Medication interactions can disrupt and ruin successful dementia treatment, says John Marek, President of the American Society of Consultant Pharmacists.
Doctors have used the same arsenal of drugs for years to treat dementia in elderly patients. But the aging population has dramatically changed thereby calling for more sophisticated drug strategies. For example, says Marek, “Our skilled nursing patients are older than they used to be. “We’re now treating the oldest old, which enhances problems with liver and kidney function and can exacerbate the length and strength of a medication’s effects and how it is absorbed.”
The Beers Criteria lists about 200 drugs that should be avoided for residents with dementia because they have a high potential for adverse events and high risk such as renal failure. Close monitoring by staff is key as cases of renal failure and cardiac incidents have been reported.
Specific complications arise with dementia medications. For example, Aricept and Benadryl are opposed pharmacologically and may cancel each other out, Marek warns. Drugs like diphenhydramine have been available over the counter for so long, people often self-administer them. They are unaware of medication interactions. Yet this drug class carries a 31 percent increased risk of death. Marek explains.
Dementia also can mask reactions to other medications that require diligent monitoring. For example, Coumadin/warfarin is one of the most dangerous drugs out there, as its affects on blood flow can swing wildly even on a daily basis. In short, medication management is a daily task and is patient specific. Frequent medication reviews and communication between the skilled nursing facility, hospital, and primary care doctor, are necessary.
The scenario is familiar to most caregivers: A resident with dementia begins to lose weight, so the physician prescribes an antidepressant. Then the resident experiences sudden sleep problems, so caregivers add a sleep aid. Now the resident shows signs of confusion and sluggish gait, skyrocketing the risk of falling. Meanwhile, the combination of Aricept and Benadryl has resulted in the side-effect of incontinence, leaving the resident open to urinary tract infections that will require antibiotics.
Skilled nursing caregivers can play an important role in helping residents avoid the “medication cascade.” Documenting and reporting side effects, and flagging symptoms that are new, can help prescribers and pharmacy consultants fine tune the medication. It may actually be possible to eliminate some of the prescriptions.
One of the most dangerous situations, and one of the easiest to correct, is the “whenever, forever” prescription. Doctors need to know for how long to prescribe the medicine, and patients need awareness that clashing medications can include antipsychotics to antihistamines. New rules are already under way on prescribing durations for sedatives and antibiotics. These prescriptions will be reviewed every two weeks before a re-order can be authorized.
“Just because a resident is on a med doesn’t mean it’s going to work,” Marek says. “Medications must be integrated into the care plan. What’s the goal? How long is the med expected to be part of the plan? How often will it be evaluated?” Electronic health record (EHR) alerts can help, but only if the medical record is completely up to date, he adds. “EHRs are great, but don’t get lazy on process. Review meds every time there’s an interaction with the resident. They may have forgotten to say they’re taking a new med or that they are no longer taking one, but it’s still stuck in the record.”
Training caregivers to document all medication instructions and administration durations is a proactive habit, even for over-the-counter medications. “Educate your prescribers to put an expiration date on all PRN orders,” Marek warns. “Sooner or later it’s going to be a rule.”
Get rehab and healthcare news from Ditmas Park Rehab Center