Long-Term Care Survey Alert

Is the resident taking an antiepileptic for behavioral issues? Read on.

Taking a look at the MAR and MDS can give you a heads up that a resident may be headed for negative outcomes  caused by sedating meds that at first glance may not seem to fit that category.

Key: Combining CNS depressants produces a synergistic rather than just an additive effect, warned Thomas Lynch, PharmD, in a presentation at the March 2010 American Medical Directors Association annual meeting.

In fact, "you can get in trouble really quickly once you start combining different types of CNS depressants." Combining CNS depressants has been shown to increase falls and respiratory failure, Lynch cautioned. Put Antiepileptics, Tricyclics, Zyrtec on the Radar Screen Antiepileptic medications are central nervous system depressants -- "that's how they work," said Lynch. And they aren't used so much for seizures in long-term care as for "everything else," including pain syndromes and bipolar disorder.

"Antiepileptics are sometimes used for dementia-related behaviors," which would be an off label use, says Albert Barber, PharmD, director of pharmacy for Golden Living based in Ft. Smith, Ark. "These drugs have fairly good anti-anxiety properties when used for anxiety-type behaviors seen in dementia," he says. In addition to first-generation antihistamines, such as diphenhydramine (Benadryl) and chlorepheniramine, tricyclic antidepressants, which are used more for neuropathic pain than depression, are sedating, said Lynch. Benzodiazepines are also obviously CNS depressants, as are hypnotic agents (Ambien, Lunesta), opiates, and barbiturates, he stressed.

Tip: "Zyrtec is not a non-sedating antihistamine," Lynch emphasized.

Tap These Strategies for Using Sedative Medications Teamwork offers your best bet for heading off problems caused by medications that have sedative effects, including respiratory depression.

"Pharmacies and facilities should flag combinations of drugs with sedative effects," says Barber. Consultant pharmacists will look to see if outcomes, including a fall, might be related to a medication, he notes. "If so, the pharmacist will recommend changes, such as eliminating a drug or lowering the dose."

Pharmacists "also look for potential problems, especially in older patients who start on a known dose of a drug with sedative properties and have an increased fall risk for another reason." In such a case, "the pharmacist may suggest the drug or dose isn't appropriate for that patient," Barber counsels.

Also flag patients at higher risk for respiratory depression before administering sedating medications. Examples include people with chronic obstructive pulmonary disease, emphysema, chronic bronchitis, and asthma, says Barber. Tip: "Typically we encourage prescribers not to start any patient on a long-acting opioid who isn't opioid tolerant," advises Barber. "These drugs, including methadone, are drugs you go to when the shorter-acting opioids aren't working anymore. You don't start with them."