Abstract

Introduction: As the population ages, the prevalence rate of behavioral and psychologic symptoms of dementia (BPSD) rises, and there appears to be an increasing need for pharmacologic treatment where nonpharmacologic treatment would not suffice. Most clinicians are well aware of the increased risks of cerebrovascular event and mortality from antipsychotic use in older adults with dementia. Nevertheless, mortality risks reported in various publications still vary considerably and lack consistency to allow direct comparison between individual drugs.

Methods: A literature search was conducted for primary and secondary sources of evidence regarding the mortality risks associated with antipsychotic use in BPSD.

Results: Available evidence suggests that antipsychotics are indeed associated with elevated risks of cerebrovascular adverse events and mortality. There is also evidence suggestive of a varied risk among individual agents, and a dose-response as well as a time-response relationship.

Discussion: This review aims to provide an updated overview of the publications available on mortality data and risks associated with antipsychotic dose and duration of use. Confounders and limitations are discussed to allow clinicians to better make judgment calls on assessing risks and benefits when treating BPSD with an antipsychotic.

Abstract

Introduction: The updated American Geriatrics Society (AGS) 2015 Beers Criteria include the following antidepressant classes as potentially inappropriate medications to be used with caution in older adults: selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, tricyclic antidepressants, and mirtazapine.

Methods: A search of the medical literature using PubMed and references included in the AGS 2015 Beers Criteria.

Results: The treatment of depression in the older adult can additionally be complicated by comorbid conditions, as 80% of older adults have at least 1 comorbid condition and 50% have at least 2. These considerations limit the pharmacologic treatment options for depression in older adults. However, the treatment of major depression should not be overlooked, as it is quite common, with estimates of up to 5% of older adults in the community and up to 13.5% in older adults who receive home health care.

Discussion: This article reviews treatment considerations of depression in the older adult, including both available screening tools and a discussion balancing the need for treatment of depression in this population with the concerns addressed in the 2015 Beers Criteria.

Abstract

Parkinson disease (PD) is a common neurodegenerative disorder in older adults characterized by motor and nonmotor symptoms and complications. Impulse control disorders (ICDs), such as pathological gambling, compulsive shopping, compulsive sexual behavior (hypersexuality), and binge eating disorder, affect 13.6% of the PD population. Use of dopamine receptor agonists (DRAs) is considered a major risk factor for ICD development. Amantadine and a high dose of levodopa were linked to ICDs to a lesser extent than DRAs. Based on the severity of behavior(s), ICDs can negatively impact social, professional, and familial lives of patients and their families. Ideally, all PD patients taking DRAs, high doses of levodopa, and/or amantadine should be routinely asked about or monitored for ICDs during therapy initiation and continuation. Dose decrease or withdrawal of the offending agent, primarily DRAs, is usually the most effective first step in ICD management. Careful dose adjustment with close monitoring is warranted due to risk for worsening of motor symptoms or emergence of dopamine agonist withdrawal syndrome (DAWS). About 1/3 of PD patients with ICD who decrease or discontinue DRA experienced DAWS. The lowest dose of DRA will need to be continued to balance ICDs and DAWS as it is not alleviated by other dopaminergic or psychotropic medications. Other therapies with low empiric evidence, such as amantadine, naloxone, cognitive behavior therapy, deep brain stimulation, and psychopharmacotherapy showed mixed results for ICD management. It is crucial that clinicians are familiar with the psychiatric complications of PD, including ICDs, beyond mere recognition and management of motor symptoms.

Abstract

Introduction: The number of homebound older adults is expected to increase as the elderly population grows. Many homebound older persons may be at high risk for depression, which has been associated with adverse health outcomes. The objective of this study was to identify selected factors that may predict depression in the homebound older population.

Methods: Data from 340 homebound adults, aged 65 and older who were enrolled in Broward Meals on Wheels and who participated in a telephone survey were analyzed. Participants were asked to report demographic information, health status, medication-taking behaviors, mental health, and life satisfaction. Multiple regression analysis was used to identify predictors of depressed mood in this sample of older adults.

Results: The majority of the sample (aged 65–95 years; mean, 77 years) were female (76.5%), white (77.1%), and living alone (52.6%). Multivariate modeling indicated that difficulty remembering the number of prescribed medications to be taken, feeling groggy after taking certain medications, poor self-reported health status, taking anxiety medications, and less satisfaction with life explained 34% (adjusted R²) of the variance in predicting depressed mood (F = 33.1, df = 5, P < .001).

Discussion: Multiple factors related to medication use were identified that may contribute to higher levels of depressed mood in homebound older adults. These factors found in our study may be used to create a screening model to be used by pharmacists to identify homebound older adults who would benefit from further assessment for depression.

Abstract

Introduction: Clinical pharmacists have become an integral part of multidisciplinary medical teams, including in the area of psychiatry. Previous studies have shown that having pharmacists in multidisciplinary medical teams has led to improved medication use, reduction of adverse drug events, and improved patient outcomes. The purpose of this study is to conduct a quantitative and economic analysis of the impact of clinical pharmacist interventions during hospital rounds in an acute care psychiatric hospital setting.

Methods: This is a retrospective analysis of 200 clinical pharmacist interventions documented between September 2013 and September 2014. Clinical pharmacist interventions were classified into several categories and types. Only clinical pharmacist interventions made during multidisciplinary team rounds were included in the study. Descriptive statistics were used for the quantitative analysis of clinical pharmacist interventions. The acceptance rate was calculated. Only the accepted clinical interventions were included in the economic analysis. Economic outcome involved an assessment of cost saving and cost avoidance.

Results: The most frequent types of clinical pharmacist interventions were discontinuation of medications (38.5%), laboratory monitoring (26%), and medication order modification (13.5%). The most common reason for drug discontinuation was polypharmacy. Clinical pharmacist interventions were associated with a 92.5% acceptance rate. Two hundred clinical pharmacist interventions were associated with $6760.19 medication cost saving and $62 806.67 cost avoidance.

Discussion: Clinical pharmacist interventions during rounds in an acute care psychiatric hospital setting mostly involve medication order modification and laboratory monitoring. They are also associated with significant cost saving and cost avoidance.

Abstract

Background: Long-acting injectable antipsychotics (LAIAs) have been developed to decrease medication nonadherence. LAIAs are usually given biweekly or monthly, with the exception of new 3-month and 6-week formulations. There has been no known evaluation regarding whether the frequency of LAIA formulation affects adherence. The purpose of this study is to evaluate whether there is a difference in adherence between LAIAs administered biweekly or monthly.

Methods: Eligible participants were identified from the Louis Stokes Cleveland VA electronic medical record as having an active prescription for a LAIA between September 1, 2009, and September 1, 2014. Participants were then evaluated using inclusion and exclusion criteria to determine study entrance. Medication possession ratios (MPRs) were calculated for each participant to determine adherence for comparison of objectives. Descriptive statistics and t tests were used to identify significant differences between groups.

Results: There were 128 participants enrolled based on eligibility criteria. There were no differences in MPRs for biweekly versus monthly administered LAIAs (0.98 versus 0.97, respectively; P = .691). No differences in adherence were observed between first- and second-generation LAIAs (0.98 versus 0.98, respectively; P = .975), or for risperidone LAI versus paliperidone palmitate (0.97 versus 0.99, respectively; P = .269). Hospitalizations were observed to decrease by 61% after LAIA initiation (P = .021).

Discussion: Based on the findings of this retrospective cohort review, there was no difference in adherence in patients prescribed biweekly versus monthly injected LAIAs. Patient preference and response, safety, tolerability, cost, and availability of follow-up appointments should be other factors to take into consideration for agent selection.

Abstract

Introduction: Nonadherence with oral antipsychotics in patients with schizophrenia has been associated with symptom relapse and rehospitalizations, resulting in increased morbidity and health care costs. Long-acting injectable antipsychotics (LAIAs) are an alternative to enhance adherence and decrease relapse requiring hospitalization. The objectives of this study are to determine the impact of LAIAs on reducing length of stay, the rate of annual readmissions, and the number of failed annual discharges (defined as a readmission in less than 30 days) in patients with schizophrenia or schizoaffective disorder admitted to an acute inpatient psychiatric unit.

Methods: Using the hospital database, 52 patients receiving a diagnosis of schizophrenia or schizoaffective disorders treated with oral antipsychotics and later transitioned to LAIAs were evaluated retrospectively.

Results: Patients treated with LAIAs did not show a statistically significant reduction in length of stay compared with their length of stay on oral antipsychotics. Patients treated with LAIAs experienced a statistically significant reduction in the rate of annual readmissions and a reduction in the number of failed annual discharges, although the latter was not statistically significant (P = .076 when compared to treatment with oral antipsychotics).

Discussion: These findings suggest a potential role for maintaining patients with a diagnosis of schizophrenia or schizoaffective disorder on LAIAs to prevent relapse and rehospitalizations. The reduction in the number of failed annual discharges between the oral versus LAIA group, although not statistically significant, warrants further investigation to determine the impact of LAIAs on readmission within 30 days.

Abstract

Introduction: The purpose of this review is to evaluate the direct delivery of health care to veterans before and after incorporating clinical pharmacy services within primary care mental health integration (PCMHI) at the Tuscaloosa Veterans Affairs Medical Center. Prior to establishing the role of the clinical pharmacy specialist (CPS) within PCMHI, the primary care providers deferred all mental health assessments to specialty mental health. As the demands of the service grew exponentially, assistance from clinical pharmacy was critical.

Methods: A randomized, computer-generated list of 114 patients selected for the retrospective chart review was used to evaluate clinical outcomes in patients enrolled in the PCMHI clinic 1 year preincorporation and postincorporation of CPS. Outcome measures included the number of patients discharged from the PCMHI clinic upon achieving therapeutic goals or discharged to specialty mental health due to therapeutic failure or adverse drug events with first- and second-line psychotropic agents.

Results: When contrasting the end points, there was a 60% increase in the number of patients who achieved therapeutic goal and a 32% decrease in the number of patients discharged to specialty mental health clinic postincorporation of CPS into PCMHI as compared to preincorporation of CPS (P = .024).

Discussion: The results support the significance of CPS in the PCMHI in providing pharmacotherapy, patient education, and medication monitoring for managing psychiatric conditions, such as depression, anxiety, and insomnia. In addition, patients had greater accessibility to medication and frequent monitoring and follow-up, ultimately improving patient outcomes.