medication friend or foe - jennifer hardesty

@Copyright 2014, Jennifer Hardesty.All right reserved. 1

Medications: Friend or Foe?The role of medications in both causing and curing

behavior and cognition problems

Jennifer Hardesty, PharmD, FASCPDirector of Clinical Services, Remedi SeniorCare

[email protected]

Could These Behaviors Be a Result of a Medication?

Altered Cognition

Confusion

Aggression

Negative Behaviors


Objectives

To identify various medications that cancontribute to cognitive impairment andbehavioral symptoms in the older individual.

To educate on appropriate interventions toaddress behavioral/cognitive problems in theelderly.

To review the implications these medications andresultant behaviors have in relation to regulatoryguidance.

Risk vs. Benefits of Medications

Medications can cause problems, even if used correctly!

MEDICATION BENEFITS

• When used correctly, medications can lead to:• Better life quality• Healthier life• Longer life

MEDICATION RISKS

• Unwanted or unexpected effects may occur• Mild adverse effect:

• upset stomach• dry mouth, nausea

• Serious adverse effects:• organ damage• coma

• CNS adverse effects:• Sedation• Confusion• Agitation/aggression• Psychosis


Organic Causes of Cognitive/Behavior Changes

Medical Conditions:

• Infections:• UTI• Pneumonia• Sepsis

• Stroke, hemorrhage• Metabolic derangements:

• electrolytes• dehydration• hyper/hypoglycemia• hyper/hypothyroid• hypoxia

• CV disease:• hypotension• MI• hypertensive crisis

Psychiatric Disorders

• Dementia

• Depression

• Anxiety

• Schizophrenia

• Psychosis

DementiaDementia is progressive deterioration in

Intellectual function

Memory/Recognition

Language

Executivefunction/skilled motor

activities

Visuospatial ability

leading to adecline in theability to performactivities of dailyliving.

Changes in Behavior &Activity Level

• Isolation/ social withdrawal/Decreased interest

• Difficulty with decisionmaking

• Problems concentrating• Unexplained anger• Anxiety• Aggression/Agitation• Sleep difficulties• Changes in appetite


Psychiatric Disorders

Depression

• Symptoms includeeither a depressedmood or loss ofinterest, PLUS:• Weight Changes,

sleep changes• Behavior that is

agitated or sloweddown.

• Fatigue• Thoughts of

worthlessness orextreme guilt

• Problemsconcentrating ormaking decisions

• Thoughts of death orsuicide

• The person'ssymptoms are a causeof great distress ordifficulty in functioningat home, work, orother important areas.

Anxiety

• Excessive anxiety andworry about a varietyof events andsituations.• Struggle to gain

control, relax, or copewith the anxiety andworry

• Feeling wound-up,tense, or restless

• Easily fatigued orworn-out

• Concentrationproblems

• Irritability• The symptoms cause

"clinically significantdistress" or problemsfunctioning in daily life.

Schizophrenia

• Delusions• Hallucinations• Disorganized speech• Grossly disorganized or

catatonic behavior• Negative symptoms:

• low levels of interest• motivation• mental activity• social drive• speech

Psychosis

• Psychosis can be asymptom of mentalillness, but it is not amental illness in itsown right

• hallucinations ordelusional beliefs

• personality changes• disorganized thinking• unusual or bizarre

behavior• impairment in activities

of daily living

Causes of Cognitive Changes

Org

an

icC

au

ses

Dementia

PsychiatricDisorders

Depression

Anxiety

Schizophrenia

Iatr

ogenic

Causes

Predictable drug sideeffects

Alcohol or illicit drugintoxication

Medications-AdverseDrug event


Iatrogenic CausesFrom outside influences

Alcohol/drugintoxicationor withdraw

Poisons

Anesthesia

• Sedation• Confusion• Agitation

Sensorydeprivation/Environment

Medications

• Numerous CNSside effects

Adverse Drug ReactionsAny noxious, unintended, and undesired effect of a drug which occurs at

doses used in humans for prophylaxis, diagnosis or therapy

Adverse Drug Reactions (ADRs)

36% of all reported adverse drug events involve an elderly patient

Elderly are at Greater Risk for ADR’s:• Multiple chronic diseases• Multiple prescribers• Multiple medications• Types of medications prescribed• Under-representation in clinical trials, particularly those over age 75


Preventable Adverse Drug Events

Incidence of ADRs in high risk seniors (=>5 Rxs)• 35% experienced ADR

• 95% of ADRs were predictable

• 63% required MD intervention

• 11% required hospitalization

Psychoactive drugs and anticoagulants are the most common medicationsassociated with preventable adverse drug events

-oversedation, confusion, hallucinations, delirium, falls and bleeds

Signs / Symptoms of Delirium:• Restlessness, agitation• Memory deficit• Drowsiness, poor attention span• Wandering• “Picking” at the air/clothes...• Hallucinations

Types of delirium:

• Hyperactive delirium: agitation, anxiety state

• Hypoactive delirium: lethargy, excess somnolence, sluggish

• Mixed delirium: symptoms of both

Medications = Most common causes of delirium22-39% of all cases

Drug-Induced Delirium

A clinical state characterized by an acute, fluctuating change in mental status,with inattention and altered levels of consciousness.


Prevalence of Delirium in the Elderly

Common in hospitalized older adults:Emergency 10% - 30%Post-operatively up to 50%Cardiac Surgery 17 - 73%Post Hip Fracture 35% - 65%General Medicine 11% - 26%Known Dementia 32% - 89%

Course: Can be quite variable

Prevalence:Typical: 10-12 daysRange: 1-8 weeksLasting > 30 days: 15%Increased Risk: Longer LOS, LTC

Risk factors for Delirium

Risk factors include:

• Advanced old age

• Underlying dementia

• Functional impairment

• Multiple medical problems

• Polypharmacy

• Renal impairment


Dementia, Depression, and Delirium

Depression Dementia Delirium

Onset Usually within aperiod of weeks

Slow, insidious, overa period ofmonths/years

Abrupt, may bewithin hours ordays

Symptoms Pervasive sadnessor loss of pleasure,plus somatic signs

Gradual decline infunctioning,including recentmemory loss andword findingdifficulty

Fluctuation inconsciousnessand attention

Possiblehallucinations,delusions,disorientation

Course Episodic, treatable,resolvable

Progressive,manageable

Treatable, usuallyresolvable

Facility

Staff

Nurse

Family

Pharmacist

MD/NP

Resident

Consultant

TEAMWORK is needed to help identify andresolve cognitive and behavioral problems!


Case Study: AD

AD is an 89 year old woman residing in your SNF for 2 weeks. She isrecovering from knee replacement surgery. Two days ago she was notcommunicating as clearly as usual with nursing staff, and after furtherinvestigation was found to have a UTI.

PMH:• Mild dementia • DM Type 2• HTN, CHF • Osteoporosis• S/P knee replacement

Current medications include:• HCTZ 25mg QD • Digoxin 0.25mg QD• Lisinopril 20mg QD • Metoprolol XL 50mg QD• Tolterodine LA 4mg QD • Amitriptyline 25mg HS for restless legs• Cipro 500 mg BID x 10 days • Metformin 500mg BID• Zolpidem 5mg HS prn sleep • Diphenhydramine 50mg PRN itchy rash

Today she is acting very confused and does not recognize her son who visitsin the morning. She does claim to see her husband and speaks with him whileshe is in her room, although he had passed away several years ago.

Can you assess this situation?

Drugs Associated with Adverse Cognitive Effects

“Medicine sometimes snatches away health, sometimes gives it.”~Ovid, Tristia

"Any symptom in an elderly patient should be considereda drug side effect until proved otherwise.”

J Gurwitz, M Monane, S Monane, J Avorn

Brown University Long-term Care Quality Letter 1995


Can you name any medications that maycause cognition or behavior problems?

Medications Associated with Cognitive Impairment

‘ACUTE CHANGE IN MS’Initial Drug Class

A Antiparkinsonian drugs

C Cardiovascular drugs

U Urinary incontinence drugs

T Theophylline

E Emptying drugs

C Corticosteroids

H H2-blockers

A Antimicrobials

N NSAIDs

G Geropsychiatric drugs

E ENT drugs

I Insomnia drugs

N Narcotics

M Muscle relaxants

S Seizure drugs


Anti-Parkinsonian Drugs

Anti-Parkinson’s drugs, besides causing psychotic symptoms, have also been linked tomood symptoms, even at therapeutic doses.

Levodopa:

About 5% of patientsdevelop delirium

from the use of thisdrug

Cognitive symptomsoccur in up to 60%of patients

• Isolated hallucinationswhile maintaining a clearstate of consciousness

• Abnormal dreaming andsleep disturbances maybe early signs

Selegiline, dopamineagonists,

amantadine:

Visual hallucinations,delusions,depression

Anticholinergics:(eg, trihexyphenidyl,

benztropine):

confusion anddelirium

Cardiovascular Drugs

Antiarrhythmics

Disopyramide :Fatigue,

nervousness,confusion

Digoxin

Confusion,delirium,

hallucinations,anxiety

Antihypertensives: (5-10%incidence in normal population)

Beta-Blockers: Depression, delirium,confusion, psychosis

Clonidine: Depression, delirium,psychosis, hallucinations

Methyldopa: May exacerbate depressionor anxiety in elderly patients

Amiodarone: long half-life may promoteprolonged confusion or memory

problems

Diuretics: can cause fluid and/or acid-base imbalances, which can result in

confusion, especially in the postoperativepatient


Urinary Incontinence Agents

oxybutnin, tolterodine, trospium, etc.

Elderly have increased sensitivity to anticholinergic effects,resulting in:

• Confusion/Delirium• Xerostomia• Constipation• Urinary Retention

Anticholinergic drugs have been linked tomemory impairment, changes in consciousness,

and even decreases in ADLs/IADLs

Anticholinergic Drugs

• Total burden of anticholinergic drugs may determinethe development of delirium, rather than any singleagent.

• The total burden of anticholinergic medications is thesum of the anticholinergic activity of all the drugsa patient is consuming.


Medications with anti-cholinergic properties

Antidepressants

Amitriptyline

Desipramine/Imipramine

Doxepin

Antipsychotics

Olanzapine

Clozapine

Antihistamines

Diphenhydramine

Hydroxyzine

Meclizine

OTCantihistamines

Prochlorperazine

Scopolamine

NarcoticsUrinary

Incontinence

Oxybutynin

Toleterodine

Muscle Relaxants

Cyclobenzaprine

Carisoprodol

Others

Ipatropium

Captopril

Furosemide

Nifedipine

Cimetidine/Ranitidine

Theophylline

Warfarin

Glycopyrrolate

Theophylline

Adverse effects usually occur in high dose or overdosesituations:• Insomnia

• Anxiety

• Agitation


Emptying Drugs (GI Drugs)

GI antispasmodics• Dicyclomine• Hyoscyamine

MetoclopramideConfusion, lethargy, delirium, hallucinations (rare)

High risk of cognitive toxicity due to:• High anticholinergic activity

• Dopaminergic activity

Symptoms occur in approximately 18% of patients onhigh doses of corticosteroids

Corticosteroids can induce mental status changes

Corticosteroids

Risks include:• Use of high-dose steroids (> 80 mg/day of prednisone)• Long duration of use• Abrupt discontinuation

Appear as a variety of mental status changes:• depressive symptoms• manic symptoms• paranoid-hallucinations• psychosis


H-2 Receptor Blockers

Cimetidine is most common offender• Confusion

• Depression

• Delusions/Psychosis

• Aggression or Mania

Predisposing factors include:• High doses, older age

• Pre-existing psychiatric illness

• Poor renal function

• Simultaneous treatment with psychotropic medications

Cimetidine, ranitidine, famotidine

Risk factors include sepsis, renal impairment, highdoses

Antimicrobials

Cephalosporins/Penicillins:• Delusions,hallucinations, agitation, confusion

Aminoglycosides:• Confusion, hallucinations

Fluoroquinolones• Confusion, agitation, depression, hallucinations, paranoia,


NSAIDs

Aspirin toxicity:Delirium is the major manifestation

Indomethacin:Depression and delirium

Naproxen/Ibuprofen:Disturbances in memory and concentration (low risk; usually occurs

at high doses).

Celecoxib:Confusion, anxiety

Geropsychiatric Drugs

Antidepressants

• Tricyclic Antidepressants: (Amitriptyline,Imipramine)

• Delirium, disorientation, and memoryimpairment

• Highly anticholinergic properties

• Fluoxetine• Long half-life of drug• Anxiety, sleep disturbances, and increasing

agitation

• Venlafaxine• Nervousness, Agitation

Antidepressant

Medication

Anticholinergic

Activity

Amitriptyline 4Trimipramine 4Doxepin 3Imipramine 3Nortriptyline 2Phenelzine 2Tranylcypromine 2Selegiline 2Desipramine 1Paroxetine 1Duloxetine 1Venlafaxine 1Mirtazapine 1Citalopram 0Escitalopram 0Fluoxetine 0Fluvoxamine 0Sertraline 0Bupropion 0Trazodone 0

Lexicomp Drug Information Handbook, 2008


Anxiolytics

Long-acting benzodiazepines (diazepam, chlordiazepoxide, flurazepam, chlordiazepoxide)

• Long half-life in elderly patients (often several days)• Produce prolonged sedation and increase risk of falls and fractures

Short- and intermediate-acting benzodiazepines preferred

All benzodiazepines have been associated with:• impaired learning of verbal and visual information• immediate and delayed memory• psychomotor performance


Antipsychotics• Sedation• Confusion• Delusions• Personality Changes• Traditional and some newer antipsychotics possess

anticholinergic properties

Lithium• May impair memory and psychomotor performance• Sedation and confusion• Associated with the development of delirium at high serum levels



1st Generation Antihistamines (diphenhydramine, brompheniramine )

• Potent anticholinergic effects• Sedation• Constipation• Confusion

Anticholinergic OTC Medications:• Cough/cold products with antihistamines• Sleep aids

Oral Decongestants (pseudoephedrine, phenylephrine)

• Anxiety, nervousness, hallucinations

ENT Drugs

Insomnia drugs

Sedative-hypnotics (zolpidem/zaleplon)• Confusion• Abnormal thinking• Behavior changes• Aggression/agitation• Hallucinations

Barbiturates (secobarbital, pentobarbital)• Confusion, agitation, hallucinations• Cause more adverse effects than other sedative or hypnotic drugs

Tylenol-PM (diphenhydramine)


Untreated pain itself can cause delirium

Narcotics

Drugs• Meperidine:

– Accumulation of normeperidine, a neurotoxic substance– fluctuations in levels of awareness, confusion, disorientation,

hallucinations, delusions• Pentazocine:

– Causes confusion and hallucinations more commonly thanother narcotic drugs

• Opioids– Probably the most important cause of delirium in postoperative

patients– Renal impairment = accumulation of metabolites

Withdraw effects

Muscle Relaxants

Muscle Relaxants• Cyclobenzaprine, methocarbamol, carisoprodol metaxalone

Anticholinergic adverse effects:

• Sedation

• Confusion

• Weakness

• Hallucinations


All anticonvulsants can affect cognition, even in thepresence of therapeutic drug levels

Seizure Drugs

Phenytoin• Confusion, mood changes, lethargy at high serum levels• In elderly patients with low albumin, a therapeutic level of phenytoin may also

be toxic.

Carbamazepine• Sedation• Confusion

Valproic Acid:• Nervousness,• Confusion, abnormal thinking

Topiramate:• Memory impairment and confusion• Cognitive and motor slowing

Others

Diabetes medications

• Reversible and irreversible brain damage secondary to hypoglycemia

• Chlorpropamide- long half-life in elderly patients and could causeprolonged hypoglycemia

Herbal Products

• St. John's Wort mania, anxiety

• Melatonin confusion, sedation


Medication-Related Problems Can Occur at ANY Time!

When Are Medication-Related ProblemsMost Likely to Occur?

• New drug is added

• Change of dose (higher or lower)

• Drug discontinued

• With alcohol or illicit drugs

• Taking multiple sedating drugs or CNS active drugs

Case Study: AD

AD is an 89 year old woman residing in your SNF for 2 weeks. She isrecovering from knee replacement surgery. Two days ago she was notcommunicating as clearly as usual with nursing staff, and after furtherinvestigation was found to have a UTI.

PMH:• Mild dementia • DM Type 2• HTN, CHF • Osteoporosis• S/P knee replacement

Current medications include:• HCTZ 25mg QD • Digoxin 0.25mg QD• Lisinopril 20mg QD • Metoprolol XL 50mg QD• Tolterodine LA 4mg QD • Amitriptyline 25mg HS for restless legs• Cipro 500 mg BID x 10 days • Metformin 500mg BID• Zolpidem 5mg HS prn sleep • Diphenhydramine 50mg PRN itchy rash

Today she is acting very confused and does not recognize her son who visits inthe morning. She does claim to see her husband and speaks with him while sheis in her room, although he had passed away several years ago.

What Medications Could be Contributing?


What medications could contribute to her confusion?

HCTZ 25mg QD

Digoxin 0.25mg QD

Lisinopril 20mg QD

Metoprolol XL 50mg QD

Tolterodine LA 4mg QD

Amitriptyline 25mg HS for restless legs

Cipro 500 mg BID x 10 days

Metformin 500mg BID

Zolpidem 5mg HS prn sleep

Diphenhydramine 50mg PRN itchy rash

Resource for Appropriate and‘Inappropriate’ Medication Therapy

http://www.cms.hhs.gov/manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

F329: Unnecessary DrugsTABLE I: MEDICATION ISSUES OF PARTICULAR RELEVANCE


Managing Cognitive and Behavioral Problems

Investigating the Cause!

Organic Disorders

• Dementia• Psychiatric

Disorders• Depression• Anxiety• Schizophrenia• Psychosis

Iatrogenic Problems

• Adverse DrugEvents

• Delirium

Managing Drug-Related Delirium & CNS- RelatedAdverse Drug Events

Basic principles:

– Identifying and treating/removing acute precipitants

– Supportive and restorative care

– Controlling disruptive behaviors with a minimum ofchemical or physical restraint

Non-pharmacological ManagementProvide general supportive measures:

• Avoid restraints• Encourage familiar faces for reassurance• Low stimulation - avoid excessive noise• Provide orientation (calendar, clock)


When control is needed to prevent harm and to allowWhen control is needed to prevent harm and to allowevaluation and treatment,

psychotropic medicationsmay be required.

Pharmacological Management

Indications for pharmacologic treatment:• Aggression

• Risk of harm to self or others

• Hallucinations

• Inconsolable or Persistent Distress

(e.g., fear, continuously yelling, screaming, end-of-life distress, or crying);

• Significant decline in function

Must seek the underlying cause of distressed behaviorbefore or while treating the symptom


Prescribing Principles:• Use a SINGLE medication

• Start with a low dose.

• Choose a drug with low anticholinergic activity

• Stop the medication as soon as possible

• Continue to use Non-Pharmacological interventions


Acute Situations/Emergency

“Acute onset or exacerbation of symptoms, or immediate threatto health or safety of resident or others”

• Acute treatment period limited to 7 days

• Clinician and IDT must reevaluate and document situation within 7 days,and define continuing need

• Non-drug therapies are attempted beyond the emergency period

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-13-35.html

Part of all medication treatment = Non-pharmacological approaches

Non-Drug Therapy Requirements

Examples of non-pharmacological interventions may include:

• Identifying, addressing, and eliminating or reducing underlying causes ofdistressed behavior

• Developing interventions that are specific to resident’s interests, abilities,strengths and needs

• Minimize distractions or overstimulated environment

• Using sleep hygiene techniques and individualized sleep routines

• ↑ exercise or therapy

• Massage, hot/warm or cold compresses

• Enhancing the taste and presentation of food

• Music therapy



When control is needed to prevent harm and to allow evaluation andtreatment, psychotropic medications may be required.

Indications for pharmacologic treatment:• Aggression• Agitation• Risk of harm to self or others• Hallucinations• Inconsolable or Persistent Distress

(e.g., fear, continuously yelling, screaming, distress associated with end-of-life,or crying);

• Significant decline in function

Must seek the underlying cause of distressed behavior before or while treatingthe symptom.

Behavioral symptoms must be reevaluated periodically to determine theeffectiveness of the antipsychotic and the potential for reducing or discontinuing

Requirements for Enduring Use of Antipsychotics

Target behavior must be clearly and specifically identified andmonitored objectively and qualitatively

Ensure the behavioral symptoms are: A. Not due to a medical condition or problem that can be expected to improve or resolve

B. Persistent or likely to reoccur without continued treatment; and

C. Not sufficiently relieved by non-pharmacological interventions; and

D. Not due to environmental stressors that can be addressed to improve the psychoticsymptoms or maintain safety

E. Not due to psychological stressors or anxiety or fear stemming from misunderstandingrelated to his or her cognitive impairment


Inadequate Indications for Antipsychotic Use:• Wandering

• Poor self-care

• Restlessness

• Impaired memory

• Mild anxiety

• Insomnia

• Unsociability

• Inattention or indifference to surroundings

• Fidgeting/Nervousness

• Uncooperativeness;

• Verbal expressions or behavior that do not represent a dangerto the resident or others

CMS State Operations Manual: Antipsychotics Usage

New Admissions to Skilled Nursing Facility

When a resident is admitted to a SNF from hospital/ communityand are already on an antipsychotic:

• Facility must re-evaluate antipsychotic medication at the time of admissionand/or within two weeks of admission

• PASRR screening (F285) - evaluation for mental illness and/or intellectualdisability


Investigator’s Review of Medication Management

Surveyors are instructed to review the clinical record todetermine if it reflects the following elements:

• Indication

• Non-pharmacological interventions

• Dose

• Duration

• Tapering/Gradual Dose Reduction documentation

• Monitoring and reporting for efficacy and adverse consequences

• Adverse consequence identification, evaluation, and actions byphysician and facility

Surveyor Investigation- Areas of Focus

• PRN orders for antipsychotic medications

• Describe how the facility provides individualized care andservices for residents with dementia

• Provide policies related to the use of antipsychoticmedications in residents with dementia

• Resident/families/representatives involvement

• Identify and document specific target behaviors

• Communicate consistently


CMS State Operations Manual: Medication Management

Medication Management Process:• All drugs implicated!

• Enhanced focus on :• Medications as cause for change in condition• Need for Medication Reviews in response to changes in condition

• Enhanced interdisciplinary teamwork• Enhanced care process• Personal responsibility• Need to document process

Medication Management

Medication management should support and promote:

1. Evaluating resident for underlying causes of signs/symptoms

2. Use of non-drug interventions

3. Selection of medications based on benefits vs. risk for individualresidents

4. Selection and use of medication in doses and duration individualresident

5. Monitoring of medications for efficacy and adverse consequences*.


Adverse Consequences: Identification

Medication review should be performed if resident has experienced a change in condition:

Weight loss or gain

Behavioral changes/ mental status changes

Bleeding or bruising

Bowel dysfunction

Dehydration/electrolyte imbalance

Dysphagia

GI bleed

Headaches or non-specific pain

Rash or itching

Respiratory changes

Sedation, insomnia, sleep changes

Seizures

Urinary retention or incontinence

How Can I Remember All of This?


Your Pharmacy Provider Service Team

• Pharmacists

• Technicians

• Nurses

• Consultant Pharmacists

• Account Managers

Facility

Staff

Nurse

Family

Pharmacist

MD/NP

Resident

Consultant

TEAMWORK is needed to help identify andresolve cognitive and behavioral problems!


Bowen JD, Larson EB. Drug-induced cognitive impairment. Defining the problem and finding the solutions. DrugsAging 1993; 3 (4): 349-57.

Cole MG, McCusker J., Dendukuri N, Han L. Symptoms of delirium among elderly medical inpatients with or withoutdementia. J. Neuropsychiatry Clin Neurosci 2002; 14(2):167-75.

Drug-Induced Delirium: Diagnosis, Management, and Prevention. Drug Ther Perspect 10(3):5-9, 1997Evidence-Based Interventions for Nursing Psychiatric Clinics of North America - Volume 28, Issue 4 Home Residents

with Dementia-Related Behavioral Symptoms (December 2005)Flaherty JH. Commonly prescribed and OTC medications: causes of confusion. Clin Geriatr Med 1998;14:101-127.Francis J. Martin D, Kkapoor WN. A prospective study of delirium in hospitalized elderly. JAMA 1990;263(8):1097-101.Gleason, OC. Am Fam Phys.67(5):1027-1034. 2003Inouye SK. The dilemma of delirium: Clinical and research controversies regarding diagnosis and evaluation of

delirium in hospitalized elderly medical patients. AM J Med 1994;97(3):278-88.Inouye, SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The confusion

assessment method. A new method for detection of delirium. Ann Intern Med 1990; 113(12):941-8.Inouye SK, Charpentier PA, Precipitating Factors for Delirium in Hospitalized Elderly Persons. JAMA. 1996;275:852-857.

Liang, BA. Diagnosis and Management of Delirium in the Elderly. Hosp Phys June 199:34-52.Lisi, D. Definition of Drug-Induced Cognitive Impairment in the Elderly Donna Medscape Pharmacotherapy 2(1), 2000.Pompei P, Foreman M, Rudberg MA, Inouye SK, Braund V, Cassel CK. Delirium in hospitalized older persons:

Outcomes and predictors. J Am Geriatr Soc 1994; 2(8):809-15.State Operations Manual: Appendix- Medications of Particular Relavence.

http://www.cms.hhs.gov/manuals/downloads/som107ap_pp_guidelines_ltcf.pdf pp. 299-339

References

Jennifer Hardesty, PharmD, FASCPDirector of Clinical Services, Remedi SeniorCare

[email protected]

Q & A

medication friend or foe - jennifer hardesty

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