The Dilemmas of Recognizing Good Medication Practices For Older Adults

1. The Dilemmas ofRecognizing GoodMedication PracticesFor Older Adults Peter S Miller MD, FRCPC Medical Director, Mental Health & Substance Abuse and Community Based Services DHS/ State of Minnesota World Elder Abuse Awareness Day

2. Disclosures • Full time employee, State of Minnesota • The usual range of 401-k Mutual Funds • No other financial interests for myself or my family

4. Ann Jones, an eighty-five-year-old woman with dementia, is confined to a wheelchair because of severe arthritis and the amputation of her right foot from complications of diabetes. In the last few weeks she has begun to scream, curse, and grab at staff and visitors. During mealtimes she takes other residents' food and casts her own food off the table. All agree that Ms Jones’s behavior is unacceptable and requires the use of a behavior-altering drug.-- Braun & Frolik

5. Background • Raised in North Idaho • Medical School- University of Washington, Seattle • Postgraduate training in US and Canada • International Psychiatry Fellowship 2005-2006 • Community Psychiatry practice in NE MN for >25 years; consulted with MDH-- QAR • Extensive work in Nursing Homes and Assisted Living settings • Subspecialty Certification in Neuropsychiatry 2008 • With State of Minnesota since Jan 2011—Mix of clinical and administrative assignments

7. Objective 1– Be able to… • Understand the Global Context of Aging

9. Objective 2– Be able to… • Understand the concept of “chemical restraint” and related dilemmas

11. Objective 3– Be able to… • Recognize medication approaches in older adults which are based in high quality evidence

13. Objective 4– Be able to… • Recognize potentially inappropriate medication treatments

15. Objective 5– Be able to… • Better communicate with physicians about the purposes, and the pros and cons, of medication treatments

17. 2017

19. 584 Million1.5 Billion

20. 44 million136 million

21. 62%71%

23. “Chemical Restraint”

24. A drug used:-- to control behavior, or -- to restrict freedom of movement And is:Not a standard treatment for the person’s medical or psychiatric condition-- MN DHS Policy

25. Chemical restraint: "any drug that is used fordisciplineor convenience and not required to treat medicalsymptoms.“--OBRA 1987

26. Rates of “chemical restraint” in nursing homes: up to 34% before regulation

27. FDA estimate:15,000 older adults die each year due to use of unnecessary anti-psychotic medications in nursing homes

28. Antipsychotic medications:increased risk of mortality in people with dementia

29. 1982 US Supreme Court Youngberg v. Romero: “Restraints are justified to protect others or self in the judgment of the health professional."

30. Expert Consensus Guidelines on Behavioral Emergencies (2005): “Medications used to treat specific psychiatric diagnoses should be considered treatment measures rather than restraints, even in the absence of provisional diagnosis.”

31. “There is no consensus among clinicians or policy makers whether such use of medications is a form of coercion or a form of patient-focused intensive care.”-- Currier GW J PsychiatrPract2003 Jan

32. Best Practices

33. Best PracticesAbuse

34. Evidence

35. RCTs:RandomisedControlledTrialsMeta-Analyses

36. Evolving Highly Reliable Practices

37. Good Practices

39. Health Problem Domains for Older Adults…

41. Sensory Loss

42. FallsDizziness

43. Malnutrition

44. OsteoporosisOsteoarthritis

45. Urinary IncontinenceConstipation

46. PainSubstance Use Problems

48. HypertensionElevated CholesterolHeart DiseaseStroke

50. Depression