DEPRESCRIBING
Deprescribing to Resolve Oversedation and Confusion in an Older Person Treated for Auditory Hallucinations and Poststroke Seizure Prophylaxis AUTHOR
Mark Branum, PharmD, BCGP, Adjunct Assistant Professor, Drake University; Adjunct Assistant Professor, University of Iowa This article was published in The Senior Care Pharmacist by the American Society of Consultant Pharmacists (ASCP). Doi:10.4140/TCP.n.2021.645.
INTRODUCTION
This case study reviews the pharmacotherapy of a resident in a longterm care facility being treated for poststroke seizure, hallucinations, and dementia, a geriatric syndrome that is both common in regard to its prevalence and severe in regard to its impact on the individual, families, caregivers, and health care system. This case describes the past medical history of an older resident in a skilled nursing facility that was receiving pharmacological therapy for auditory hallucinations and for poststroke seizure prophylaxis, was noted to be having side effects from drug therapy, and how the nursing staff communicated with the consultant pharmacist to resolve these issues. KEY WORDS: Antipsychotic medication, Case study, Dementia, Geriatric syndrome, Hallucinations, Interprofessional communication, Older person, Poststroke seizure, Deprescribing, Potentially inappropriate medications. ABBREVIATIONS: CVA = cerebrovascular accident, D2 = dopamine receptor D2, PIMs = Potentially inappropriate medications, SVA = synaptic vesicle protein type 2A, SV2A = synaptic vesicle glycoprotein 2A. Sr Care Pharm 2021;36:645-51.
depressive disorder with psychotic features.” She had a stroke approximately two years prior to her recent hospitalization for pneumonia and had subsequent left-sided hemiplegia and hemiparesis. Progress notes from the psychiatrist prior to her hospitalization for pneumonia included “auditory hallucinations,” a “euthymic mood,” and also that she “does not hear well.” A similar note from a telehealth psychologist noted that Betsy had a “pleasant and cooperative demeanor” with some “auditory hallucinations” but no visual hallucinations noted. Upon admission to her present nursing facility after her hospitalization, nursing staff noticed that Betsy was quite lethargic and asked if medications could be contributing. Nursing staff, including one that happened to be Betsy’s niece, reached out to the facility’s consultant pharmacist with their concerns regarding Betsy, her medications, and possible side effects. Nursing staff raised questions about her Seroquel dose at bedtime for “auditory hallucinations” and questioned whether the “man singing” that she hears might be either tinnitus or perhaps sounds overheard from another resident's television in the neighboring room. As the consultant pharmacist for the facility, you listened to the staff members’ concerns regarding Betsy’s medications, sedation, and began a thorough medication regimen review.
Past Medical History
Any medication therapy can cause adverse effects, especially in older patients. Betsy: A 91-Year-Old Female Living in a Skilled Nursing Facility Betsy is a 91-year-old resident of a skilled nursing facility where most residents are 80 years of age or older, many have significant functional limitations in terms of mobility, and most need partial or total assists with activities of daily living. The facility has an occupancy of 55 residents with a central dining room, several common areas including a sunroom, patio, activities area, chapel, and an attached clinic-run physical therapy office.
HISTORY OF PRESENT ILLNESSES
Betsy was admitted to her present nursing facility after a brief hospitalization for pneumonia. Prior to her hospitalization, she was living in a different nursing facility and was doing reasonably well. She was seen by her primary care physician every two months in that facility and was treated by a telehealth psychiatrist who diagnosed her with “major
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Heart failure, vascular dementia, cerebrovascular accident (CVA), hypertension, chronic atrial fibrillation, anxiety, depression, chronic obstructive pulmonary disorder, osteoarthritis, depression with psychotic features.
Social History
Alcohol use: none noted; nicotine: former smoker for many years, no indication of pack/year history.
Physical Exam
Height: 66”, Weight: 165 lbs, BP: 129/77, HR: 66, RR: 16, Blood sugar: 153, O2 sat: 95%, pain level: 0.
Laboratory Results
RBC = 4.53 M/uL, Hgb = 14.4 g/dL, Hct = 44.4%, Na = 137 mmol/L, K = 4.2 mmol/L, Cl = 95 mmol/L, Anion Gap = 13 mmol/L, Cr = 0.70 mg/dL, eGFR = 76 mL/min/1.73 m2, glucose = 186 mg/dL.
