Medications: Friend or Foe? The Role of Medications in both Causing and Curing Behavior and Cognitive Problems

Live event held Tuesday, May 6, 2014, 1:30-2:45 pm Eastern Time
(Second in the Mental Health and Aging Training Initiative, Series III)
This third installment in the series of webinars initiated by the Geriatric Mental Health Partnership (GMHP)--an informal, voluntary group of diverse stakeholders which focuses on geriatric mental/ behavioral health care in the Commonwealth--aims to improve communication and service coordination between the mental/behavioral health and long term care systems to facilitate timely care for older adults in the most appropriate setting. Lack of adequate training regarding the complex needs of an aging population with behavioral health issues has been identified as a major barrier to successfully providing community-based care for these individuals. Six previous webinars have attracted a continuously growing audience, which attests to the unmet need for this type of training. In fact, in 2012, our webinars reached 600 senior service providers and in 2013, more than 1,300 professionals benefitted from our online training.

As the aging population continues to grow, and use of State Hospitals as the site of extended behavioral health care continues to diminish, it is essential that community based staff and providers be prepared for the rapid growth of older adults with behavioral health and dementia-related issues. This is a key issue for workforce development as the Commonwealth prepares for the future. Effective training enables staff to more quickly identify and address behavioral health-related issues before the older adult’s condition declines further or situations escalate to possibly becoming dangerous to other frail elders (or caregivers) nearby. It also helps staff distinguish between behavioral issues which can be safely addressed at the facility (or at home) versus those which constitute a true psychiatric emergency and might require inpatient treatment.
This webinar focused on various medications that can contribute to cognitive impairment and behavioral symptoms in the older individual and will provide information on appropriate interventions to address behavioral/ cognitive problems in older adults. Implications on the use of these medications and resultant behaviors in relation to regulatory guidance were reviewed. Drugs associated with adverse cognitive effects and the risks versus benefits of medications were examined.
This presentation is intended for staff from many levels, disciplines and settings (both acute care and long term care).  Attendees included, behavioral health staff, nurse practitioners, nurses, CNAs, Nursing Home Administrators, Social Workers and Case Manages from both Acute and Long term care. 
At the end of this one-hour presentation, participants will learn:
  • To identify various medications that can contribute to cognitive impairment and behavioral symptoms in the older individual.
  • Appropriate interventions to address behavioral/cognitive problems in the elderly.
  • The implications these medications and resultant behaviors have in relation to regulatory guidance.
The live event was open to all and free for all. 

Attendees were required to have a computer with access to high speed internet (to view the slide presentation) and computer speakers OR access to a telephone.  Additional information was provided through the registration form.
The webinar was recorded - see bottom of page.  

Download the slides from SlideShare or from this link.

This event was made possible through a grant from the Virginia Center on Aging's Geriatric Training Education Initiative and supported by the Riverside Center for Excellence in Aging and Lifelong Health, the Virginia Geriatric Mental Health Partnership* and the VCU's Department of Gerontology.‎

Jennifer L. Hardesty
Jennifer Hardesty, PharmD, FSACP, is the Clinical Services Manager at Remedi SeniorCare in Baltimore, MD. 

After graduating with her Doctor of Pharmacy from the University of Maryland School of Pharmacy, Dr. Hardesty went on to complete a residency in Geriatric Pharmacotherapy.  

Currently, she is also a Clinical Assistant Professor and Preceptor at the University of Maryland School of Pharmacy.  She is involved in numerous projects, including the Maryland Assisted Living Facility Stakeholder’s Group.

The Maryland Chapter of the American Society of Consultant Pharmacists awarded Dr. Hardesty with Pharmacist of the Year for 2006-2007.

E. Ayn Welleford, PhDreceived her BA in Management/Psychology from Averett College, M.S. in Gerontology and PhD in Developmental Psychology from Virginia Commonwealth University. She has taught extensively in the areas of Lifespan Development, and Adult Development and Aging, Geropsychology, and Aging & Human Values. As an educator, researcher, and previously as a practitioner she has worked with a broad spectrum of individuals across the caregiving and long term care continuum.

As Associate Professor and Chair of VCU’s Department of Gerontology, she currently works to “Improve Elder Care through Education” through her Teaching, Scholarship, and Community Engagement. Outside of the classroom, Dr. Welleford provides community education and serves on several boards and committees.
Dr. Welleford is former Chair of the Governor’s Commonwealth of Virginia Alzheimer’s and Related Disorders Commission, as well as a recipient of the AGHE Distinguished Teacher Award. In 2011, Dr. Welleford was honored by the Alzheimer’s Association at their annual Recognition Reception for her statewide advocacy. Dr. Welleford is the author of numerous publications and presentations given at national, state and local conferences, community engagement and continuing education forums. In 2012, Dr. Welleford was appointed to the Advisory Board for VCU’s West Grace Village project.  She is also the recipient of the 2012 Mary Creath Payne Leadership Award from Senior Connections, the Capital Area Agency on Aging.


ADDITIONAL QUESTIONS POSTED DURING THE EVENT (our many thanks to Dr. Hardesty for taking the time to provide these answers):

Q: Would a supplement such as Melatonin produce the same effects as Benadryl?
JH: These two drugs work completely differently so both their efficacy and side effects will be different. In general terms, I believe that trying melatonin is a safer option; however it is likely not going to produce the obvious sedation effects that Benadryl causes. The safest option is to start with basic non-drug sleep hygiene techniques and ensure no stimulating medications are being giving in the evening.

Q: What regular testing (blood, urine) can assure being proactive and not waiting for bad effects to manifest?
JH: Each medication therapy should have an accompanying monitoring plan, which monitors for both effectiveness of the medication, and potential toxicity/side effects. Sometimes lab tests are the most effective option to monitor (i.e. fingersticks/HgA1C for patient on insulin); in other cases lab tests may useful for identifying toxicities and therapeutic range. (phenytoin, valproic acid). A prescriber or clinical pharmacist should be outlining the monitoring plan individualized for each patient, which will likely be a combination of lab tests, physical monitoring/exam, and observation depending on the medications and other concomitant diseases of the individual.

Q: What about vitamins and/or supplements?  
JH: Vitamins and supplements can be useful but they are not totally benign. Many pharmaceutical substances are derived from natural products; herbal products or ‘natural’ supplements oftentimes have properties that are similar to medications.  There are additional risks with supplements for several reasons: 1) these products are not strictly tested and regulated by agencies like the FDA; consequently you may not necessarily ‘get what you pay for’, and in some cases may get ‘more than what you pay for’- meaning other substances or impure ingredients. 2) Vitamins and supplements can interact with medications a patient is currently taking  3) Some supplements and herbal products can produce significant adverse effects.   The best advice is to check with your prescriber and/or pharmacist before using any supplement or herbal/alternative product other than a standard multivitamin or calcium supplement.

Q: Is there a better choice than Warfarin? and Is there a better choice than Zoloft?
JH: All drugs have “pros” and “cons”, and the choice really depends on an individual patient’s variables. Concomitant diseases, current medications, previous medical history, cost/insurance coverage- are just a few variables that need to be considered when deciding on the most appropriate medication for and individual.  With medications for psychiatric conditions, this becomes even more complex because it may take some trial-and-error to determine which medication an individual will best respond to, even after a careful consideration of variables mentioned above.

Q: How do you communicate this information to GNA/CNA and have them recognize these side effects/ADEs while they care for the residents?
JH: Having GNA/CNAs that know their patients well, and having them report significant observed changes in behavior or condition is a critical way to identify side effects.   Whether it is a change in behavior,  appetite, communication, or ambulation--- any change in condition of an elderly patient can be attributed to a medication. 

Q: Do you recommend giving prn antipsychotic medications for aggressive behaviors in older adults or should they be on scheduled medications
The treatment is really going to depend on the situation- but the most important thing to remember in context of a progressive disease like dementia is that the behaviors and demeanor of a resident will change over time.  Therefore, the treatments will also change over time.  Non-drug therapies should be first line treatment and should continue to be attempted; and if drug therapy is used it should be for the shortest time possible.  If a resident has aggressive behaviors once or twice a year, than it is likely safer for them to use and antipsychotic on a PRN basis to avoid unnecessary continued exposure to a potentially dangerous drug. However, in resident that is persistently aggressive and a danger to others, daily administration may be necessary for a period of time.  However, the IDT should continue to perform non-drug interventions and periodically attempt to reduce the dose when appropriate.

Q: Can you follow up on Warfarin as so many are being put on it due to A-Fib? Any alternatives?
JH: There are several new drugs on the market for Atrial Fibrillation that provide consistent anticoagulation effects and avoid the INR ‘ups and downs’ that occur with warfarin. However these drugs are not necessarily safer and are certainly more expensive that warfarin. A consideration of the patient’s specific variables is necessary to determine if warfarin or the other novel agents would be preferred.

Q: Can vaccinations also interact, adversely with other medications?  
JH: Yes, vaccinations can interact with other medications in the body, or alter the way they are processed.  Talk to your prescriber of pharmacist to determine if that interaction is significant enough to warrant additional monitoring or other actions.  It makes good practice to question if any potential interactions exist when patients are on drugs that have narrow therapeutic windows, such as warfarin or phenytoin.

Q: Can you speak to long-term use of psychotropic drugs in combination with the drugs you are describing?  
JH: At the end of the day, drug therapy--regardless of the drug--is going to have more potential for adverse effects that a non-drug therapy.  Risk vs benefit should continually be re-assessed, keeping in mind the overall goals of therapy for each individual patient.   As patients improve or decline, as they age, as other diseases or illnesses occur,  the drug, dose, or need for any psychotropic drugs may also change.  


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