Dr Cynthia Hadfield PharmD Director of Pharmacy for Employee LTC amp Retail Pharmacies Lead Clinical Pharmacist Geriatric Specialist Citizens Memorial Healthcare Dr Hadfield has no financial other relationship or other support from the pharmaceutical industry ID: 774952
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Slide1
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 Specialist
Citizens Memorial Healthcare
Slide2Dr. Hadfield has no financial, other relationship or other support from the pharmaceutical industryDr. Hadfield will be discussing off-label use of Psychoactive medications and other medications
Faculty Disclosure
Slide3Prescribing of a medication for a condition other than its FDA approved indicationCommon practice allowed by FDA and Medical boards and often appropriate and beneficialFDA approval expensive>50% Cancer Drugs used off label All Anti-psychotic use for Behavioral and psychological Symptoms of Dementia (BPSD) in USA is off-labelRisperdal is approved in CanadaOIG report 2011—83% Antipsychotic use off label
Off-label Medication Use
Slide4Outline CMS Regulations and initiatives related to use of AntipsychoticsUnderstand how Antipsychotics work and why they can cause serious side effects Understand how Anti-anxiety and Hypnotic medications work and related side effectsUnderstand effects and side effects of Antidepressants and AnticonvulsantsUnderstand how analgesics and other main classes of medications affect cognition and behaviorsStrategies to ensure safe and effective use of Psychoactive medications in Long Term Care and how to reduce Psychoactive medication use rates
Objectives
Slide5CMS reports by late 2014 nursing homes in the US had achieved a 19.4% reduction in Antipsychotic use >30,000 fewer residents on AntipsychoticsAll 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
Slide6CMS 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 CY2016Feb 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 !
Slide7Antipsychotics
Typical (first generation / conventional)
Atypical (second generation)
Chlorpromazine (Thorazine)Fluphenazine Haloperidol (Haldol)LoxapineMesoridazineMolindonePerphenazinePromazineThioridazine (Mellaril)ThiothixineTrifluperazineTriflupromazine
Asenapine
(
Saphris
)
Aripiprazole
(
Abilify
)
Clozapine (
Clozaril
)
Iloperidone
(
Fanapt
)
Lurasidone
(
Latuda
)
Olanzepine
(
Zyprexa
)
Paliperidone
(
Invega
)
Quetiapine
(Seroquel)
Riperidone
(Risperdal)
Ziprasidone
(Geodon)
Slide8Psychotic 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 movementNewer Antipsychotics (Atypical) developed to be more selective but still have the same side effects also affect serotonin receptors
How Antipsychotics work
Slide9The “why” behind all of the regulations!General: anticholinergic effects , falls, sedationCardiovascular: arrhythmias, orthostatic hypotensionPerform orthostatic blood pressures every shift for the first week and again with dose increasesECG recommended with older agentsMetabolic: Increase in total cholesterol and triglycerides, unstable or poorly controlled blood sugar, weight gainFasting lipid profile and fasting blood glucose / A1c (prior to treatment, at 3 months, then annually)Weight, BMI waist circumference
Side
E
ffects of Antipsychotics
Slide10Esophageal dysmotility /AspirationLowers seizure thresholdNeuroleptic malignant syndrome (NMS)Mental status changesMuscle rigidityFeverImpaired temperature regulation Worsened by heat exposure, dehydration and medications with anticholinergic properties
Side Effects of Antipsychotics
Slide11Extrapyramidal Symptoms (EPS)Pseudo parkinsonismAcute dystonic reactionsDose relatedHigher risk in males and younger patientsAkathesiaInability 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
Slide12Sternest warning from FDA that a medication can cary and still remain on the US marketIndicating serious side effects or life threatening risksThioridazine (Mellaril)QTC prolongationDose relatedShould be avoided and reserved for patients with Schizophrenia who have failed other antipsychoticsAll AntipsychoticsElderly patients with dementia-related psychosis are at increased risk of deathCardiovascular (stroke, heart failure, sudden death)Infectious (pneumonia)Issued in 2005Careful consideration of Risk versus Benefit
Black Box Warnings for Antipsychotics
Slide13SchizophreniaBipolar DisorderTreatment Resistant Depression (Olanzapine, Aripirazole )Major Depressive Disorder (Quetiapine)Tourettes (Pimozide)ICU Delirium (Quetiapine)
Antipsychotic FDA Approved Diagnosis
Slide14Emphasis on Person Centered Care, especially for residents with dementiaSame diagnosis and dosage limitsGuidelines 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
Slide15SchizophreniaHuntington’s DiseaseTourette’s DisorderSchizo-affective disorderSchizophreniform disorderDelusional DisorderMoods DisordersBipolarSevere depression refractory to other therapies and/ or with psychotic featuresPsychosis in the absence of dementiaHiccups (not induced by other medications)Nausea and vomiting associated with cancer or chemotherapyMedical illnesses with psychotic symptomsNeoplastic diseaseTreatment related psychosis (high dose steroids)Delirium BPSD
F329- Antipsychotic Indications for Use
Slide16Behavior 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 causeAgitation, Aberrant Motor behavior, Anxiety, Elation, Irritability, Depression, Apathy, Disinhibition, Delusions, Hallucinations, sleep and appetite changesNOT included in the defining criteria of dementia in the current classifications“Dementia with Behaviors” is the closest ICD code
BPSD
Slide17Clinical Indications
in
Meditech
EMR for Antipsychotic use
Slide18Diagnosis alone does NOT warrant the use of an AntipsychoticIdentify the specific behaviorDocument all of the non- medication interventions tried and how they workedMust also be included in the care planDescribe how the behavior poses a threat to the resident or to othersDescribe how the behavior seriously impairs the resident’s quality of lifeIdentify the behavior as related to mania or psychosis (hallucinations, delusions, paranoia, grandiosity)
Behavior Documentation
Slide19Specific Target Behaviors
Cannot Use
Can Use
WanderingConfusionAgitationUncooperativeResisting careNervousnessRestlessnessfidgetingIndifferenceunsociabilityPoor self careDepressionImpaired memoryInsomniaCrying 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
Slide20CNAs & CMTs should document every shiftCharge Nurses should document a meaningful summary once per weekDocument before and after a PRN is administeredInterdisciplinary team document every care planConsultant Pharmacist: at least every quarterPhysician: every monthDocument more often when behaviors occur or when medication is changed
How often to document
Slide21Documentation 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 AntipsychoticWeekly behavior documentation is done by both CNAs and Charge nurses for residents on any psychoactive medication
CMH Behavior Documentation in
Meditech
Slide22Behavior Monitoring Intervention for Charge Nurses, CNAs & CMTs
Slide23Weekly Antipsychotic Medication Monitoring Intervention for Charge Nurses
Slide24Weekly Antipsychotic Medication Monitoring Intervention for Charge Nurses (continued…)
Slide25Weekly Antipsychotic Medication Monitoring Intervention for Charge Nurses (continued…)
Slide26Weekly Antipsychotic Medication Monitoring Intervention for Charge Nurses (continued…)
Slide27Acute onset or exacerbation of symptomsImmediate threat to health or safety of resident or othersAcute 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
Slide28Encourage Prescribers to only prescribe a one time dose for emergenciesLimit 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 failedExtensive documentation before and after dose administeredTeam follow up after each dose administered to confirm positive response and continued need for PRN dose
Acute Situations / PRN Antipsychotic Use
Slide29PRN Reason Dictionary
Slide30Facility 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 useOther 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
Slide31Anticholinergic MedicationsAntiparkinson’s MedicationsBenzodiazepinesAlcohol (including withdrawal)Cardiac Medications (especially digoxin)CorticosteroidsOpioid AnalgesicsStimulantsAny medication can cause a psychiatric side effect in an individual patientalways note new medications (even antibiotics and OTCs)
Common Medication causes of Psychotic symptoms and behaviors
Slide32AntihistaminesHydroxyzine, diphenhydramineMuscle RelaxantsCyclobenzaprine, TizanidineUrinary agents (Antimuscarinics)OxybutyninGI antispasmodicsDicyclomine, AtropineTricyclic AntidepressantAmitriptyline, DoxepinAntiparkinson AgentsBenztropine, Trihexyphenidyl
Common Anticholinergic medications that worsen cognition and Behaviors with Dementia
Slide33How Opioid Analgesics affect Behavior
BENEFITS
POTENTIAL SIDE EFFECTS
Control pain which is a major cause of anxiety, irritability and behavior problemsAnti-anxiety effectHelp with shortness of breath a major cause of anxiety in COPD patientsImproved quality of life
Sedation
Confusion
Falls
Insomnia
Hallucinations (visual)
Constipation
Urinary retention
Slide34Significantly increase with ageGeneralized Anxiety Disorder (GAD)Diffuse constant anxiety and worry for >6 months90% of presentations of late-life anxiety accounted for by Generalized Anxiety Disorder(GAD) or a specific phobia10% are Obsessive-compulsive (OCD), post-traumatic Stress (PTSD) and panic disordersIncreasing frailty, medical illness, and losses can contribute to feelings of vulnerability, fear and can reactivate anxiety disordersAgoraphobia (fear of being trapped in a place from which escape might be difficult)Afraid of being alone and unable to get helpFear of leaving homeFear of fallingRule out underlying causes
Anxiety Disorders
Slide35Angina, arrhythmia, MI, StrokeDiabetes, low calcium, hyperthyroidismPUD, Pancreatic cancer, UTIAnemia, low blood sugar, low potassium, low sodiumCOPD, Pneumonia, Pulmonary EmbolismDelirium, Dementia, hearing and visual impairment, Parkinson’s, Seizures, brain cancerPAIN
Medical Conditions Associated with Late-Life Anxiety
Slide36Bronchodilators, Steroids, TheophyllineNasal decongestants, AntihistaminesCaffeineNicotine; benzodiazepine or alcohol withdrawalOpioid analgesic withdrawalThyroid medication, EstrogenDigoxinCalcium channel blockers, alpha-blockers, beta-blockersLevodopa
Medication causes of Anxiety
Slide37GADPhobiaPTSDOCDFirst LineSSRI, SNRI, BuspironeSSRISSRI, TCASSRI Second LineTCASNRISNRISNRIThird Line/ AdjunctBenzodiazepineBenzodiazepineBenzodiazepine, Divalproex, ClonidineBenzodiazepine, Gabapentin
Pharmacological Treatment of Anxiety
Adapted from Cassidy, K.L., Rector, N.A. et al.
Slide38SSRIs generally safest and most effectiveCelexa, Lexapro, Zoloft, Prozac, Luvox, PaxilMany residents also have depressionMay take up to 6 – 8 weeks to see full benefit at any given doseNausea, diarrhea, tremor, increased anxiety can occur for the first few weeksStart with low doseUse of benzodiazepine in the short term may be beneficial Remember to get stop date
SSRIs for Treatment of Anxiety
Slide39Mechanism of Action unknownHigh affinity for serotonin receptorsModerate affinity for dopamine receptorDoes NOT affect benzodiazepine-GABA receptorsMost Common Adverse EffectsDizzinessHeadacheNauseaDose: 5 mg BID, increase by 5mg/day every 2-3 days as needed up to 20-30mg/dayMaximum dose: 60 mg /dayNot as effective on a PRN basis but is sometimes acceptable to use PRN
Buspirone
Slide40Benzodiazepines
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
)
Slide41SedationRespiratory depressionHypotension, dizzinessFalls, FracturesDisinhibitingAkathesia, Ataxia, weaknessAmnesia, headacheIncreased Risk of DementiaProspective Population based study in France1063 men & women, free of Dementia and did not start taking benzodiazepines until at least the 3rd year of follow-up15 year follow up50% 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
Slide42Sleep cycle deteriorates with ageHypnotics provide minimal improvements on sleep latency and duration with high risk of adverse eventsUnderlying causes for insomnia should always be addressed prior to starting medicationEnvironmental (light, noise, temperature)Physical (Pain, shortness of breath)Medications (including caffeine intake)Persons life long sleep habits
Insomnia and Use of hypnotics
Slide43FDA labeled for InsomniaLorazepam (Ativan)OxazepamEstazolam Temazepam (Restoril) 7.5mg – 15 mg Capsules QHSHard to dose reduce because 7.5 mg capsules are more expensiveTriazolam (Halcion)----NOT RECOMMENDEDShort half-lifeIncreased risk of anterograde amnesiaInability to create new memoriesAlprazolam (Xanax)-off labelConsider using same benzo for insomnia that is being used for anxiety to minimize polypharmacy
Benzodiazepines for Insomnia
Slide44Zolpidem (Ambien & Ambien CR, Intermezzo5-10 mg (max 10mg) of immediate release6.25-12.5 extended releaseZolpimist Spray – 5 mg / actuationShould only be administered when patient is able to stay in bed a full nightIntermezzo- 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 daysHigh fat meals prolong absorptionEszopiclone (Lunesta)1-3 mg (2 mg max for geriatrics)Do NOT take with or immediately after a high fat mealRapid onset and should be administered when resident is already in bed and having difficulty sleepingWithdrawal can occur with abrupt discontinuanceChronic use >90 days NOT recommended
Non-benzodiazepine Hypnotics
Slide45Abnormal thinking & behaviorDecreased inhibition, aggression, agitation, hallucinationsWorsen depressionSuicidal ideationCNS depression Impairment of physical and mental capabilitiesRespiratory depression (caution with COPD & apnea)Sedation, Delirium Falls, FracturesAngioedema and anaphylaxisComplex sleep-related behaviorDriving, making phone calls, preparing food while asleep with no memory
Side Effects of hypnotic medications
Slide46Trazodone Unlabeled but common use25 mg – 150 mg at bedtime less than antidepressant dose of up to 600mg /day in divided dosesOrthostatic hypotension & SyncopeQT prolongation & tachycardia (less than SSRIs)Mirtazapine (Remeron) 7.5-15 mg QHSAlso helpful with appetiteHigher doses actually are less sedating and less effective for sleep and appetite
Use of sedating Antidepressants to help sleep
Slide47Not recommended due to Anticholinergic side effects and adverse effect on sleep architectureDiphenhydramine (Benadryl)In Tylenol PMHydroxyzine (Atarax, Vistaril)Safely used for anxiety in younger adultsFor a resident with allergies and anxiety consider Cetirizine (Zytrec) 5-10mg QHSActive metabolite of hydroxyzine with slightly less anticholinergic effect
Use of Antihistamines for Anxiety or Insomnia
Slide48Increase the amount of Serotonin available in the BrainCitalopram (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 bleedingTremor, headacheDecreased libido, sexual dysfunctionInsomnia or somnolenceSuicide (in early treatment, younger patients)Serotonin Syndrome
Selective Serotonin –Reuptake Inhibitors (SSRIs)
Slide49Results from too much Serotonin in the brainOften occurs when more than one medication that increases serotoninSSRIs (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) LithiumOndansetron (Zofran)St. John’s Wart, GinsengOr agents that impair metabolism of serotoninLinezolid (Zyvox), IV Methylene blueMarplan, Nardil (MOAI antidepressants)
Serotonin Syndrome
Slide50Mental Status ChangesHallucinationsAgitation, increased anxietyDeliriumComaAutonomic InstabilityTachycardiaLabile blood pressureDiaphoresis, feverNeuromuscular changesTremorRigidityMyoclonus GI SymptomsNausea / vomitingSeizures, coma, deathAnxiety, Ankle clonus, agitation and tremor most common signs
Symptoms / Signs of Serotonin Syndrome
Slide51Tricyclic AntidpressantsAmitriptyline (Elavil), Imipramine (Tofranil)Nortriptyline (Pamelor), Desipramine (Norpramin)Side Effects:Hypotension, sedation, cardiac arrhythmiasDuloxetine (Cymbalta)Approved for anxiety Approved for fibromyalgia, diabetic neuropathy, chronic painNausea, dry mouth, dizzinessHypertensionReduce dose if CrCl 30-60ml/min and contraindicated if CrCl <30 ml/min
Antidepressants for Pain
Slide52LithiumMore commonly used in Bipolar patientsNarrow therapeutic index drugAdversely effects renal function and is cleared renalyHigh risk of toxicity with dehydration and with medications that affect sodium excretion (ACEIs, diuretics, NSAIDs)AnticonvulsantsDivalproex (Valproic acid, Depakote)Most commonly used for behaviors in seniorsBetter tolerated than other mood stabilizers in older adultsCarbamazepine (Tegretol)Lots of monitoring required: cbc, thyroid, LFTsLamotrigine (Lamictal)Gabapentin (Neurontin)Topiramate (Topamax) helpful in patients that need to lose weight
Mood Stabilizers for behavioral disturbances in Dementia
Slide53Side effects: Sedation, confusion, falls, Nausea, Low sodium, pancreatitis, low platelets, high ammonia levelsMonitoring: 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
Slide54Seizure disordersBipolar disorderChronic painNeuropathic painDiabetic neuropathyPost-herpetic neuralgiaTrigeminal neuralgiaPost-Stroke painRestless Leg SyndromeWatch for Polypharmacy with Gabapentin for neuropathic pain
Other uses for Anticonvulsants
Slide55AntipsychoticsWithin 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 thereafterSemi-annually if dementia with no behaviorsMore Aggressive Protocol: Consider GDR every quarter until behaviors emergeLimit PRN use to 1x doses or to 10 days when titrating routine doses Anti-Anxiety, Antidepressants, AnticonvulsantsWithin 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 thereafterIf used for pain dose reduction not recommended unless side effectsHypnoticsManufacturer Guidelines consideredAttempt QuarterlyGDRs May be clinically contraindicated if target symptoms returned or worsened after dose reduction or physician has well documented rationale
Gradual Dose Reduction (GDR) Guidelines
Slide56How long it took to titrate to therapeutic dose and residents history of depression or anxietyInherent physical dependence /withdrawal properties of the medicationDosage forms available, price, whether or not tablets can be splitNumber of different psychoactive medications resident is on and set priorities based on symptoms Is the resident experiencing side effectsFALLSWEAKNESSTREMORS
GDR Guidelines – Other factors to consider
Slide57Behavioral health Committee or teamConsultant Pharmacist, Psychologist, Medical Director, Administrator, D.O.N.Activities, Therapy, Social servicesDirect care staff (Nurses, RMTs, CNAs)Meet at least monthly to discuss dementia patients, residents on antipsychotics or residents with problematic behavior issuesLook for underlying causes of behaviorPain, medication side effects, metabolic conditions, psychosocial factorsConsider gradual dose reductionsEnsure supportive documentation
Strategies to Reduce
I
nappropriate Psychoactive Medication
U
se
Slide58Educate Nursing Staff (including CNAs) regarding the use of Psychoactive MedicationsWhich medications work for which symptomsSide effects to monitorDiagnosis and specific behaviors that must be documented to justify / support the use of the medicationConsider implementing policy / ProcessNo 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
Slide59?
Slide60Advanced 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.govBillioti 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):150-156Cerejeira, 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.phpPolicy 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.orgLexicomp online drug information: www.online.lexi.com
References