Due to the ever-expanding pool of psychopharmacologic agents available to treat mental health conditions, prescribers need to be vigilant about ensuring appropriate medication selection, evaluation, and monitoring. In response to this need, the Office of Mental Health Operations, Mental Health Services, and Pharmacy Benefits Management Services launched the Psychotropic Drug Safety Initiative (PDSI) to improve evidence-based psychotropic prescribing habits within the VA. Considering the large geriatric population in the VA, PDSI was particularly concerned with benzodiazepines and antipsychotic medications.
Background
The management of neuropsychiatric symptoms (NPS) for dementia is particularly burdensome to patients, caregivers, and prescribers. When nonpharmacologic interventions fail, patients are often prescribed antipsychotic medications to target these symptoms. The FDA has issued a black box warning regarding an increased risk of death associated with the use of both first- and second-generation antipsychotics for the treatment of dementia-related psychosis. 1 Due to these risks, tapering or discontinuing these medications should be considered at regular intervals.
Recently, the Centers for Medicare & Medicaid Services (CMS) expanded its goal to reduce antipsychotic use in nursing facilities by 25% by the end of 2015 and 30% by the end of 2016. 2 A review investigated the impact of withdrawal vs continuation of antipsychotic medications in the setting of Alzheimer dementia (AD) and found that antipsychotic medications could be withdrawn without detrimental effects on patient behaviors. 3 However, the study also noted that those patients with severe NPS at baseline or who had a history of positive response to an antipsychotic might be at increased risk of relapse or have a shorter time to relapse when antipsychotic medications are withdrawn.
Benzodiazepines as a class may be used for many indications, including anxiety disorders, seizure disorders, sleep disorders, or muscle spasms. However, due to known risks of cognitive impairments, sedation, falls, or dependence and addiction, these agents are typically recommended for only short-term treatment. These risks are potentially amplified in a geriatric population, because elderly patients have an increased sensitivity to the effects of these agents and may have impaired hepatic or renal function, leading to accumulation.
Due to these risks, the American Geriatrics Society (AGS) recommends against the use of any benzodiazepines for the treatment of insomnia, agitation, or delirium. Additionally, the AGS recommends that use of these agents for the treatment of behavioral problems related to dementia be reserved for those who have failed nonpharmacologic options and are at risk to themselves or others. 4
Growing evidence suggests that benzodiazepine use may increase the risk of developing AD. A recent casecontrol study compare records of 1,796 patients with an AD diagnosis to 7,184 patients with no cognitive deficits. This study found that patients with a history of benzodiazepine use had a 51% increase in risk for AD. Additionally, use of long-acting benzodiazepines, such as diazepam and clonazepam, was strongly associated with the development of AD. 5 These data further illustrate the importance of minimizing the use of benzodiazepines.
To ensure proper use of these 2 classes of medications, clinical pharmacy specialists (CPSs) at the Lexington VAMC (LVAMC) in Kentucky began conducting psychotropic medication reviews (PMRs). Each PMR contained a brief summary of evidence-based recommendations (both pharmacologic and nonpharmacologic) and a clinical review of the patient’s medication history, including an evaluation of the appropriateness of current therapy and supportive documentation. Patients were candidates for PMR if they met one of the following criteria: (1) use of a benzodiazepine in a patient with dementia; (2) use of a benzodiazepine in a patient aged > 75 years; and (3) use of an antipsychotic in a patient with dementia. These criteria were selected based on guidance set forth by the PDSI. The figure provides a sample of the PMR template in the electronic medical record (EMR).