Description
As a consultant pharmacist I manage multiple medication regimens for patients who are often times at a very advanced stage of Allzhiemer's with Dementia. My current career objective is to provide house psychiatrists with updated CMS guidelines on the use of psychotropic medications. Specifically antipsychotics, as well as the use of medications which have anticholinergic adverse effects. Recently I came across a peer reviewed paper in a long term care journal that showed statistical significance in patients who were prescribed antipsychotics had a 50% increased risk of falls. These falls often lead to skin tears, broken limbs, etc. An additional peer reviewed paper researched the correlation between the number of anticholinergic medications in long term care and a direct relation to a significant decrease in cognitive function. Patients prior to taking the anticholinergic medications could all independently do their Activitiess of Daily Living. As the number of anticholinergic medications increased, the patients were no longer to do these independently, often times the nursing assistant doing all the ADL's. Another area of antipsychotics is the misnomer that they are no sedative. Now they may not directly sedate the patient, but without a douby patient gait is altered. ( increasing risk of falls ), reaction time is slowed significantly, speech is slow and slurred. At the 12 or so facilities I practice at, I religiously asked psych to attempt GDR's every 6 months. This excludes shizophrenics. Anticonvulsants now used regularly for behavior problems in my opinion has no evidence of efficousy. I can't definitevly say what the levels in a peer reviewed paper were when treating Bipolar patients, but they were just about at par with accepted levels used for seizure patients. For example, I work with a psych doctor and he doses Depakote Sprinkles 125 mg at bedtime, and levels come back <10. The patient still yells and screams obscenities and I tried convincing him the current dose is ineffective if these behaviors continue. He ignored my professional opinion and the patient still today is not stable. I have no problems admitting I'm young in this profession and continue to learn daily, and he refuses to take my advice as the facilities drug expert. With that said, my goal as a consultant pharmacist would be to form a P & T committee and devise a formulary of medications that are safe and effective in geriatric patients. Using BEERs criteria as a resource, and accumulating more information on the disease process of Aolzhiemer's. With the natural progession of the disease and atrophy of the brain. Do antipsychotics really produce a significant benefit to patients over the risk presented on the black box warning? Inservices are a must with LVN's and CNA's when monitoring pain. 80% of the pain management flow sheets I review, the patient complains of a pain level of 9. Then on all follow ups: 30 minutes, hour, 2 hours. Miraculously the pain levels are all zeros, which we know that patient's in pain don't ever reach a pain level of zero. Behavior flow sheets are another serious problem. When the patient requires an Ativan, the reason documented is stress. This needs to be more specific.. Were the bitting their nails, pulling their hair, scratching themselves, becoming agitated at roomates. This documentation is essential to evaluating if the current regimen is working.
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