG recommended with older agents Metabolic: Increase in total cholesterol and triglycerides, unstable or poorly controlled blood sugar, weight gain Fasting lipid profile and fasting blood glucose / A1c (prior to treatment, at 3 months, then annually) Weight, BMI waist circumference Side Effects of Antipsychotics Esophageal dysmotility /Aspiration Lowers seizure threshold Neuroleptic malignant syndrome (NMS)

Mental status changes Muscle rigidity Fever Impaired temperature regulation Worsened by heat exposure, dehydration and medications with anticholinergic properties Neurologic Side Effects of Antipsychotics Extrapyramidal Symptoms (EPS) Pseudo parkinsonism Acute dystonic reactions Dose related

Higher risk in males and younger patients Akathesia Inability to stay still, restlessness, feeling of crawling out of ones skin Tardive Dyskinesia Irreversible Tongue and facial movements Abnormal Involuntary Movement Scale (AIMS) test recommended prior to treatment then every 3 months while on antipsychotic Black Box Warnings for Antipsychotics

Sternest warning from FDA that a medication can cary and still remain on the US market Indicating serious side effects or life threatening risks Thioridazine (Mellaril) QTC prolongation Dose related Should be avoided and reserved for patients with Schizophrenia who have failed other antipsychotics All Antipsychotics Elderly patients with dementia-related psychosis are at increased risk of death Cardiovascular (stroke, heart failure, sudden death) Infectious (pneumonia) Issued in 2005

Careful consideration of Risk versus Benefit Antipsychotic FDA Approved Diagnosis Schizophrenia Bipolar Disorder Treatment Resistant Depression (Olanzapine, Aripirazole ) Major Depressive Disorder (Quetiapine) Tourettes (Pimozide) ICU Delirium (Quetiapine) Changes to F309 & F329 Related to antipsychotics Emphasis on Person Centered Care, especially for residents with dementia Same diagnosis and dosage limits Guidelines are just more defined Bottom line: If resident has dementia, the facility must:

Do everything possible to manage behaviors without medication If medication is used, more than one person had better put a lot of thought into the selection of the medication Continual monitoring & documentation of the residents behaviors, medical conditions, social situation F329- Antipsychotic Indications for Use Schizophrenia Huntingtons Disease Tourettes Disorder Schizo-affective disorder Schizophreniform disorder Delusional Disorder Moods Disorders Bipolar Severe depression refractory to other therapies and/ or with psychotic features Psychosis in the absence of dementia Hiccups (not induced by other medications)

Nausea and vomiting associated with cancer or chemotherapy Medical illnesses with psychotic symptoms Neoplastic disease Treatment related psychosis (high dose steroids) Delirium BPSD BPSD Behavior or Psychological Symptoms of Dementia (BPSD) Also referred to as Neuropsychiatric Symptoms Describes behavior or other symptoms in individuals with dementia that cannot be attributed to a specific medical or psychiatric cause Agitation, Aberrant Motor behavior, Anxiety, Elation, Irritability, Depression, Apathy, Disinhibition, Delusions, Hallucinations, sleep and appetite changes NOT included in the defining criteria of dementia in the current classifications

Dementia with Behaviors is the closest ICD code Clinical Indications in Meditech EMR for Antipsychotic use Behavior Documentation Diagnosis alone does NOT warrant the use of an Antipsychotic Identify the specific behavior Document all of the non- medication interventions tried and how they worked Must also be included in the care plan

Describe how the behavior poses a threat to the resident or to others Describe how the behavior seriously impairs the residents quality of life Identify the behavior as related to mania or psychosis (hallucinations, delusions, paranoia, grandiosity) Specific Target Behaviors

Wandering Confusion Agitation Uncooperative Resisting care Nervousness Restlessness fidgeting Indifference unsociability Poor self care Depression Impaired memory Insomnia Crying out (occasional) Yelling or screaming (occasional) Cannot Use

Spitting, Biting, pinching Kicking, Punching Scratching, Slapping Extreme fear

Frightful distress Inappropriate Sexual Behavior Continuous pacing Finger painting feces Throwing objects Purposeful vomiting Purposeful B/B inappropriately Tripping, Ramming, Pushing others Head banging Self inflicted injuries Hallucinations Delusions Paranoia Continuous and extreme crying out, yelling, screaming Can Use How often to document

CNAs & CMTs should document every shift Charge Nurses should document a meaningful summary once per week Document before and after a PRN is administered Interdisciplinary team document every care plan Consultant Pharmacist: at least every quarter Physician: every month Document more often when behaviors occur or when medication is changed CMH Behavior Documentation in Meditech Documentation reminder comes up whenever an Antipsychotic Medication is ordered. CNAs document behaviors every shift for

residents on Antipsychotics. Charge nurses complete detailed Antipsychotic Medication Documentation every week for residents on an Antipsychotic Weekly behavior documentation is done by both CNAs and Charge nurses for residents on any psychoactive medication Behavior Monitoring Intervention for Charge Nurses, CNAs & CMTs Weekly Antipsychotic Medication Monitoring Intervention for Charge Nurses Weekly Antipsychotic Medication Monitoring Intervention for Charge Nurses (continued) Weekly Antipsychotic Medication Monitoring Intervention for Charge Nurses (continued)

Weekly Antipsychotic Medication Monitoring Intervention for Charge Nurses (continued) F329- Acute Situations / Emergency Acute onset or exacerbation of symptoms Immediate threat to health or safety of resident or others Acute treatment is limited to 7 days AND Clinician and interdisciplinary team must evaluate and document the situation within 7 days to identify and address any contributing and underlying causes of the acute condition and verify the continuing need for antipsychotic medication Acute Situations / PRN Antipsychotic Use Encourage Prescribers to only prescribe a one time dose for emergencies Limit PRN Antipsychotic orders to residents who

occasionally exhibit very psychotic and dangerous behavior Only allow Charge nurse to administer PRN Antipsychotics Only after all non-medication and other medication interventions have been tried and failed Extensive documentation before and after dose administered Team follow up after each dose administered to confirm positive response and continued need for PRN dose PRN Reason Dictionary Residents admitted on an Antipsychotic Facility is responsible for pre-admission screening for mentally ill and intellectually disabled individuals AND obtaining physicians orders for residents immediate care. This screening (F285) should provide diagnosis

for Antipsychotic use Other residents admitted on Antipsychotic must have use evaluated at time of admission and / or within 2 weeks of admission (initial MDS) Consider dose reduction or discontinuance of Antipsychotic Common Medication causes of Psychotic symptoms and behaviors Anticholinergic Medications Antiparkinsons Medications

Benzodiazepines Alcohol (including withdrawal) Cardiac Medications (especially digoxin) Corticosteroids Opioid Analgesics Stimulants Any medication can cause a psychiatric side effect in an individual patient always note new medications (even antibiotics and OTCs) Common Anticholinergic medications that worsen cognition and Behaviors with Dementia Antihistamines Hydroxyzine, diphenhydramine Muscle Relaxants Cyclobenzaprine, Tizanidine

Urinary agents (Antimuscarinics) Oxybutynin GI antispasmodics Dicyclomine, Atropine Tricyclic Antidepressant Amitriptyline, Doxepin Antiparkinson Agents Benztropine, Trihexyphenidyl How Opioid Analgesics affect Behavior Control pain which is a

major cause of anxiety, irritability and behavior problems Anti-anxiety effect Help with shortness of breath a major cause of anxiety in COPD patients Improved quality of life BENEFITS Sedation Confusion

Falls Insomnia Hallucinations (visual) Constipation Urinary retention POTENTIAL SIDE EFFECTS Anxiety Disorders

Significantly increase with age Generalized Anxiety Disorder (GAD) Diffuse constant anxiety and worry for >6 months 90% of presentations of late-life anxiety accounted for by Generalized Anxiety Disorder(GAD) or a specific phobia 10% are Obsessive-compulsive (OCD), post-traumatic Stress (PTSD) and panic disorders Increasing frailty, medical illness, and losses can contribute to feelings of vulnerability, fear and can reactivate anxiety disorders Agoraphobia (fear of being trapped in a place from which escape might be difficult) Afraid of being alone and unable to get help Fear of leaving home Fear of falling Rule out underlying causes Medical Conditions Associated with Late-Life Anxiety

Angina, arrhythmia, MI, Stroke Diabetes, low calcium, hyperthyroidism PUD, Pancreatic cancer, UTI Anemia, low blood sugar, low potassium, low sodium COPD, Pneumonia, Pulmonary Embolism Delirium, Dementia, hearing and visual impairment, Parkinsons, Seizures, brain cancer PAIN Medication causes of Anxiety

Bronchodilators, Steroids, Theophylline Nasal decongestants, Antihistamines Caffeine Nicotine; benzodiazepine or alcohol withdrawal Opioid analgesic withdrawal Thyroid medication, Estrogen Digoxin Calcium channel blockers, alpha-blockers, beta-blockers Levodopa Pharmacological Treatment of Anxiety GAD Phobia


SNRI Third Line/ Adjunct Benzodiazepine Benzodiazepine Benzodiazepine , Divalproex, Clonidine Benzodiazepine , Gabapentin Adapted from Cassidy, K.L., Rector, N.A. et al. SSRIs for Treatment of Anxiety

SSRIs generally safest and most effective Celexa, Lexapro, Zoloft, Prozac, Luvox, Paxil Many residents also have depression May take up to 6 8 weeks to see full benefit at any given dose Nausea, diarrhea, tremor, increased anxiety can occur for the first few weeks Start with low dose Use of benzodiazepine in the short term may be beneficial Remember to get stop date Buspirone

Mechanism of Action unknown High affinity for serotonin receptors Moderate affinity for dopamine receptor Does NOT affect benzodiazepine-GABA receptors Most Common Adverse Effects Dizziness Headache Nausea Dose: 5 mg BID, increase by 5mg/day every 2-3 days as needed up to 20-30mg/day Maximum dose: 60 mg /day Not as effective on a PRN basis but is sometimes acceptable to use PRN

Benzodiazepines Alprazolam (Xanax) Lorazepam (Ativan) Temazepam (Restoril) Oxazepam (Serax) Triazolam (Halcion) Estazolam

Short Acting Clonazepam (Klonopin) Diazepam (Valium) Chlordiazepoxide (Librium) Clorazepate Flurazepam Quazepam Chlordiazepoxide Amitriptyline ClidiniumChlordiazepoxide (Librax) Long Acting Benzodiazepine Side Effects

Sedation Respiratory depression Hypotension, dizziness Falls, Fractures Disinhibiting Akathesia, Ataxia, weakness Amnesia, headache Increased Risk of Dementia Prospective Population based study in France 1063 men & women, free of Dementia and did not start taking benzodiazepines until at least the 3rd year of follow-up 15 year follow up 50% increase in the risk of Dementia for patients that ever used a benzodiazepine versus those who never used

Long acting agent should NOT be used unless shorter acting medication has failed Insomnia and Use of hypnotics Sleep cycle deteriorates with age Hypnotics provide minimal improvements on sleep latency and duration with high risk of adverse events Underlying causes for insomnia should always be addressed prior to starting medication Environmental (light, noise, temperature) Physical (Pain, shortness of breath) Medications (including caffeine intake) Persons life long sleep habits Benzodiazepines for Insomnia

FDA labeled for Insomnia Lorazepam (Ativan) Oxazepam Estazolam Temazepam (Restoril) 7.5mg 15 mg Capsules QHS Hard to dose reduce because 7.5 mg capsules are more expensive Triazolam (Halcion)----NOT RECOMMENDED Short half-life Increased risk of anterograde amnesia Inability to create new memories Alprazolam (Xanax)-off label Consider using same benzo for insomnia that is being used for anxiety to minimize polypharmacy Non-benzodiazepine Hypnotics

Zolpidem (Ambien & Ambien CR, Intermezzo 5-10 mg (max 10mg) of immediate release 6.25-12.5 extended release Zolpimist Spray 5 mg / actuation Should only be administered when patient is able to stay in bed a full night Intermezzo- 1.75 or 3.5 mg SL tab for middle of night (>4 hrs left) Zaleplon (Sonata) 5 mg-20 mg at bedtime (max. 10 mg in geriatrics) for 7-10 days High fat meals prolong absorption Eszopiclone (Lunesta) 1-3 mg (2 mg max for geriatrics) Do NOT take with or immediately after a high fat meal

Rapid onset and should be administered when resident is already in bed and having difficulty sleeping Withdrawal can occur with abrupt discontinuance Chronic use >90 days NOT recommended Side Effects of hypnotic medications Abnormal thinking & behavior Decreased inhibition, aggression, agitation, hallucinations Worsen depression Suicidal ideation CNS depression Impairment of physical and mental capabilities Respiratory depression (caution with COPD & apnea)

Sedation, Delirium Falls, Fractures Angioedema and anaphylaxis Complex sleep-related behavior Driving, making phone calls, preparing food while asleep with no memory Use of sedating Antidepressants to help sleep Trazodone Unlabeled but common use 25 mg 150 mg at bedtime less than antidepressant dose of up to 600mg /day in divided doses Orthostatic hypotension & Syncope QT prolongation & tachycardia (less than SSRIs)

Mirtazapine (Remeron) 7.5-15 mg QHS Also helpful with appetite Higher doses actually are less sedating and less effective for sleep and appetite Use of Antihistamines for Anxiety or Insomnia Not recommended due to Anticholinergic side effects and adverse effect on sleep architecture Diphenhydramine (Benadryl) In Tylenol PM Hydroxyzine (Atarax, Vistaril) Safely used for anxiety in younger adults

For a resident with allergies and anxiety consider Cetirizine (Zytrec) 5-10mg QHS Active metabolite of hydroxyzine with slightly less anticholinergic effect Selective Serotonin Reuptake Inhibitors (SSRIs) Increase the amount of Serotonin available in the Brain Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft), Fluvoxamine (Luvox) Most also FDA approved for Anxiety Adverse Effects: EPS (movement disorders)

Hypernatremia (low sodium) GI upset, nausea, GI bleeding Tremor, headache Decreased libido, sexual dysfunction Insomnia or somnolence Suicide (in early treatment, younger patients) Serotonin Syndrome Serotonin Syndrome Results from too much Serotonin in the brain Often occurs when more than one medication that increases serotonin SSRIs (Prozac, Zoloft, Celexa etc) SNRIs (Cymbalta, Effexor) Tramadol (Ultram) Buprenorphine (Butrans patch) Dextromethorphan (Robitussin DM) Buproprion (Wellbutrin, Zyban) Buspirone (Buspar) Anti Migraine medicines (Triptans Amerge, Zomig) TCAs (Amitriptyline, Nortriptyline)

Lithium Ondansetron (Zofran) St. Johns Wart, Ginseng Or agents that impair metabolism of serotonin Linezolid (Zyvox), IV Methylene blue Marplan, Nardil (MOAI antidepressants) Symptoms / Signs of Serotonin Syndrome Mental Status Changes Hallucinations Agitation, increased anxiety Delirium Coma Autonomic Instability

Tachycardia Labile blood pressure Diaphoresis, fever Neuromuscular changes Tremor Rigidity Myoclonus GI Symptoms Nausea / vomiting Seizures, coma, death Anxiety, Ankle clonus, agitation and tremor most common signs Antidepressants for Pain

Tricyclic Antidpressants Amitriptyline (Elavil), Imipramine (Tofranil) Nortriptyline (Pamelor), Desipramine (Norpramin) Side Effects:Hypotension, sedation, cardiac arrhythmias Duloxetine (Cymbalta) Approved for anxiety Approved for fibromyalgia, diabetic neuropathy, chronic pain Nausea, dry mouth, dizziness Hypertension Reduce dose if CrCl 30-60ml/min and contraindicated if CrCl <30 ml/min Mood Stabilizers for behavioral disturbances in Dementia Lithium More commonly used in Bipolar patients Narrow therapeutic index drug Adversely effects renal function and is cleared renaly

High risk of toxicity with dehydration and with medications that affect sodium excretion (ACEIs, diuretics, NSAIDs) Anticonvulsants Divalproex (Valproic acid, Depakote) Most commonly used for behaviors in seniors Better tolerated than other mood stabilizers in older adults Carbamazepine (Tegretol) Lots of monitoring required: cbc, thyroid, LFTs Lamotrigine (Lamictal) Gabapentin (Neurontin) Topiramate (Topamax) helpful in patients that need to lose weight Anticonvulsants for Mood Side effects: Sedation, confusion, falls,

Nausea, Low sodium, pancreatitis, low platelets, high ammonia levels Monitoring: CBC, Platelets, Liver function at baseline and every 6 months. Monitoring Serum levels for carbamazepine and valproic acid (every 612 months depending on dose) Maintain on minimum effective dose Other uses for Anticonvulsants

Seizure disorders Bipolar disorder Chronic pain Neuropathic pain Diabetic neuropathy Post-herpetic neuralgia Trigeminal neuralgia Post-Stroke pain Restless Leg Syndrome Watch for Polypharmacy with Gabapentin for neuropathic pain Gradual Dose Reduction (GDR) Guidelines

Antipsychotics Within the first year of admission or initiating of medication, attempt GDR during two separate quarters (with at least one month between attempts) Then at least annually thereafter Semi-annually if dementia with no behaviors More Aggressive Protocol: Consider GDR every quarter until behaviors emerge Limit PRN use to 1x doses or to 10 days when titrating routine doses Anti-Anxiety, Antidepressants, Anticonvulsants Within the first year of admission or initiating of medication, attempt GDR during two separate quarters (with at least one month between attempts) Then at least annually thereafter If used for pain dose reduction not recommended unless side effects Hypnotics Manufacturer Guidelines considered Attempt Quarterly

GDRs May be clinically contraindicated if target symptoms returned or worsened after dose reduction or physician has well documented rationale GDR Guidelines Other factors to consider How long it took to titrate to therapeutic dose and residents history of depression or anxiety Inherent physical dependence /withdrawal properties of the medication Dosage forms available, price, whether or not tablets can be split Number of different psychoactive medications resident is on and set priorities based on symptoms Is the resident experiencing side effects FALLS WEAKNESS TREMORS

Strategies to Reduce Inappropriate Psychoactive Medication Use Behavioral health Committee or team Consultant Pharmacist, Psychologist, Medical Director, Administrator, D.O.N. Activities, Therapy, Social services Direct care staff (Nurses, RMTs, CNAs) Meet at least monthly to discuss dementia patients, residents on antipsychotics or residents with problematic behavior issues Look for underlying causes of behavior Pain, medication side effects, metabolic conditions, psychosocial factors Consider gradual dose reductions Ensure supportive documentation Strategies to Reduce Inappropriate

Psychoactive Medication Use Educate Nursing Staff (including CNAs) regarding the use of Psychoactive Medications Which medications work for which symptoms Side effects to monitor Diagnosis and specific behaviors that must be documented to justify / support the use of the medication Consider implementing policy / Process No single nurse allowed to call and request and antipsychotic Psychoactive medications started by on-call physicians be reevaluated promptly by the behavior team ? References Advanced Copy: Dementia Care in Nursing Homes: Clarification to Appendix P State

Operations Manual (SOM) and appendix PP in the SOM for F309-Quality of Care and F329Unnecessary Drugs. Accessed online August 2013 at: http://surveytraining.cms.hhs.gov Billioti de Gage, S.,Begaud, B., Bazin, F. et al. Benzodiazepine Use and Risk of Dementia Prospective Population Based Study. BMJ. Accessed online Sept. 2013 at: http//www.medscape.com/viewarticle/771934. Cassidy, k.L., Rector, Neil A. The Silent Geriatric Giant: Anxiety Disorders in Late Life. Geriatrics and Aging. 2008;11(3):150-156 Cerejeira, J., Lagarto, and Mukaetova-Ladinska, E.B., Behavioral and Psychological Symptoms of Demetia. Published online 201 May 7. frontiers in Neurology. Guide to the Management of Psychotic Disorders and Neuropsychiatric Symptoms of Dementia in Older Adults. October 2012. Accessed online Sept. 2013 at: ht tp://dementia.americangeriatrics.org/GeriPsych_index.php Policy Statement. Use of Antipsychotic Medications in Nursing Facility Residents. Accessed online Sept. 2013 at: www.ascp.com The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. JAGS 2012. Accessed online September 2013 at: www.americangeriatrics.org Lexicomp online drug information: www.online.lexi.com

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