Hospice Pharmacy Case Study: Agitation in a Nursing Home

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DO is a 64-year-old hospice patient admitted to an LTC facility when her family could no longer manage her care at home. She has been receiving hospice care for two months with a primary diagnosis of lung cancer with brain metastases and a history of DVT, but no other comorbid conditions. Lately, DO has been experiencing agitation and mood issues due to her brain metastases that are generally well- controlled on a regimen of Haloperidol 1mg PO BID, Olanzapine 20mg disintegrating tablet QHS and Quetiapine 50mg BID (receiving 1-2 doses/day consistently).

Five days after DO’s admission to the LTC facility, the hospice nurse calls the pharmacist for advice regarding the antipsychotic regimen. According to the LTC staff, DO is tolerating her medications well and not experiencing any side effects. The LTC facility, however, is concerned about the number of antipsychotic medications that the patient is prescribed as they are “trying to perform well in CMS’s Five-Star Quality Rating System”. DO’s nurse is requesting information regarding the use of multiple antipsychotic agents at EOL to pass along to the facility to help them better understand antipsychotic use in patients with metastatic cancer. The nurse recognizes that streamlining to one antipsychotic agent is ideal, but for this particular patient, the regimen is working well and the patient is tolerating it without issues.

WHAT IS CMS 5-STAR QUALITY RATING?

CMS established a set of publically available quality ratings for nursing home performance with an overall quality rating of 1 to 5 stars in each of three measures: Health Inspections domain (state results, repeat visits), Staffing domain (ratios of staff to residents), and Quality Measure domain.

  • Quality Measure domain: This measure was updated earlier this year as a means to reduce the percentage of antipsychotics prescribed for residents with dementia.
  • Eight (8) measures relate to long-stay residents. New since Feb 2015 measures the percent of patients who received an antipsychotic medication
  • Three (3) measures relate to short-stay residents. New since Feb 2015 measures the percent of patients who newly received an antipsychotic medication
  • Despite the fact that these new measures were added to target patients with dementia, the measures INCLUDE ALL patients. The only exceptions for antipsychotic prescribing are patients with schizophrenia, Huntington’s disease, and Tourette’s syndrome
  • There currently are NO EXCEPTIONS for the following:
    • Patients on hospice
    • Patients with delirium
    • Patients without dementia

HOW MIGHT THE STAR MEASURE AFFECT PRESCRIBING?

  • Less likely that patients with terminal-related psychosis or other behavioral problems will be prescribed antipsychotics
  • Hospice clinicians need to try managing terminal agitation, dementia-related agitation and other behavioral problems with other pharmacological and non-pharmacological modalities
  • Hospice clinicians need to recognize the changes in CMS 5-Star Quality Rating, however, they should be advocates for their patients when antipsychotics are appropriately needed or prescribed

HOW DO WE TREAT AGITATION IN THE ABSENCE OF ANTIPSYCHOTICS?

  • Non-pharmacological therapy focused on monitoring personal comfort and simplifying and calming the environment. Modalities recommended include music therapy, group activities providing physical as well as mental stimulation, provision of a security object, avoidance of being confrontational, acknowledging requests and responding accordingly and redirecting the person’s attention.
  • Medication management focused on behavioral and psychiatric symptoms including benzodiazepines (anxiety, restlessness and verbally disruptive behavior), antidepressants (anxiety, depression, low mood, and irritability) and anticonvulsants (agitation, mood stabilization).

WHEN IS ANTIPSYCHOTIC USE APPROPRIATE IN THE ELDERLY DEMENTIA POPULATION?

  • Only when symptoms persist despite non-pharmacological and medical intervention and…
    • Behavioral symptoms are due to mania or psychosis
    • Symptoms present a danger to the patient or others
    • Patient is experiencing inconsolable or persistent distress
    • Patient is experiencing a significant decline in function or substantial difficulty receiving needed care
  • Antipsychotics should NOT be used for purpose of sedation or restraining

PATIENT CASE FOLLOW-UP

DO’s nurse was provided the summary points above to relay to the nursing home staff. During their discussion, the hospice nurse stressed that her patient was not suffering from dementia-related agitation, but agitation and mood issues brought on by brain metastases. Although the 5-Star Quality Rating system does not exclude this condition in their ratings, based on the patient’s underlying diagnosis and positive response to therapy, a decision was made to continue to treat her with antipsychotics. As a result of their discussion, and to address polypharmacy, Olanzapine was discontinued and Quetiapine was increased to 75mg PO BID. The haloperidol regimen was adjusted to 1mg PO every 6 hours as needed. DO’s symptoms continued to be controlled on this simplified regimen.

 

FOR ADDITIONAL INFORMATION ON THIS TOPIC, PLEASE REVIEW THESE REFERENCES:

 

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