1
|
Case Report: Performing a Medication Safety Review Assisted by Pharmacogenomics to Explain a Prescribing Cascade Resulting in a Patient Fall. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59010118. [PMID: 36676742 PMCID: PMC9863497 DOI: 10.3390/medicina59010118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/31/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023]
Abstract
Pharmacotherapy for major depressive disorder (MDD) typically consists of trial-and-error and clinician preference approaches, where patients often fail one or more antidepressants before finding an optimal regimen. Pharmacogenomics (PGx) can assist in prescribing appropriate antidepressants, thereby reducing the time to MDD remission and occurrence of adverse drug events. Since many antidepressants are metabolized by and/or inhibit cytochrome P450 enzymes (e.g., CYP2C19 or CYP2D6), drug-induced phenoconversion is common in patients on antidepressant combinations. This condition influences the interpretation of a patient's PGx results, overall risk of ineffective/adverse medication response due to multi-drug interactions, and the recommendations. This complex case describes a patient with MDD, generalized anxiety disorder, and chronic pain who experienced a fall due to excessive sedation following a prescribing cascade of fluoxetine, bupropion, and doxepin. These antidepressants delivered a significant additive sedative effect and interacted with the patient's hydrocodone, potentially contributing to uncontrolled pain, upward dose titration of hydrocodone, and a higher overall sedative burden. The PGx results and drug-induced phenoconversion described in this case report explain the patient's excessive sedation and possibly ineffective/toxic antidepressant and opioid treatment. This case report also illustrates how a more timely multi-drug interaction assessment (preferably in conjunction with preemptive PGx testing) may have informed a different prescribing pattern, reduced/avoided a prescribing cascade, and potentially prevented a drug-related fall.
Collapse
|
2
|
Nalls V, Galik E, Klinedinst NJ, Barr E, Brandt N, Lerner N, Resnick B. Racial Differences in Antidepressant Use in Nursing Facility Residents With Moderate to Severe Cognitive Impairment. Sr Care Pharm 2022; 37:448-457. [PMID: 36039002 DOI: 10.4140/tcp.n.2022.448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Objective To describe and compare the use of antidepressants between Black or African descent and White nursing facility residents with moderate to severe cognitive impairment. Design This was a secondary data analysis using baseline data from the Function and Behavior Focused Care for Nursing Facility Residents with Dementia randomized control trial. Setting Participants were recruited from 10 urban and two rural nursing facilities from Maryland. Methods Participants had to be 55 years of age or older, English-speaking, reside in long-term care at time of recruitment, and score a 15 or less on the Mini Mental-State Examination. A total of 336 residents participated at baseline. Data were collected by a research evaluator through observation, proxy report from staff caring for the resident the day of testing, and patient charts. Main Outcomes A significant difference of antidepressant use between Black or African descent and White nursing facility residents with moderate to severe cognitive impairment would be noted when controlling for depression, age, gender, functional status, agitation, and number of co-morbidities. Results In adjusted models, Black or African descent residents were less likely to be prescribed antidepressants compared with White residents. Conclusion Racial differences were noted regarding antidepressant use among nursing facility residents with moderate to severe cognitive impairment, but it is unknown if race could impact prescribing practices when indications for use are known. Further research is needed to ascertain if knowing the specific indications for use might contribute to racial disparities with antidepressant prescribing in nursing facility residents with moderate to severe cognitive impairment.
Collapse
Affiliation(s)
- Victoria Nalls
- 1 School of Nursing, University of Maryland, Baltimore, Maryland
| | - Elizabeth Galik
- 1 School of Nursing, University of Maryland, Baltimore, Maryland
| | | | - Erik Barr
- 1 School of Nursing, University of Maryland, Baltimore, Maryland
| | - Nicole Brandt
- 2 School of Pharmacy, University of Maryland, Baltimore, Maryland
| | - Nancy Lerner
- 1 School of Nursing, University of Maryland, Baltimore, Maryland
| | - Barbara Resnick
- 1 School of Nursing, University of Maryland, Baltimore, Maryland
| |
Collapse
|
3
|
Douglas S, Stott J, Spector A, Brede J, Hanratty É, Charlesworth G, Noone D, Payne J, Patel M, Aguirre E. Mindfulness-based cognitive therapy for depression in people with dementia: A qualitative study on participant, carer and facilitator experiences. DEMENTIA 2021; 21:457-476. [PMID: 34558340 PMCID: PMC8811330 DOI: 10.1177/14713012211046150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Depression in dementia is common and associated with negative health outcomes. Mindfulness-based cognitive therapy is a recommended treatment of choice for recurrent depression, but its use for depression in dementia is yet to be assessed. Objective This study aimed to investigate the experiences of people with depression and dementia who participated in the mindfulness-based cognitive therapy intervention and those of their carers and facilitators. Methods This qualitative study was nested within a randomised controlled feasibility study. Semi-structured interviews were conducted with 18 people (eight people with dementia and depression, six carers and four course facilitators). Thematic analysis was used to analyse the data. Findings Several beneficial effects of mindfulness-based cognitive therapy were described. These were a sense of shared suffering among the group, greater present moment focus and awareness, various positive emotional changes, including greater self-compassion, and benefits for carers, such as the reduction of anxiety. Specific aspects of the programme were identified as particularly useful, including facilitator characteristics and certain mindfulness practices. Carer involvement, cognitive difficulties and barriers to home practice influenced engagement with the course. Facilitators described adaptations made to mindfulness-based cognitive therapy and suggested additional modifications for future groups. Conclusion Results of this process evaluation suggest that mindfulness-based cognitive therapy is a potentially useful intervention for people with depression in dementia, but that further adaptation of the intervention is required to make the programme suitable for this clinical population.
Collapse
Affiliation(s)
- Sarah Douglas
- Division of Psychiatry, 4919University College London, UK
| | - Josh Stott
- Department of Clinical, Education and Health Psychology, 4919University College London, UK
| | - Aimee Spector
- Department of Clinical, Education and Health Psychology, 4919University College London, UK
| | - Janina Brede
- Department of Clinical, Education and Health Psychology, 4919University College London, UK
| | - Éanna Hanratty
- Waltham Forest Child and Family Consultation Service, 5098North East London NHS Foundation Trust, UK
| | - Georgina Charlesworth
- Department of Clinical, Education and Health Psychology, 4919University College London; Goodmayes Hospital, 5098North East London NHS Foundation Trust, UK
| | - Deirdre Noone
- Department of Clinical, Education and Health Psychology, 4919University College London, UK
| | - Jacob Payne
- Department of Clinical, Education and Health Psychology, 4919University College London, UK
| | - Mina Patel
- 5098North East London NHS Foundation Trust, UK
| | - Elisa Aguirre
- Department of Clinical, Education and Health Psychology, 4919University College London; Goodmayes Hospital, 5098North East London NHS Foundation Trust, UK
| |
Collapse
|
4
|
Meraya AM, Banji OJ, Khobrani MA, Alhossan A. Evaluation of psychotropic medications use among elderly with psychiatric disorders in Saudi Arabia. Saudi Pharm J 2021; 29:603-608. [PMID: 34194267 PMCID: PMC8233536 DOI: 10.1016/j.jsps.2021.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 04/13/2021] [Indexed: 12/02/2022] Open
Abstract
AIMS Potentially inappropriate psychotropic medications (PIPMs) prescribed to older adults with psychiatric disorders can inadvertently affect their health. The use of standards and guidelines can ensure prudent prescribing and minimize the risk of morbidities. This study assessed the pattern and prevalence of prescription of PIPMs to older individuals in outpatient psychiatric settings in Saudi Arabia, using the updated 2015 Beers criteria, as well as the probability of polypharmacy. METHODS The study was conducted in the outpatient psychiatric clinics of the only psychiatric hospital in Jazan region of Saudi Arabia. A retrospective cross-sectional review of electronic medical records was undertaken during 2018 to assess PIPM use and psychotropic polypharmacy. Descriptive statistics were generated and associations between PIPM use and baseline characteristics were assessed using multivariable logistic regression. RESULTS Overall, 68% of 1300 older adults received PIPMs, and 77.7% were on psychotropic polypharmacy. Amitriptyline, chlorpromazine, and trifluoperazine were extensively prescribed. Paroxetine (1.2%) and benzodiazepines were prescribed to a smaller proportion of the patients. Elderly with schizophrenia (AOR = 0.046, p < 0.001) and anxiety (AOR = 0.530, p = 0.036) were significantly less likely to have PIPMs than those with dementia. Likewise, elderly with depression and anxiety were less likely to have psychotropic polypharmacy as compared to those with dementia. CONCLUSION A substantial number of the elderly received PIPMs possibly based on implicit criteria. It is therefore important to provide mental health care providers in the region with educational programs to increase their awareness of PIPMs.
Collapse
Affiliation(s)
- Abdulkarim M. Meraya
- Department of Clinical Pharmacy, Pharmacy Practice Research Unit, College of Pharmacy, Jazan University, Saudi Arabia
| | - Otilia J.F. Banji
- Department of Clinical Pharmacy, Pharmacy Practice Research Unit, College of Pharmacy, Jazan University, Saudi Arabia
| | - Moteb A. Khobrani
- Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Saudi Arabia
| | - Abdulaziz Alhossan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Saudi Arabia
- Corporate of Pharmacy Services, King Saud University Medical City, Saudi Arabia
| |
Collapse
|
5
|
Levine AMP, Emonds EE, Smith MA, Rickles NM, Kuchel GA, Steffens DC, Ohlheiser A, Fortinsky RH. Pharmacist Identification of Medication Therapy Problems Involving Cognition Among Older Adults Followed by a Home-Based Care Team. Drugs Aging 2020; 38:157-168. [PMID: 33354755 DOI: 10.1007/s40266-020-00821-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dementia, depression, and delirium alone or in combination (3Ds) can threaten independence among older adults, and polypharmacy may further accelerate decline. Clinical pharmacists can play an important role on multidisciplinary home-based care teams by identifying medication therapy problems (MTPs) involving cognition. Within a larger ongoing clinical trial, this paper describes cognition-related MTPs and pharmacist recommendations among older adults with 3Ds followed by a home-based care team. METHODS We conducted a retrospective analysis of medication data among Medicare Advantage members aged ≥ 65 years living at home in Connecticut with International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes related to 3Ds; analyses include the first 105 subjects randomized to the home-based care team from March 2017 to January 2019. Advanced practice registered nurses conducted in-home medication reconciliations along with medical and cognitive assessments. Clinical pharmacists then conducted medication reviews centered on agents treating or exacerbating 3Ds. After review by the study advanced practice registered nurse, geriatrician, and psychiatrist, salient recommendations were forwarded to primary care providers for consideration. Medication therapy problems related to cognition were retrospectively abstracted and classified as: (1) indication: underuse or overuse; (2) effectiveness: ineffective agent or low dose (mainly for antidepressants); and (3) safety: undesirable effect (e.g., impaired cognition, dementia treatment side effects), unsafe medication (e.g., potentially inappropriate medications that can harm cognition), drug interaction, or high dose. RESULTS Pharmacists identified 166 cognitive MTPs, with a mean (standard deviation) of 1.58 (1.35) [range 0-6] MTPs per subject. Indication MTPs represented 34% of total MTPs, of which 79% involved underuse and 21% overuse; effectiveness represented 13% of total MTPs; and safety represented over half (52%) of all MTPs, with benzodiazepines and anticholinergics frequently implicated. Recommendations commonly included medication reduction (discontinuation 23% and dose reduction 19%). We found MTPs involving cognition among most (79%) patients. CONCLUSIONS Our study findings support the role of pharmacists on multidisciplinary teams to identify cognitively harmful medications, dementia treatment side effects, and untreated cognitive conditions. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT02945085.
Collapse
Affiliation(s)
- Allison M P Levine
- Center on Aging, UConn Health, 263 Farmington Avenue, Farmington, CT, 06030, USA.
| | - Erin E Emonds
- PGY1 Pharmacy Practice Residency Program, UConn Health, Farmington, CT, USA
| | - Marie A Smith
- Center on Aging, UConn Health, 263 Farmington Avenue, Farmington, CT, 06030, USA.,Department of Pharmacy Practice, School of Pharmacy, University of Connecticut, Storrs, CT, USA
| | - Nathaniel M Rickles
- Department of Pharmacy Practice, School of Pharmacy, University of Connecticut, Storrs, CT, USA
| | - George A Kuchel
- Center on Aging, UConn Health, 263 Farmington Avenue, Farmington, CT, 06030, USA
| | - David C Steffens
- Department of Psychiatry, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Alis Ohlheiser
- Center on Aging, UConn Health, 263 Farmington Avenue, Farmington, CT, 06030, USA
| | - Richard H Fortinsky
- Center on Aging, UConn Health, 263 Farmington Avenue, Farmington, CT, 06030, USA
| |
Collapse
|
6
|
Health Outcomes Associated with Adherence to Antidepressant Use during Acute and Continuation Phases of Depression Treatment among Older Adults with Dementia and Major Depressive Disorder. J Clin Med 2020; 9:jcm9103358. [PMID: 33092169 PMCID: PMC7589937 DOI: 10.3390/jcm9103358] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/16/2020] [Accepted: 10/17/2020] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES To examine health outcomes associated with adherence to Healthcare Effectiveness Data and Information Set (HEDIS) antidepressant medication management (AMM) during acute and continuation phases of depression treatment among older adults with dementia and major depressive disorder (MDD). DESIGN Retrospective cohort study. SETTING Medicare 5% sample data (2011-2013). PARTICIPANTS Older adults (aged 65 years or older) with dementia and MDD. MEASUREMENTS The first antidepressant prescription claim from 1 May 2011 through 30 April 2012 was considered the index prescription start date (IPSD). Adherence during acute- and continuation-phase AMM was based on HEDIS guidelines. Study outcomes included all-cause mortality, all-cause hospitalization, and falls/factures (with mortality being the competing event for hospitalization and falls/fractures) during follow-up from end of acute-/continuation-phase AMM adherence. Due to the proportionality assumption violation of Cox models, fully non-parametric approaches (Kaplan-Meier and modified Gray's test) were used for time-to-event analysis adjusting for the inverse probability of treatment weights. RESULTS Final study samples consisted of 4330 (adherent (N) = 3114 (71.92%)) and 3941 (adherent (N) = 2407 (61.08%)) older adults with dementia and MDD during acute- and continuation-phase treatments, respectively. No significant difference (p > 0.05) between adherent and non-adherent groups was observed for all-cause mortality and falls/fractures in both the acute and continuation phases. There was a significant difference in time to all-cause hospitalization during acute-phase treatment (p = 0.018), with median times of 530 (95% CI: 499-587) and 425 (95% CI: 364-492) days for adherent and non-adherent groups, respectively. CONCLUSIONS Acute-phase adherence to HEDIS AMM was associated with reductions in all-cause hospitalization risk among older adults with dementia and MDD.
Collapse
|
7
|
Bhattacharjee S, Lee JK, Vadiei N, Patanwala AE, Malone DC, Knapp SM, Lo-Ciganic WH, Burke WJ. Extent and Factors Associated with Adherence to Antidepressant Treatment During Acute and Continuation Phase Depression Treatment Among Older Adults with Dementia and Major Depressive Disorder. Neuropsychiatr Dis Treat 2020; 16:1433-1450. [PMID: 32606697 PMCID: PMC7292261 DOI: 10.2147/ndt.s241749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 05/12/2020] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Little is known about adherence to antidepressant treatment during acute and continuation phase of depression among older adults with dementia and newly diagnosed major depressive disorders (MDD). This study estimated the extent of and factors associated with adherence to acute and continuation phase antidepressant treatment among older adults with dementia and newly diagnosed MDD. METHODS We conducted a retrospective cohort study using the Medicare 5% sample claims data (2012-2013) among older adults (age≥65 years) with dementia who were newly diagnosed with MDD. Intake period of our study was from 01-May-2012 through 30-April-2013. The dependent variables of this study were acute and continuation phase depression treatment adherence. Factors associated with acute and continuation phase antidepressant treatment adherence were identified using multiple logistic regression analyses. RESULTS The final study sample consisted of 6239 [adherent: N=4644 (74.44%)] and 5617 [adherent: N=3584 (63.81%)] older adults with dementia and MDD during the acute and continuation phase treatment, respectively. During the acute phase, only race/ethnicity was significantly associated with adherence to depression treatment, whereas race/ethnicity and baseline antipsychotic use were significantly associated with adherence to depression treatment during the continuation phase. CONCLUSION Approximately, 74% and 64% older adults with dementia and MDD were adherent to acute and continuation phase antidepressant treatment in this nationally representative sample of Medicare beneficiaries, and we identified several modifiable and non-modifiable factors associated with adherence.
Collapse
Affiliation(s)
- Sandipan Bhattacharjee
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, Tucson, AZ, USA
| | - Jeannie K Lee
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, Tucson, AZ, USA
| | - Nina Vadiei
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, Tucson, AZ, USA
| | | | - Daniel C Malone
- Department of Pharmacotherapy, Skaggs College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - Shannon M Knapp
- Statistics Consulting Laboratory, Bio5 Institute, The University of Arizona, Tucson, AZ, USA
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | | |
Collapse
|
8
|
Nelson JC. Comments on the Use of "Inappropriate" Antidepressants in Older Adults With Dementia and Major Depressive Disorder. Am J Geriatr Psychiatry 2019; 27:806-808. [PMID: 30904261 DOI: 10.1016/j.jagp.2019.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 02/25/2019] [Indexed: 11/29/2022]
|