1. Reducing Medications in Persons with Dementia Helping to Brighten Someones Day!! Session W24 AMDA Annual Symposium March 7, 2003 Alva S. Buzz Baker, MD, CMD Arthur Riley, MS, PD

2. 2 Why Medications are Used in Persons with Dementia treatment of the dementing disease process treatment of the side effects or consequences of the dementing illness treatment of medical co-morbidities

3. 3 Treating the Dementing Illness Alzheimers disease –cholinesterase inhibitors –perhaps: anti-inflammatory agents Vitamin E vascular dementia –treating risk factors –cholinesterase inhibitors

4. 4 Treating the side-effects of the dementing illness delusions, hallucinations –neuroleptics agitation, anxiety –mood stabilizers, benzodiazepines depression –SSRIs disinhibition –mood stabilizers, amantadine, androgen blockade

5. 5 Treating medical co- morbidities most often treated –hypertension, arrhythmias, hyperlipidemia –diabetes –arthritis –UGI symptoms –COPD –prostate –skin

6. 6 Institutional Philosophy of Medication Use in Dementia tie em up or drug em down –low tolerance for the un-cooperative or hard-to-handle resident the wandering resident crying out –zero tolerance for resident-to-resident negative interactions

7. 7 Institutional Philosophy of Medication Use in Dementia tie em up or drug em down –lack of knowledge or understanding of dementia syndromes as an illness –lack of knowledge and skills in how to manage behavioral issues in persons with cognitive impairment –it takes less staff time and effort to use this approach as opposed to making every effort to optimize abilities

8. 8 Institutional Philosophy of Medication Use in Dementia But, these people need these medicines, dont they? –the Hospice experience: enter a near- dead dementia patient into Hospice (all) medicines stopped patient improves – 10 - 20% to where they no longer meet Hospice criteria (at least for a while…) subsequent care not an issue for caregivers

9. 9 Medication reduction Basic Questions –Do all persons with dementia need all the medications they are receiving? benefits of medication use: –ethical quality-of-life issues –bothersome (to resident) symptom control burdens of medication use: –deterioration in overall health status –decreased quality of life –medication side-effects, drug interactions –possible earlier death

10. 10 Medication reduction program process: medical director process: working to achieve reduction education –medical staff –nursing staff –residents and families

11. 11 Process: medical director flow sheet for medical director activity –need commitment from medical director –need commitment from DON and NHA –need cooperation of pharmacist

12. 12 Process: medication reduction program flow sheet for program process –education –pilot –minimize confounding issues –implement system-wide –use QI program as vehicle to sustain gains

13. 13 Process: education medical staff nursing staff residents and families

14. 14 Benefits of medication reduction program to residents/families to caregivers to facility

15. 15 Benefits: to resident and families gain of benefits and reductions of burdens cost savings to –responsible agent –facility –health care system

16. 16 Benefits: to caregivers increased feeling of doing the best for the residents they care for may, in fact, make it easier to provide care

17. 17 Benefits: to facility decreased medication costs decreased medication administration costs positive public relations and marketing spin (we have an active medication reduction program…) assist with complying with regulations and facilitating survey

18. 18 Medication Reduction Program: Example in action design program, do education do resident reviews conference: pharmacist and medical director, develop recommendations present recommendations to attending physician monitor results

19. 19 Results resident profile medication use in this cohort recommendations made and how received by attending physicians medication reduction –accomplished –failed examples

20. 20 Resident profile ItemMeanRangeComment Age (yrs)8269-92excl. 4 <65 (80) MMSE30-10excl. 2 >20 (4) Gender: male – 16% female – 84%

21. 21 Resident profile: dementia diagnosis

22. 22 Medication use in this cohort Mean # of Rxs: 7.29 Least # of Rx: 1 Highest # of Rx: 15

23. 23 Classes of medications in use and IDd Class/use# of Rxs# IDd Parkinsons155 Gut3318 Brain12117 CVS8020 Arthritis195 Diabetes130 Anticoags140 Other10619

24. 24 Brain drugs Type# of Rxs (# of Res.) # IDd CNI21 (20) 10 neuroleptic26 (21) 0 anti-depr51 (38) 6 benzo22 (18) 1 hypnotic10

25. 25 CVS drugs Type# of Rxs (# of Res.) # IDd HTN17 (16) 5 cardiac35 (24) 5 diuretic15 (14) 0 hyperlipidemia13 (13) 10

26. 26 Program at work: reduction ItemNumberPer Res.Comment Residents56-- Rxs4017.29 IDd for Reduction 82 meds (44 Res.) 1.9 (per Res. IDd) 20% of total Rxs Rx Reduced15 meds (14 Res.).34 Rx (per Res. IDd) 18% of IDd Rxs 4% of total Rxs $$ Reduced1,079.0019.27

27. 27 Medications reduced, by class Class/use# of Rxs# IDd# DCd Parkinsons1551 Gut33181 Brain121171 CVS80208* Arthritis1951 Diabetes1300 Anticoags1400 Other106193 * 7 = lipid lowering agents

28. 28 Reason for medication not being changed (82% of IDd)

29. 29 Discussion Considering the ethical, economic and operational aspects of a comprehensive medication-reduction program: Is it worth it?

30. 30 Think about it: maybe YOU could brighten someones day! Thank You!!