Page 76 - rp-may-2020

CPD ACTIVITY 74
RET AIL PHARMA C Y • MA Y 2020
dose of 2.5mg may be given once daily,
with dose increases of 2.5mg every two
or more days if necessary, to a maximum
daily dose of 10mg.
24
Behavioural and psychological
symptoms in dementia are variable over
time, so ongoing therapy may not be
necessary or appropriate. Guidelines
14
suggest the ‘start low, go slow’ strategy
for antipsychotics: starting with a low
dose and avoiding rapid titration, using
one drug at a time, regular monitoring,
and reviewing every 12 weeks with
a view to reduce the dose or cease
treatment if possible.
6, 14
When initiating
a psychotropic, the efficacy and adverse
effects should be reviewed weekly.
24
Benzodiazepines
The use of benzodiazepines for the
treatment of behavioural problems,
particularly in dementia, is generally
discouraged due to potential adverse
effects.
12, 13
Some adverse effects are
counterproductive and can include
paradoxical excitation, aggression,
and hostility. Adverse effects are more
19
common in the elderly population.
The frequency of adverse effects
increases with age. If benzodiazepines
25
are necessary, they should be
prescribed at the lowest effective dose
and only for limited duration. The
25
Therapeutic Guidelines recommend
the use of oxazepam 7.5mg up to three
times a day if required for severe anxiety
and agitation, but state that this should
not be used for more than two weeks.
24
Other medicines
Other classes of medicines that
have been considered include
antidepressants and anticonvulsants, but
limited data currently supports their use.
Sertraline and citalopram were
superior in treating symptoms of
agitation compared with placebo in
dementia sufferers, but more research
is needed to confirm safety and efficacy
for this indication. An Australian study
26
found that more than 16 per cent of
nursing home residents were prescribed
a sedating antidepressant, with
mirtazapine being the most common.
1
Anticonvulsants such as valproate have
been investigated for efficacy and safety
in agitation associated with dementia.
Evidence suggests that valproate isn’t
effective for this indication, but does
have an increased risk of adverse
effects, leading to the recommendation
that it not be researched further in
this setting.
27
The role of the pharmacist
Pharmacists have been identified as
able to assist with addressing the issue
of overreliance on psychotropics in
aged care.
The RedUSe study, a clinical trial
conducted in 150 residential aged
care facilities around Australia,
demonstrated that targeted
interdisciplinary interventions can
decrease regular psychotropic
medication prescribing without
these being substituted with other
PRN psychotropics or sedating
antidepressants. The interventions
16
used in the RedUSe study used
psychotropic medication audits,
feedback, education sessions and
collaboration between accredited
consultant pharmacists and nurses.
16
The interim report from the Aged
Care Royal Commission highlights the
usefulness of regular and targeted
reviews (residential medication
management reviews) conducted by
accredited consultant pharmacists,
and recognises pharmacist medication
reviews for residents as an evidenced
based method of reducing psychotropic
use. As medicine experts, pharmacists
4
can play a key role in reviewing the
medicines of nursing home residents,
both in identifying medicines potentially
contributing to a patient’s behaviour
and reviewing any psychotropic
medicines prescribed.
13
Conclusion
A high proportion of people with
dementia live in residential aged
care. Behavioural and psychological
symptoms of dementia are common.
This results in a need for management
strategies for challenging behaviours.
While psychosocial interventions are
recommended first line, a variety of
factors influence the choices made by
prescribers and staff when selecting a
treatment strategy for a patient. These
include staff knowledge, staff availability
to implement the chosen treatment, and
the ease of implementing the treatment.
Psychosocial interventions are often
more time consuming to implement,
and for individual patients can involve
trial and error. It’s likely that these
factors have contributed to the apparent
overreliance on chemical restraint
in Australian residential aged care
facilities. An interdisciplinary approach,
including pharmacist input and regular
review, can help to reduce the use of
chemical restraint and the prescribing of
psychotropic medicines to residents of
aged care facilities.
FROM PAGE 73
References
1. Westbury J, Gee P, Ling T, Kitsos A, Peterson G.
‘More action needed: Psychotropic prescribing in
Australian residential aged care’.
Aust and NZ Journ
Psych
, 2019; 53 (2): 136-47.
2. Simoni-Wastila L, Wei YJ, Luong M, Franey
C, Huang TY, Rattinger GB, et al. ‘Quality of
psychopharmacological medication use in nursing
home residents’.
RSAP
, 2014; 10 (3): 494-507.
3. Prime Minister of Australia. Royal Commission into
Aged Care Quality and Safety [media release] (2018
Sep 16) [cited 2020 Mar 02]. [Available from: https://
www.pm.gov.au/media/royal-commission-aged-care-
quality-and-safety.
4. Briggs L, Tracey R. Interim report: Neglect. Royal
Commission into Aged Care Quality and Safety, 2019.