Frank Grosso, Rph

The use of antipsychotic medications in long-term care has been an ongoing target for scrutiny because of concerns with appropriateness and safety in older adults with dementia. Recently, the U.S. Government Accountability Office released a report showing that antipsychotic medications are frequently prescribed to older adults with dementia.

The GAO recommend in 2012 that the Department of Health and Human Services expand its outreach and educational efforts aimed at reducing antipsychotic drug use among older adults with dementia to include those residing outside of nursing facilities by updating its National Alzheimer’s Plan, which is implemented at the state level. (These state government action plans can be accessed on the Alzheimer’s Association Web site).

Various tactics to address overprescribing of antipsychotic medications are employed within the states; however, there is little or no mention of how pharmacists and pharmacies can be used to help address this public health concern.

The Centers for Medicare & Medicaid Services has taken steps to help reduce this risk of psychotropic overprescribing with an initiative to decrease the rate of antipsychotic use for treating behaviors associated with dementia and to improve dementia care in nursing facilities. One tactic to reduce use has been through educating state coalitions and asking stakeholders to be involved in the initiative.

Pharmacists are identified as a valuable team member in this initiative by helping to educate (e.g., academic detailing, in-service trainings) and address clinical concerns (e.g., monitoring, asking for appropriate documentation and justification for antipsychotic medication use, accessing cost-effective/safe choices) prior to initiating prescriptions for antipsychotics. In addition, pharmacists are increasingly asked to be part of the behavioral health teams to ensure that there is an appropriate indication for all medication use and that ongoing effectiveness and adverse event monitoring is being implemented. This is critical because many side effects emerge early in the treatment course that could eventually lead to negative outcomes such as falls or a decrease in day-to-day functioning. Outside of nursing facilities, family members and caregivers may not understand the possible adverse events secondary to antipsychotic treatment or how to assess whether their loved one is benefiting from the medication. This is where specially trained senior care pharmacists can help meet these needs and address caregiver concerns.

When working with patients and caregivers, there are some simple steps to optimize use of antipsychotics or any medication that might be used to address neuropsychiatric symptoms (e.g., agitation, hallucinations, delusions) or associated behaviors (e.g., screaming, hitting). These include:

  • Obtaining details about the patient and his/her symptoms (nature, frequency, severity, and duration of symptoms) and risks of not treating, which could include harm to self or others
  • Determining appropriateness of proposed treatment by matching patient-specific details to the known indications and the potential complications for a treatment
  • Considering medications only after ruling out potentially remediable causes of symptoms (e.g., pain or other unmet needs) by other nonpharmacologic means and trying to limit use to individuals whose symptoms are severe enough to adversely affect functioning and quality of life
  • Monitoring often so that benefits as well as complications can be identified in a timely fashion
  • Using the lowest effective dose for the shortest possible duration, based on evaluation of the specific individual
  • Tapering the medication when symptoms have been stable at least for several months or adjusting doses to obtain benefits with the lowest possible risk
  • Monitoring closely for adverse consequences that can be attributed to the medications (e.g., falls, worsening confusion) and reducing or stopping doses if adverse consequences are identified

The American Society of Consultant Pharmacists will continue to work not only with professional organizations (e.g., AMDA – The Society for Post-Acute and Long-Term Care Medicine, College of Psychiatric and Neurologic Pharmacists), and consumer advocacy organizations (e.g., National Consumer Voice for Quality Long-Term Care, National Council on Aging). This will increase the involvement as well as the visibility of pharmacists in improving the appropriate use of antipsychotics across all care settings.

Frank L. Grosso, RPh, is the executive director and CEO of the American Society of Consultant Pharmacists. Nicole J. Brandt, PharmD, MBA, CGP, BCPP, FASCP, is President-Elect, American Society of Consultant Pharmacists. She also is a professor at the University of Maryland, Baltimore, School of Pharmacy and the director of Clinical and Educational Programs of the Peter Lamy Center for Drug Therapy and Aging.