APPROPRIATE USE OF ANTIPSYCHOTIC DRUG THERAPIES

To advocate for the documentation of appropriate indication and goals of therapy to promote the judicious use of antipsychotic drugs and reduce the potential for harm; further, 

To support the participation of pharmacists in the management of antipsychotic drug use, which is an interprofessional, collaborative process for selecting appropriate drug therapies, educating patients or their caregivers, monitoring patients, continually assessing outcomes of therapy, and identifying opportunities for discontinuation or dose adjustment; further,

To advocate that pharmacists lead efforts to prevent inappropriate use of antipsychotic drugs, including engaging in strategies to detect and address patterns of use in patient populations at increased risk for adverse outcomes.

Rationale

Antipsychotic drugs are often prescribed and continued in nursing homes after transition from other care settings without appropriate justification. Although there is currently no FDA- approved drug for behavioral and psychological symptoms of dementia (BPSD), antipsychotic drugs are consistently used off-label for BPSD. According to the Agency for Healthcare Research and Quality, there is medium-level evidence to suggest effectiveness of olanzapine, risperidone, and quetiapine to reduce agitation and behavioral disturbances for people with dementia.

Some nursing homes are turning away patients with these conditions because of changes to the CMS Five-Star Quality Rating System for nursing homes, which includes two quality measures on antipsychotic drug use. These quality measures exclude patients with schizophrenia, Huntington’s disease, and Tourette syndrome.

Antipsychotic drugs have a black-box warning for increased mortality in the elderly population. In certain patients there is a benefit for use, and these patients may require more intense monitoring and assessment. Some studies suggest a significant increase in cognitive function for Alzheimer’s patients with aggressive behavior (Vigen 2011). Another study (Bonner 2015) looked at rationales for prescribing and found vague, generalized indications such as anger and agitation, which is not appropriate, according to guidelines. Nonpharmacological interventions are also supported in managing BPSD. These interventions may be more appropriate in the elderly population, despite being time consuming and labor-intensive in recent years, the use of antipsychotics has expanded into the prehospital setting, most commonly with the ketamine, a dissociative anesthetic used as a treatment for the control of delirium in acute psychotic emergencies. Ketamine has been shown to be an effective treatment for this condition but does not come without risks and should be used in the appropriate clinical scenario. The American Society of Anesthesiologists and American College of Emergency Physicians recently issued a joint statement on the Safe Use of Ketamine in Prehospital Care that opposes its use for conditions other than pain management, sedation, excited delirium syndrome, and drug intoxications, as reports of using this medication as a chemical restraint outside of these indication were on the rise, often with deadly effect.