Psychiatric Consultation in Long-Term Care: A Guide for Health Care Professionals

12 Pharmacological Interventions

Pharmacological interventions are the primary treatments for many medical (e.g., moderate to severe pain) and psychiatric disorders (e.g., schizophrenia, bipolar disorder, recurrent MDD). Evidence-based pharmacological interventions, when used judiciously, have the potential to substantially improve the quality of life for many residents in long-term care facilities who are experiencing significant and persistent behavioral and psychological symptoms. Pharmacological interventions during psychiatric emergencies (e.g., physical aggression toward oneself and/or others) may be life saving not only for the resident, but also for others (e.g., staff members, other residents ). Despite these benefits, pharmacological interventions need to be used judiciously in LTC populations, because their use is associated with a significant risk of increased morbidity and mortality. LTC residents often do not tolerate medications well (prescription as well as over-the-counter ones), and even small doses may cause intolerable adverse effects. This is due to age and medical-illness-related changes in the disposition of a medication; altered sensitivity to the medication’s adverse effects; complicated medication interactions because of polypharmacy; multiple comorbidities ; and an impaired ability to physiologically compensate for even minor nuisance effects (e.g., mild sedation, nausea). The need to minimize risk and enhance outcomes in clinical practice entails taking into consideration all these age-related complications. There can be tremendous heterogeneity between residents in each of these areas, and there is often a lack of rigorous data on the efficacy and safety of many of the medications prescribed for LTC populations. Thus the task of managing medications for all residents, and particularly for residents who are frail, is complex and difficult. In adC H A P T E R 12 Pharmacological Interventions P H A R M A C O L O G I C A L I N T E RV E N T I O N S 297 dition, race and culture may irrationally influence prescribing patterns. For example, elderly African Americans are three times less likely to receive antidepressants than Caucasians, and atypical antipsychotics (compared with conventional antipsychotics) are more likely to be prescribed for middle-class Caucasians than for African Americans, perhaps because of their higher cost. Pharmacological interventions for behavioral and psychological symptoms in LTC populations involve much more than the prescription of psychotropic medications. Table 12.1 lists pharmacological interventions for the prevention and treatment of behavioral and psychological symptoms in LTC residents. Minimizing Medication Errors A substantial number of daily medications are given in LTC facilities, and medication errors are common in LTC populations. The most common errors involve medications given at the wrong time (young et al. 2008). Other common errors include a wrong dose given, a dose omitted, an extra dose given, an unauthorized drug given, or a wrong drug given. Medication errors carry the risk of adverse effects on cognition, behavior, and psychological well-being; they may also be fatal. Residents who are taking high-risk medications (e.g., warfarin) and residents with complex health problems are especially at risk of serious adverse consequences of medication errors. All LTC facilities should have policies and procedures in place to minimize medication errors. We recommend a systems-based approach to medication errors that T A B L E 1 2 . 1 Key pharmacological principles for the prevention and treatment of behavioral and psychological symptoms in the long-term care population Minimize medication errors (wrong drug, wrong dose, drug not given/taken) Reduce the use of potentially inappropriate medications Improve the prescribing of appropriate medications Reduce and treat adverse drug events Prevent and treat drug-drug interactions Reduce the medication burden (i.e., reduce the number of medications and/or the amount of medication consumed) Address psychiatric aspects/manifestations of medical problems (e.g., pain, constipation, falls, fractures, osteoporosis, seizures) commonly encountered in residents with behavioral and psychological symptoms Consider pharmacological interventions for cognitive impairments in residents with dementia Consider pharmacological interventions for persistent behavioral and psychological symptoms and for chronic and persistent mental illnesses 298 P S y C H I AT R I C C O N S U L TAT I O N I N L O N G - T E R M C A R E assumes that individuals are doing their best. Such an approach should use proven protocols and processes that ensure effective communication, consistent knowledge and education, and a means of flagging errors and potential problems. We also recommend institutional safeguards to minimize medication errors. CLINICAL...