October 29, 2014
In her recent New York Times blog (@TheNewOldAge) author Paula Span asks the question: “Is It Really Dementia?” Or is it really something else. We ask:“Is It Really Your Medication?”
The blog raises the point that while there are other reasons for memory and cognitive impairment symptoms, most often for a 75 year old person with longer-onset symptoms, the diagnosis is usually dementia and usually Alzheimer ’s disease.
While this is generally true, the discussion continues around other causes of memory and cognitive decline, especially when symptoms appear abruptly. We concur, and posit that a large contributor to the development of ‘delirium’ symptoms (as opposed to a dementia presentation time-line) is medication use, specifically Adverse Drug Events (ADEs).
Ms. Span quotes Dr.P Murali Doraiswamy, a noted researcher at Duke: “There’s a long list, several hundred drugs, both prescription and over the counter, that can impair memory.”
Indeed, in 2012 The American Geriatrics Society (AGS) published a revision of the Beers’ Criteria- an exhaustive list of medications known to cause memory and cognitive decline in older adults as well as many other types of ADEs. CMS has continued that thread with their STAR RATINGS quality measures for Medicare Part D Health Plans, warning of potential ADEs as a result of a set of ‘High Risk Medications’.
Two articles recently published in the pharmacy literature point out the connection between older adults, medication use and ADEs. Older adults just use more medications. A study in The Consultant Pharmacist (ConsultPharm 2014;29:689-97) showed a study group of older adults used an average of 7.2 medications AND an additional 6 over-the-counter medications on top of that (OTCs are available today that were once prescription-only, and at the same Rx strength). The authors found that ADE risk doubled when patients were in the 5-7 Rx range and quadrupled when patients were taking 8 Rxs or more.
Synder et al, in a study published this month in Pharmacotherapy (Pharmacotherapy 2014;34(10):1022-32) supports that the number of medications used by older adults is predictive of ADEs. Both authors state that the current CMS requirement of Medicare Plans to provide Medicare Therapy Management Programs may be inadequate to predict and intervene specifically on patients with increased risk of ADEs.
Dr. Doraiswamy also states that older adults suffer from conditions that also impair memory and cognition, such as depression, anxiety and insomnia. We observe that in addition, medications used to TREAT those conditions can also worsen memory and cognition in their own right (see previous blogs by us on this topic)
So, follow the convergence. Older adults are most at risk from dementia, who have conditions which cause dementia-like symptoms, are treated for those conditions with medications which cause dementia-like symptoms, who take the most medications, who are also mostly at risk for ADEs, which is a predictor of future ADEs which can cause memory and cognitive decline symptoms in a population already at risk for dementia. It sounds like Catch-22.
Okay, how do we break this cascade of convergence, and what do we do? As Span says, many times it’s dementia, but as we observe above, sometimes it’s not. We need to make sure we do a thorough medication reconciliation when we start the medication management process, starting by really validating “known” quantities from claims or orders, but also making sure to include a structured patient interview which captures over-the-counter (OTCs) and complementary-alternative medications (CAMs). We need to have a clear and complete picture of the patient’s actual medication use, and combining all best possible sources of data gives the clinician a clear starting point for assessment, and streamlines the process of assessing a complex situation. We also need to make sure we have the resources to understand how those medications are interacting to the detriment of the patient’s memory and cognition, and have a good process to communicate our finding to the rest of the health care team. Better yet, let’s use our analytics and talents to design predictive programs that reach out, identify patients who are at risk for ADEs, and do our best to resolve and prevent them. Understanding risk isn’t enough if we haven’t established an efficient, scalable process for making those risks actionable across the care team.
Joseph Gruber, RPh, CGP, FASCP: Chief Clinical Officer, ActualMeds Corporation. Past President, American Society of Consultant Pharmacists. @jgactualmeds