Effective and Appropriate Use of Psychoactive Medications in Long Term Care Residents

Dr. Cynthia Hadfield, Pharm.D.Director of Pharmacy for Employee, LTC & Retail Pharmacies

Lead Clinical Pharmacist, Geriatric SpecialistCitizens Memorial Healthcare

Dr. Hadfield has no financial, other relationship or other support from the pharmaceutical industry

Dr. Hadfield will be discussing off-label use of Psychoactive medications and other medications

Faculty Disclosure

Prescribing of a medication for a condition other than its FDA approved indication

Common practice allowed by FDA and Medical boards and often appropriate and beneficial

FDA approval expensive >50% Cancer Drugs used off label All Anti-psychotic use for Behavioral and

psychological Symptoms of Dementia (BPSD) in USA is off-label◦ Risperdal is approved in Canada◦ OIG report 2011—83% Antipsychotic use off label

Off-label Medication Use

Outline CMS Regulations and initiatives related to use of Antipsychotics

Understand how Antipsychotics work and why they can cause serious side effects

Understand how Anti-anxiety and Hypnotic medications work and related side effects

Understand effects and side effects of Antidepressants and Anticonvulsants

Understand how analgesics and other main classes of medications affect cognition and behaviors

Strategies to ensure safe and effective use of Psychoactive medications in Long Term Care and how to reduce Psychoactive medication use rates

Objectives

CMS reports by late 2014 nursing homes in the US had achieved a 19.4% reduction in Antipsychotic use

>30,000 fewer residents on Antipsychotics All but 8 states have met or exceeded 15% reduction

target Missouri Antipsychotic rate was25.5% in 2nd quarter of

2011 but rose to 26.1% in 4th Quarter of 2011, then dropped to to 20.7% in the 4th Quarter of 2014 ◦ 5.43% percentage point decrease, which translates to a 20.8

“% change”◦ Excludes individuals with Schizophrenia, Tourette’s and

Huntington’s disease CMH LTC overall rate is13% (11% if Schizophrenia,

Tourette’s and Huntington’s Excluded)

Some Good News

CMS and national organizations that are actively participating in the Partnership, recently announced an updated goal to achieve 30% reduction in the use of Antipsychotic medications nationally, no later than the end of CY2016

Feb 2015 CMS added two measures of Antipsychotic use (one for long stay residents and one for short stay) to the algorithm that is used to calculate each nursing home’s Five Star Rating System on CMS Nursing Home Compare website

Focus on Antipsychotic Reduction Will Continue !

Antipsychotics

Typical (first generation / conventional)

Atypical (second generation)

Chlorpromazine (Thorazine) Fluphenazine Haloperidol (Haldol) Loxapine Mesoridazine Molindone Perphenazine Promazine Thioridazine (Mellaril) Thiothixine Trifluperazine Triflupromazine

Asenapine (Saphris) Aripiprazole (Abilify) Clozapine (Clozaril) Iloperidone (Fanapt) Lurasidone (Latuda) Olanzepine (Zyprexa) Paliperidone(Invega) Quetiapine (Seroquel) Riperidone(Risperdal) Ziprasidone(Geodon)

Psychotic symptoms (hallucinations, delusions) linked to abnormal dopamine release and function in the brain

Antipsychotic Medications block Dopamine receptors in the brain causing dopamine to have less effect

Older Antipsychotics (Typical) not particularly selective and also block dopamine receptors in other areas of the brain including the nigrostriatal pathway responsible for movement

Newer Antipsychotics (Atypical) developed to be more selective but still have the same side effects• also affect serotonin receptors

How Antipsychotics work

The “why” behind all of the regulations! General: anticholinergic effects , falls, sedation Cardiovascular: arrhythmias, orthostatic

hypotension◦ Perform orthostatic blood pressures every shift for the first

week and again with dose increases◦ ECG recommended with older agents

Metabolic: Increase in total cholesterol and triglycerides, unstable or poorly controlled blood sugar, weight gain◦ Fasting lipid profile and fasting blood glucose / A1c (prior to

treatment, at 3 months, then annually)◦ Weight, BMI waist circumference

Side Effects of Antipsychotics

Esophageal dysmotility /Aspiration

Lowers seizure threshold

Neuroleptic malignant syndrome (NMS) Mental status changes Muscle rigidity Fever Impaired temperature regulation Worsened by heat exposure, dehydration and

medications with anticholinergic properties

Side Effects of Antipsychotics

Extrapyramidal Symptoms (EPS)◦ Pseudo parkinsonism◦ Acute dystonic reactions

Dose related Higher risk in males and younger patients

Akathesia Inability to stay still, restlessness, feeling of crawling out of one’s

skin Tardive Dyskinesia

Irreversible Tongue and facial movements

Abnormal Involuntary Movement Scale (AIMS) test recommended prior to treatment then every 3 months while on antipsychotic

Neurologic Side Effects of Antipsychotics

Sternest warning from FDA that a medication can cary and still remain on the US market

Indicating serious side effects or life threatening risks Thioridazine (Mellaril)

◦ QTC prolongation◦ Dose related◦ Should be avoided and reserved for patients with Schizophrenia

who have failed other antipsychotics All Antipsychotics

◦ Elderly patients with dementia-related psychosis are at increased risk of death Cardiovascular (stroke, heart failure, sudden death) Infectious (pneumonia) Issued in 2005

◦ Careful consideration of Risk versus Benefit

Black Box Warnings for Antipsychotics

Schizophrenia Bipolar Disorder Treatment Resistant Depression

(Olanzapine, Aripirazole ) Major Depressive Disorder (Quetiapine) Tourettes (Pimozide) ICU Delirium (Quetiapine)

Antipsychotic FDA Approved Diagnosis

Emphasis on Person Centered Care, especially for residents with dementia

Same diagnosis and dosage limits Guidelines are just more defined Bottom line: If resident has dementia, the facility

must:◦ Do everything possible to manage behaviors without

medication ◦ If medication is used, more than one person had better

put a lot of thought into the selection of the medication ◦ Continual monitoring & documentation of the residents’

behaviors, medical conditions, social situation

Changes to F309 & F329 Related to antipsychotics

◦ Schizophrenia◦ Huntington’s Disease◦ Tourette’s Disorder◦ Schizo-affective disorder◦ Schizophreniform disorder◦ Delusional Disorder◦ Moods Disorders

Bipolar Severe depression refractory to other therapies and/ or with

psychotic features◦ Psychosis in the absence of dementia◦ Hiccups (not induced by other medications)◦ Nausea and vomiting associated with cancer or chemotherapy◦ Medical illnesses with psychotic symptoms

Neoplastic disease Treatment related psychosis (high dose steroids) Delirium

BPSD

F329- Antipsychotic Indications for Use

Behavior or Psychological Symptoms of Dementia (BPSD)

Also referred to as “Neuropsychiatric Symptoms” Describes behavior or other symptoms in

individuals with dementia that cannot be attributed to a specific medical or psychiatric cause◦ Agitation, Aberrant Motor behavior, Anxiety, Elation,

Irritability, Depression, Apathy, Disinhibition, Delusions, Hallucinations, sleep and appetite changes

NOT included in the defining criteria of dementia in the current classifications

“Dementia with Behaviors” is the closest ICD code

BPSD

Clinical Indications in Meditech EMR for Antipsychotic use

Diagnosis alone does NOT warrant the use of an Antipsychotic

Identify the specific behavior Document all of the non- medication interventions

tried and how they worked◦ Must also be included in the care plan

Describe how the behavior poses a threat to the resident or to others

Describe how the behavior seriously impairs the resident’s quality of life

Identify the behavior as related to mania or psychosis (hallucinations, delusions, paranoia, grandiosity)

Behavior Documentation

Specific Target Behaviors

Cannot Use Can Use

Wandering Confusion Agitation Uncooperative Resisting care Nervousness Restlessness fidgeting Indifference unsociability Poor self care Depression Impaired memory Insomnia Crying out (occasional) Yelling or screaming (occasional)

Spitting, Biting, pinching Kicking, Punching Scratching, Slapping Extreme fear Frightful distress Inappropriate Sexual Behavior Continuous pacing Finger painting feces Throwing objects Purposeful vomiting Purposeful B/B inappropriately Tripping, Ramming, Pushing others Head banging Self inflicted injuries Hallucinations Delusions Paranoia Continuous and extreme crying out,

yelling, screaming

CNAs & CMTs should document every shift Charge Nurses should document a meaningful

summary once per week Document before and after a PRN is

administered Interdisciplinary team document every care

plan Consultant Pharmacist: at least every quarter Physician: every month Document more often when behaviors occur or

when medication is changed

How often to document

Documentation reminder comes up whenever an Antipsychotic Medication is ordered.

CNAs document behaviors every shift for residents on Antipsychotics.

Charge nurses complete detailed Antipsychotic Medication Documentation every week for residents on an Antipsychotic

Weekly behavior documentation is done by both CNAs and Charge nurses for residents on any psychoactive medication

CMH Behavior Documentation in Meditech

Behavior Monitoring Intervention for Charge Nurses, CNAs & CMTs

Weekly Antipsychotic Medication Monitoring Intervention for Charge Nurses

Weekly Antipsychotic Medication Monitoring Intervention for Charge Nurses (continued…)

Weekly Antipsychotic Medication Monitoring Intervention for Charge Nurses (continued…)

Weekly Antipsychotic Medication Monitoring Intervention for Charge Nurses (continued…)

Acute onset or exacerbation of symptoms Immediate threat to health or safety of

resident or others Acute treatment is limited to 7 days

ANDClinician and interdisciplinary team must evaluate and document the situation within 7 days to identify and address any contributing and underlying causes of the acute condition and verify the continuing need for antipsychotic medication

F329- Acute Situations / Emergency

Encourage Prescribers to only prescribe a one time dose for emergencies

Limit PRN Antipsychotic orders to residents who occasionally exhibit very psychotic and dangerous behavior

Only allow Charge nurse to administer PRN Antipsychotics ◦ Only after all non-medication and other medication

interventions have been tried and failed◦ Extensive documentation before and after dose administered

Team follow up after each dose administered to confirm positive response and continued need for PRN dose

Acute Situations / PRN Antipsychotic Use

PRN Reason Dictionary

Facility is responsible for pre-admission screening for mentally ill and intellectually disabled individuals AND obtaining physicians orders for resident’s immediate care.

This screening (F285) should provide diagnosis for Antipsychotic use

Other residents admitted on Antipsychotic must have use evaluated at time of admission and / or within 2 weeks of admission (initial MDS)◦ Consider dose reduction or discontinuance of

Antipsychotic

Residents admitted on an Antipsychotic

Anticholinergic Medications Antiparkinson’s Medications Benzodiazepines Alcohol (including withdrawal) Cardiac Medications (especially digoxin) Corticosteroids Opioid Analgesics Stimulants Any medication can cause a psychiatric side effect

in an individual patient◦ always note new medications (even antibiotics and OTCs)

Common Medication causes of Psychotic symptoms and behaviors

Antihistamines◦ Hydroxyzine, diphenhydramine

Muscle Relaxants◦ Cyclobenzaprine, Tizanidine

Urinary agents (Antimuscarinics)◦ Oxybutynin

GI antispasmodics◦ Dicyclomine, Atropine

Tricyclic Antidepressant◦ Amitriptyline, Doxepin

Antiparkinson Agents◦ Benztropine, Trihexyphenidyl

Common Anticholinergic medications that worsen cognition and Behaviors with Dementia

How Opioid Analgesics affect Behavior

BENEFITSPOTENTIAL SIDE EFFECTS

Control pain which is a major cause of anxiety, irritability and behavior problems

Anti-anxiety effect Help with shortness of

breath a major cause of anxiety in COPD patients

Improved quality of life

Sedation Confusion Falls Insomnia Hallucinations (visual) Constipation Urinary retention

Significantly increase with age Generalized Anxiety Disorder (GAD)

◦ Diffuse constant anxiety and worry for >6 months 90% of presentations of late-life anxiety accounted for by Generalized

Anxiety Disorder(GAD) or a specific phobia 10% are Obsessive-compulsive (OCD), post-traumatic Stress (PTSD) and

panic disorders Increasing frailty, medical illness, and losses can contribute to feelings of

vulnerability, fear and can reactivate anxiety disorders Agoraphobia (fear of being trapped in a place from which escape might be

difficult)◦ Afraid of being alone and unable to get help◦ Fear of leaving home◦ Fear of falling

Rule out underlying causes

Anxiety Disorders

Angina, arrhythmia, MI, Stroke Diabetes, low calcium, hyperthyroidism PUD, Pancreatic cancer, UTI Anemia, low blood sugar, low potassium,

low sodium COPD, Pneumonia, Pulmonary Embolism Delirium, Dementia, hearing and visual

impairment, Parkinson’s, Seizures, brain cancer PAIN

Medical Conditions Associated with Late-Life Anxiety

Bronchodilators, Steroids, Theophylline Nasal decongestants, Antihistamines Caffeine Nicotine; benzodiazepine or alcohol withdrawal Opioid analgesic withdrawal Thyroid medication, Estrogen Digoxin Calcium channel blockers, alpha-blockers, beta-

blockers Levodopa

Medication causes of Anxiety

GAD Phobia PTSD OCD

First Line SSRI, SNRI, Buspirone

SSRI SSRI, TCA SSRI

Second Line TCA SNRI SNRI SNRI

Third Line/ Adjunct

Benzodiazepine Benzodiazepine Benzodiazepine, Divalproex, Clonidine

Benzodiazepine, Gabapentin

Pharmacological Treatment of Anxiety

Adapted from Cassidy, K.L., Rector, N.A. et al.

SSRIs generally safest and most effective◦ Celexa, Lexapro, Zoloft, Prozac, Luvox, Paxil

Many residents also have depression May take up to 6 – 8 weeks to see full benefit at

any given dose Nausea, diarrhea, tremor, increased anxiety can

occur for the first few weeks◦ Start with low dose

Use of benzodiazepine in the short term may be beneficial ◦ Remember to get stop date

SSRIs for Treatment of Anxiety

Mechanism of Action unknown◦ High affinity for serotonin receptors◦ Moderate affinity for dopamine receptor◦ Does NOT affect benzodiazepine-GABA receptors

Most Common Adverse Effects◦ Dizziness◦ Headache◦ Nausea

Dose: 5 mg BID, increase by 5mg/day every 2-3 days as needed up to 20-30mg/day◦ Maximum dose: 60 mg /day

Not as effective on a PRN basis but is sometimes acceptable to use PRN

Buspirone

Benzodiazepines

Short Acting Long Acting

Alprazolam (Xanax) Lorazepam (Ativan) Temazepam (Restoril) Oxazepam (Serax) Triazolam (Halcion) Estazolam

Clonazepam (Klonopin) Diazepam (Valium) Chlordiazepoxide

(Librium) Clorazepate Flurazepam Quazepam Chlordiazepoxide –

Amitriptyline Clidinium-

Chlordiazepoxide (Librax)

Sedation Respiratory depression Hypotension, dizziness Falls, Fractures Disinhibiting Akathesia, Ataxia, weakness Amnesia, headache Increased Risk of Dementia

◦ Prospective Population based study in France◦ 1063 men & women, free of Dementia and did not start taking

benzodiazepines until at least the 3rd year of follow-up◦ 15 year follow up◦ 50% increase in the risk of Dementia for patients that ever used a

benzodiazepine versus those who never used Long acting agent should NOT be used unless shorter acting

medication has failed

Benzodiazepine Side Effects

Sleep cycle deteriorates with age Hypnotics provide minimal improvements

on sleep latency and duration with high risk of adverse events

Underlying causes for insomnia should always be addressed prior to starting medication◦ Environmental (light, noise, temperature)◦ Physical (Pain, shortness of breath)◦ Medications (including caffeine intake)◦ Persons life long sleep habits

Insomnia and Use of hypnotics

FDA labeled for Insomnia◦ Lorazepam (Ativan)◦ Oxazepam◦ Estazolam◦ Temazepam (Restoril)

7.5mg – 15 mg Capsules QHS Hard to dose reduce because 7.5 mg capsules are more expensive

◦ Triazolam (Halcion)----NOT RECOMMENDED Short half-life Increased risk of anterograde amnesia Inability to create new memories

◦ Alprazolam (Xanax)-off label Consider using same benzo for insomnia that is being

used for anxiety to minimize polypharmacy

Benzodiazepines for Insomnia

Zolpidem (Ambien & Ambien CR, Intermezzo◦ 5-10 mg (max 10mg) of immediate release◦ 6.25-12.5 extended release◦ Zolpimist Spray – 5 mg / actuation◦ Should only be administered when patient is able to stay in bed a full night◦ Intermezzo- 1.75 or 3.5 mg SL tab for middle of night (>4 hrs left)

Zaleplon (Sonata)◦ 5 mg-20 mg at bedtime (max. 10 mg in geriatrics) for 7-10 days◦ High fat meals prolong absorption

Eszopiclone (Lunesta)◦ 1-3 mg (2 mg max for geriatrics)◦ Do NOT take with or immediately after a high fat meal

Rapid onset and should be administered when resident is already in bed and having difficulty sleeping

Withdrawal can occur with abrupt discontinuance Chronic use >90 days NOT recommended

Non-benzodiazepine Hypnotics

Abnormal thinking & behavior◦ Decreased inhibition, aggression, agitation, hallucinations

Worsen depression◦ Suicidal ideation

CNS depression ◦ Impairment of physical and mental capabilities◦ Respiratory depression (caution with COPD & apnea)

Sedation, Delirium Falls, Fractures Angioedema and anaphylaxis Complex sleep-related behavior

◦ Driving, making phone calls, preparing food while asleep with no memory

Side Effects of hypnotic medications

Trazodone ◦ Unlabeled but common use◦ 25 mg – 150 mg at bedtime

less than antidepressant dose of up to 600mg /day in divided doses

◦ Orthostatic hypotension & Syncope◦ QT prolongation & tachycardia (less than SSRIs)

Mirtazapine (Remeron) ◦ 7.5-15 mg QHS◦ Also helpful with appetite◦ Higher doses actually are less sedating and less

effective for sleep and appetite

Use of sedating Antidepressants to help sleep

Not recommended due to Anticholinergic side effects and adverse effect on sleep architecture

Diphenhydramine (Benadryl)◦ In Tylenol PM

Hydroxyzine (Atarax, Vistaril)◦ Safely used for anxiety in younger adults

For a resident with allergies and anxiety consider Cetirizine (Zytrec) 5-10mg QHS◦ Active metabolite of hydroxyzine with slightly less

anticholinergic effect

Use of Antihistamines for Anxiety or Insomnia

Increase the amount of Serotonin available in the Brain Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine

(Prozac), Paroxetine (Paxil), Sertraline (Zoloft), Fluvoxamine (Luvox)

Most also FDA approved for Anxiety Adverse Effects:

◦ EPS (movement disorders)◦ Hypernatremia (low sodium)◦ GI upset, nausea, GI bleeding◦ Tremor, headache◦ Decreased libido, sexual dysfunction◦ Insomnia or somnolence◦ Suicide (in early treatment, younger patients)◦ Serotonin Syndrome

Selective Serotonin –Reuptake Inhibitors (SSRIs)

Results from too much Serotonin in the brain Often occurs when more than one medication that increases

serotonin◦ SSRIs (Prozac, Zoloft, Celexa etc…)◦ SNRIs (Cymbalta, Effexor)◦ Tramadol (Ultram)◦ Buprenorphine (Butrans patch)◦ Dextromethorphan (Robitussin DM)◦ Buproprion (Wellbutrin, Zyban)◦ Buspirone (Buspar)◦ Anti –Migraine medicines (Triptans – Amerge, Zomig)◦ TCAs (Amitriptyline, Nortriptyline) ◦ Lithium◦ Ondansetron (Zofran)◦ St. John’s Wart, Ginseng

Or agents that impair metabolism of serotonin◦ Linezolid (Zyvox), IV Methylene blue◦ Marplan, Nardil (MOAI antidepressants)

Serotonin Syndrome

Mental Status Changes◦ Hallucinations◦ Agitation, increased anxiety◦ Delirium◦ Coma

Autonomic Instability◦ Tachycardia◦ Labile blood pressure◦ Diaphoresis, fever

Neuromuscular changes◦ Tremor◦ Rigidity◦ Myoclonus

GI Symptoms◦ Nausea / vomiting

Seizures, coma, death Anxiety, Ankle clonus, agitation and tremor most common signs

Symptoms / Signs of Serotonin Syndrome

◦ Tricyclic Antidpressants Amitriptyline (Elavil), Imipramine (Tofranil) Nortriptyline (Pamelor), Desipramine (Norpramin) Side Effects:Hypotension, sedation, cardiac arrhythmias

Duloxetine (Cymbalta)◦ Approved for anxiety ◦ Approved for fibromyalgia, diabetic neuropathy,

chronic pain◦ Nausea, dry mouth, dizziness◦ Hypertension◦ Reduce dose if CrCl 30-60ml/min and

contraindicated if CrCl <30 ml/min

Antidepressants for Pain

Lithium◦ More commonly used in Bipolar patients◦ Narrow therapeutic index drug◦ Adversely effects renal function and is cleared renaly◦ High risk of toxicity with dehydration and with medications that

affect sodium excretion (ACEIs, diuretics, NSAIDs) Anticonvulsants

◦ Divalproex (Valproic acid, Depakote) Most commonly used for behaviors in seniors Better tolerated than other mood stabilizers in older adults

◦ Carbamazepine (Tegretol) Lots of monitoring required: cbc, thyroid, LFTs

◦ Lamotrigine (Lamictal)◦ Gabapentin (Neurontin)◦ Topiramate (Topamax)

helpful in patients that need to lose weight

Mood Stabilizers for behavioral disturbances in Dementia

Side effects: Sedation, confusion, falls, Nausea, Low sodium, pancreatitis, low platelets, high ammonia

levels Monitoring:

CBC, Platelets, Liver function at baseline and every 6 months. Monitoring

Serum levels for carbamazepine and valproic acid (every 6-12 months depending on dose)

Maintain on minimum effective dose

Anticonvulsants for Mood

Seizure disorders Bipolar disorder Chronic pain Neuropathic pain

◦ Diabetic neuropathy◦ Post-herpetic neuralgia◦ Trigeminal neuralgia◦ Post-Stroke pain

Restless Leg Syndrome Watch for Polypharmacy with Gabapentin for

neuropathic pain

Other uses for Anticonvulsants

Antipsychotics◦ Within the first year of admission or initiating of medication, attempt GDR

during two separate quarters (with at least one month between attempts)◦ Then at least annually thereafter◦ Semi-annually if dementia with no behaviors◦ More Aggressive Protocol: Consider GDR every quarter until behaviors

emerge◦ Limit PRN use to 1x doses or to 10 days when titrating routine doses

Anti-Anxiety, Antidepressants, Anticonvulsants◦ Within the first year of admission or initiating of medication, attempt GDR

during two separate quarters (with at least one month between attempts)◦ Then at least annually thereafter◦ If used for pain dose reduction not recommended unless side effects

Hypnotics◦ Manufacturer Guidelines considered◦ Attempt Quarterly

GDRs May be clinically contraindicated if target symptoms returned or worsened after dose reduction or physician has well documented rationale

Gradual Dose Reduction (GDR) Guidelines

How long it took to titrate to therapeutic dose and residents history of depression or anxiety

Inherent physical dependence /withdrawal properties of the medication

Dosage forms available, price, whether or not tablets can be split

Number of different psychoactive medications resident is on and set priorities based on symptoms

Is the resident experiencing side effects◦ FALLS◦ WEAKNESS◦ TREMORS

GDR Guidelines – Other factors to consider

Behavioral health Committee or team◦ Consultant Pharmacist, Psychologist, Medical Director,

Administrator, D.O.N.◦ Activities, Therapy, Social services◦ Direct care staff (Nurses, RMTs, CNAs)

Meet at least monthly to discuss dementia patients, residents on antipsychotics or residents with problematic behavior issues◦ Look for underlying causes of behavior

Pain, medication side effects, metabolic conditions, psychosocial factors

◦ Consider gradual dose reductions◦ Ensure supportive documentation

Strategies to Reduce Inappropriate Psychoactive Medication Use

Educate Nursing Staff (including CNAs) regarding the use of Psychoactive Medications◦ Which medications work for which symptoms◦ Side effects to monitor◦ Diagnosis and specific behaviors that must be

documented to justify / support the use of the medication

Consider implementing policy / Process◦ No single nurse allowed to call and request and

antipsychotic ◦ Psychoactive medications started by on-call physicians

be reevaluated promptly by the behavior team

Strategies to Reduce Inappropriate Psychoactive Medication Use

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Advanced Copy: Dementia Care in Nursing Homes: Clarification to Appendix P State Operations Manual (SOM) and appendix PP in the SOM for F309-Quality of Care and F329-Unnecessary Drugs. Accessed online August 2013 at: http://surveytraining.cms.hhs.gov

Billioti de Gage, S.,Begaud, B., Bazin, F. et al. Benzodiazepine Use and Risk of Dementia Prospective Population Based Study. BMJ. Accessed online Sept. 2013 at: http//www.medscape.com/viewarticle/771934.

Cassidy, k.L., Rector, Neil A. The Silent Geriatric Giant: Anxiety Disorders in Late Life. Geriatrics and Aging. 2008;11(3):150-156

Cerejeira, J., Lagarto, and Mukaetova-Ladinska, E.B., Behavioral and Psychological Symptoms of Demetia. Published online 201 May 7. frontiers in Neurology.

Guide to the Management of Psychotic Disorders and Neuropsychiatric Symptoms of Dementia in Older Adults. October 2012. Accessed online Sept. 2013 at: http://dementia.americangeriatrics.org/GeriPsych_index.php

Policy Statement. Use of Antipsychotic Medications in Nursing Facility Residents. Accessed online Sept. 2013 at: www.ascp.com

The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. JAGS 2012. Accessed online September 2013 at: www.americangeriatrics.org

Lexicomp online drug information: www.online.lexi.com

References