Overuse of antipsychotics a growing concern

Overuse of antipsychotic drugs is a growing concern.

Antipsychotic medications and the risks associated with their use in nursing homes to treat dementia is an issue of growing concern in the U.S. An interprofessional approach, enlisting pharmacists to work closely with other providers, is key to addressing the issue to ensure that dementia patients receive the most benefit from their treatment. As a pharmacist who actively works with older adults across the continuum of care, I am witnessing the growth of our population of seniors as the baby boomers age. This increasing number of older adults lends even more significance to the treatment issues surrounding older Americans. The topic has seen a flurry of news coverage lately, including a recent series by NPR.

In Maryland, numerous stakeholders, including the University of Maryland School of Pharmacy, are actively developing a multipronged approach not only to reduce the use of antipsychotics but also to improve the care and support for patients with dementia. The School of Pharmacy supports interprofessional education initiatives and clinical training in dementia care to help health care providers learn about the risks of antipsychotics and alternative ways of treating elderly patients. Initiatives like these are critical to making the next generation of providers aware of the issue and to raising awareness of the risks among patients and their families.

The Food and Drug Administration acted on the issue of antipsychotics and the elderly 10 years ago, issuing a warning regarding the increased risk for cerebrovascular events, such as strokes and transient ischemic attacks, associated with the use of all antipsychotics in older adults with dementia. The U.S. Centers for Medicare and Medicaid Services, the federal agency that administers Medicare and Medicaid, since then has taken steps to help reduce this risk with its initiative to decrease the rate of antipsychotic use and improve dementia care in America's nursing homes. In Maryland, providers and students, from pharmacists to nurses to geriatricians, need to heed these actions and recognize the risks of antipsychotic medications as well as when their use may be appropriate.

The entire health care team needs to work collaboratively to assess the risks and benefits of antipsychotics and to develop individualized treatment plans for each patient. Providers must avoid using potentially inappropriate medications such as antipsychotics as stopgap measures to control unwanted or inconvenient behavior. In Maryland, many nursing homes are instituting quality assurance programs to engage nursing home staff, medical providers and pharmacists in clinical decision-making about the appropriateness of medications such as antipsychotics. These tactics are also being used in the inpatient care setting. For instance, Sheppard Pratt Health System has instituted a multidisciplinary approach that involves psychiatrists, nurses, pharmacists and music, occupational and rehabilitation therapists collaborating to reduce the use of antipsychotics as well as improve transitions in care for patients with dementia.

Health care professionals can take several simple steps to optimize use of antipsychotics in the treatment of neuropsychiatric symptoms such as agitation, hallucinations, delusions or associated behaviors, like screaming or hitting. They should consider such medications only after ruling out alternative causes of symptoms, such as pain or unmet needs. Use of antipsychotics should be limited to those patients whose symptoms are severe enough to adversely affect function and quality of life. Patients should be closely monitored in order to track benefits and identify complications as quickly as possible. Providers should begin treatment with the lowest effective dose for the shortest possible duration, based on the specific patient. Providers should try to taper the medication when symptoms have been stable for several months. Patients should also be watched closely for adverse consequences that could be traced back to the medications — such as falls, worsening confusion or malaise — and reduce or stop doses if such consequences are found.

As a pharmacist who works with both dementia patients and caregivers, I know that awareness of this issue among providers and families is key to making sure antipsychotics are used appropriately in the care of older adults with dementia across all settings of care. Ongoing support for and the proliferation of interprofessional training and clinical initiatives in dementia care, like those at the University of Maryland School of Pharmacy, are paramount to reducing the use of antipsychotics. Such programs are vital to improving the delivery of care for patients with dementia in both the community and in nursing homes.

Nicole Brandt is a professor of pharmacy practice and science at the University of Maryland School of Pharmacy. Her email address is nbrandt@rx.umaryland.edu.

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