1. Returning to a sense of calm is good medicine, say experts. This should help the use of antipsychotics trend in the right direction.
“Keeping the brain and body engaged as much and for as long as possible is the best medication to combat use of psychoactive medications,” said Lori Newcomb, RPh, BCGP, geriatric pharmacist consultant at Guardian Pharmacy of Atlanta.
iN2L CEO Lisa Taylor agreed.
“Connecting residents to meaningful experiences has been proven to engage and calm them, creating a positive intervention in situations where PRN medication might otherwise be used,” she said.
Kim Blackmon, Pharm.D., a consultant pharmacist for Turenne PharMedCo, said confining resident activities to smaller “pods,” or groups should help residents ease back into routines safely, calmly and purposefully.
2. Tap into the vast array of non-pharmacologic therapies that stimulate the senses.
Chad Worz, PharmD, BCGP, chief executive officer of the American Society of Consultant Pharmacists, said sensory activities, such as watching movies, or tactile activities, including art therapy or gardening, can sometimes be more beneficial.
“If symptoms become harmful, these approaches may only serve to help alongside medications,” Worz added.
Erin Foti, PharmD, BCGP, director of consulting services for Remedi SeniorCare, relies strongly on consultant pharmacists to reduce unnecessary medications. As “deprescribing advocates,” her pharmacists “look for non-pharmacological interventions.”
“While it is always important to consult with a medical professional, there is a growing body of research for herbs and their use in stress management,” said Joe Kramer, vice president of sales, Geri-Care Pharmaceuticals Corp. These can include ashwagandha (Withania somnifera) and melatonin (for sleep).
3. COVID has required special considerations in seniors when dosing antipsychotics, according to experts.
“The decision to prescribe antipsychotic drugs needs to be considered with extreme caution, especially for residents residing in memory care,” said Justin Williams, OTD, CDP, HealthPRO Heritage vice president of clinical strategies. “Those with Alzheimer’s disease and dementia who take these types of medications are at an increased risk for stroke and even death.”
Worz stressed the adage of “start low and go slow.”
“It’s important to recognize that it takes six to eight weeks to see the full effect of many medications used in these situations,” he said.
4. Pharmacists roundly defend what they see as a judicious and prudent use of higher levels of antipsychotics during the pandemic.
“The pandemic stressed the long-term care industry to the max and long-term caregivers were heroic in many ways. Often, use of an antipsychotic is necessary to prevent harm,” said PharMerica’s Marti Wdowicki, PharmD, director of clinical operations-South.
Wdowicki added that engaging in alternative analysis with a multi-disciplinary team would be helpful. Crisis management protocols with respect to antipsychotic prescribing could include specific criteria for appropriate use and a method for tapering and discontinuation post crisis.
As the environment returns to pre-pandemic, Wdowicki said providers need to re-visit and re-evaluate their medication regimens and “set a specific cadence” for potential tapering and discontinuation.
“A ‘set it and forget it’ mindset is the nemesis of antipsychotic medication management best practice,” she said.
“It comes down to clear diagnosis,” said Worz. “People with dementia and behavioral issues can be pleasant and non-threatening, but they can also progress to be harmful.
“There are a number of nonpharmacologic approaches that can be tried. The key is to be very patient-centric in these approaches as there are no non-pharmacologic approaches that work for everyone.”
5. Going forward, the lessons of the pandemic should provide evidence that prescribers approached the use of psychotropic medications with the same prudence and caution they began with.
“I don’t think anyone was ready for the isolation and the length of time people would be isolated and restricted from visitors,” said Worz. “That said, we should be more experienced going forward and work to learn what things did work during the pandemic and what we could have done sooner to reduce the negative consequences of those kinds of strategies.”
“When looking back to help drive psychotropic medication reduction efforts, it’s incumbent for the LTC community staff to stay engaged with the pharmacy that serves their residents,” added Newcomb.