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Combinatorial Pharmacogenomics Reduces Polypharmacy and Medication Cost in Elderly Patients with Anxiety and Depression
2017 AAGP Annual Meeting Poster Number: NR 30
Ability of the Maze Navigation Test (MNT) to Predict Performance on a Specialist Driving Assessment for Individuals with Dementia Etuini Ma’u, MBCHB, FRANZCP Waikato District Health Board, Hamilton, New Zealand Introduction: Whilst it is generally accepted that those with a moderate dementia should not drive, the driving ability of those with early cognitive decline or mild dementia is less clear. With no reliable measure to guide decisions, it is left to the physician’s subjective judgment as to whether further on-road testing is necessary, the cost of which is prohibitive for many. The Maze Navigation test (MNT) was developed as a measure of executive functioning and has been shown to predict driving ability. The aim of this study was to assess the ability of the MNT to predict driving performance on a specialist driving assessment for individuals with dementia. Methods: 35 participants recently diagnosed with dementia in the Waikato memory service and still driving were administered the MNT, Montreal Cognitive Assessment (MoCA) and Trail making tests A & B, then completed a specialist occupational therapist on-road driving assessment. Results: Of the 20 completed assessments to date, 10 (50%) passed without restrictions, 7 (35%) passed with restrictions and 3 (15%) failed the on road assessment, with only Trails A (p = .007) and Trails B (p = .027), but not MNT (p = .11), correctly predicting driving outcome. When participants were dichotomised into those with imposed driving restrictions (including driving cessation) or without, neither the MNT (p = .07), MoCA (p = .18), Trails A (p = .546) or Trails B (p = .226) predicted driving outcome. Conclusions: Preliminary results indicate most individuals diagnosed with dementia and still driving are safe to do so, with only the Trails A&B tests predicting on-road driving outcome.
Poster Number: NR 31
Combinatorial Pharmacogenomics Reduces Polypharmacy and Medication Cost in Elderly Patients with Anxiety and Depression Mark Mayhew, PhD; Michael Jablonski, PhD; Jim Li, PhD; Bryan Dechairo, PhD Assurex Health, Mason, OH Introduction: The frequency of adverse drug reactions (ADRs) and therapeutic failures are often increased in elderly patients. Individual genetic variations in drug-metabolizing enzymes and neurotransmitter transporters and receptors add to the heterogeneity of treatment response and safety. Selection of genetically concordant medications is not only important for proper efficacy and avoiding ADRs, but also affects polypharmacy, the number of prescriptions needed to treat psychiatric and associated comorbid conditions, and therefore also impacts healthcare costs. Methods: In this subanalysis of a large pharmacogenomics trial (Winner et al. 2015), we aimed to better understand the medication cost savings and polypharmacy differences between medication selection guided by the GeneSight® combinatorial pharmacogenomic test (congruent) versus medication selection that did not follow the genetic test results (incongruent) in patients 65 years of age or older. Specifically, we assessed polypharmacy and the cost differences when patients were treated by primary care providers or psychiatrists for major depressive disorder (MDD) and generalized anxiety disorder (GAD). Results: As a driver of cost savings, polypharmacy was reduced in both CNS and non-CNS medications with 2 less medications and 10 less medication refills per patient per year (PPPY) when healthcare providers made congruent decisions in patients 65 years of age or older. Congruence with the GeneSight® test recommendations, resulted in total medication cost savings of $4,114 PPPY for PCPs (p = 0.026) and $120 PPPY for psychiatrists (p = 0.719) compared to incongruence. Specific to psychiatric medications, PPPY cost savings were $1,738 PPPY for PCPs (p = 0.001) and $514 PPPY for psychiatrists (p = 0.397). The greatest cost savings was for GAD patients where congruent medication selection decisions resulted in $9,367 PPPY compared to incongruent decision making (p = 0.045). Meaningful cost savings of $5,538 PPPY (p = 0.176) were also observed for patients with MDD. Conclusions: Significant medication cost savings were observed in patients 65 years of age or older when clinicians were congruent with pharmacogenomic test recommendations. Medication cost savings occurred for a number of reasons including a reduction in polypharmacy for both psychiatric and comorbid disorders. It has been shown in several studies that relieving depression symptoms results in improvement of other comorbid conditions like diabetes. We speculate that total medication savings are partly driven by improving depression, anxiety, and other comorbid disorders in combination. This is evident from
Am J Geriatr Psychiatry 25:3S, Supplement 1
S143
2017 AAGP Annual Meeting the reduction in medication spend across CNS and non-CNS medications and the greater cost savings associated with PCP treatment compared to treatment by a psychiatrist. Psychiatrist, in contrast to PDPs, might not be willing to reduce neuropsychiatric medications due to medication trials being the primary source of treatment for patients. Understanding the genetic and phenotypic heterogeneity of patients, particularly in the over 65 age group, allows clinicians to choose optimal therapeutic treatments, avoid ADRs, and save money on medication. This research was funded by: Assurex Health.
Poster Number: NR 32
Implementation of a Screening Tool for Outpatient Palliative Care Referrals from Geriatric Psychiatry: A Quality Improvement Project Erin Zahradnik, MD1; Matthew Majeske, MD2 1
University of Chicago, Chicago, IL Icahn School of Medicine at Mount Sinai, New York, NY
2
Introduction: Geriatric psychiatry patients often have significant medical problems in addition to their mental health concerns. Diseases such as dementia frequently present with neuropsychiatric symptoms, and serious health problems are associated with increased risk of depression and anxiety. Palliative care is a specialty that focuses on the treatment of physical and psychological symptoms related to life-limiting illnesses, many of which occur in the geriatric population. This quality improvement (QI) project aimed to develop a tool to facilitate outpatient referrals from geriatric psychiatry to palliative care. Methods: The tool was developed using criteria based on palliative care and hospice eligibility, such as frequent hospitalizations, recent declining functional status, and unmet end-of-life needs. It contained both an educational component to help psychiatry providers understand specific palliative care goals, as well as a guide for determining which patients may benefit most. Patients (n = 230) were screened during their geriatric psychiatry clinic visits and then a more in-depth chart review was performed for those initially deemed good candidates (n = 13). Results: Ultimately, 11 patients were found to warrant outpatient palliative care referral. We found that the most useful criteria for facilitating these referrals was 1) presence of a life-limiting or life-threatening condition, and 2) psychiatric symptoms related to the life-threatening condition. Conclusions: The development of a palliative care screening tool and referral pathway for geriatric psychiatry patients with serious medical illnesses may help provide these patients with improved comprehensive care for their interrelated medical and psychiatric diseases.
Poster Number: NR 33
Pharmacogenetics-Guided Treatment of Mental Illness in Late-Life: A Case Series Ksenia Freeman, MD; Carl Cohen, MD; Michael Reinhardt, MD; Anup Mani, DO; Dina Ghoneim, MD SUNY Downstate, New York, NY Introduction: Psychopharmacotherapy of older adults is an exceptionally challenging and sensitive process. Safe implementation of pharmacotherapy requires: comprehensive assessment, careful person-centered planning, standardized monitoring, pharmacodynamic, and pharmacokinetic consideration. Given the complexity and high rates of adverse effects of psychopharmacotherapy in older adults, all potential tools to minimize risk and increase benefit merit investigation. Methods: Pharmacogenetic testing has undergone only minimal investigation in older adults with mental health disorders. Through evaluation of an individual’s pharmacogenetic profile, this testing offers the promise of personalized pharmacotherapy, decreased polypharmacy, and increased adherence through minimization of adverse effects. Pharmacogenetics testing analyzes medications via pharmacokinetic and pharmacodynamic genes, related to the metabolism of pharmaceutical agents commonly used in psychiatry, evaluating both single gene effects and gene drug interactions. In this study, three multicomorbid, treatment-resistant geropsychiatric cases are reviewed and the results of their pharmacogenetic testing discussed. Results: In each case, pharmacogenetic testing revealed a complex interaction between genes and drugs, potential pharmacokinetic and pharmacodynamic concerns, and suggested possible paths forwards symptom reduction or remission.
S144
Am J Geriatr Psychiatry 25:3S, Supplement 1
Ability of the Maze Navigation Test (MNT) to Predict Performance on a Specialist Driving Assessment for Individuals with Dementia Etuini Ma’u, MBCHB, FRANZCP Waikato District Health Board, Hamilton, New Zealand Introduction: Whilst it is generally accepted that those with a moderate dementia should not drive, the driving ability of those with early cognitive decline or mild dementia is less clear. With no reliable measure to guide decisions, it is left to the physician’s subjective judgment as to whether further on-road testing is necessary, the cost of which is prohibitive for many. The Maze Navigation test (MNT) was developed as a measure of executive functioning and has been shown to predict driving ability. The aim of this study was to assess the ability of the MNT to predict driving performance on a specialist driving assessment for individuals with dementia. Methods: 35 participants recently diagnosed with dementia in the Waikato memory service and still driving were administered the MNT, Montreal Cognitive Assessment (MoCA) and Trail making tests A & B, then completed a specialist occupational therapist on-road driving assessment. Results: Of the 20 completed assessments to date, 10 (50%) passed without restrictions, 7 (35%) passed with restrictions and 3 (15%) failed the on road assessment, with only Trails A (p = .007) and Trails B (p = .027), but not MNT (p = .11), correctly predicting driving outcome. When participants were dichotomised into those with imposed driving restrictions (including driving cessation) or without, neither the MNT (p = .07), MoCA (p = .18), Trails A (p = .546) or Trails B (p = .226) predicted driving outcome. Conclusions: Preliminary results indicate most individuals diagnosed with dementia and still driving are safe to do so, with only the Trails A&B tests predicting on-road driving outcome.
Poster Number: NR 31
Combinatorial Pharmacogenomics Reduces Polypharmacy and Medication Cost in Elderly Patients with Anxiety and Depression Mark Mayhew, PhD; Michael Jablonski, PhD; Jim Li, PhD; Bryan Dechairo, PhD Assurex Health, Mason, OH Introduction: The frequency of adverse drug reactions (ADRs) and therapeutic failures are often increased in elderly patients. Individual genetic variations in drug-metabolizing enzymes and neurotransmitter transporters and receptors add to the heterogeneity of treatment response and safety. Selection of genetically concordant medications is not only important for proper efficacy and avoiding ADRs, but also affects polypharmacy, the number of prescriptions needed to treat psychiatric and associated comorbid conditions, and therefore also impacts healthcare costs. Methods: In this subanalysis of a large pharmacogenomics trial (Winner et al. 2015), we aimed to better understand the medication cost savings and polypharmacy differences between medication selection guided by the GeneSight® combinatorial pharmacogenomic test (congruent) versus medication selection that did not follow the genetic test results (incongruent) in patients 65 years of age or older. Specifically, we assessed polypharmacy and the cost differences when patients were treated by primary care providers or psychiatrists for major depressive disorder (MDD) and generalized anxiety disorder (GAD). Results: As a driver of cost savings, polypharmacy was reduced in both CNS and non-CNS medications with 2 less medications and 10 less medication refills per patient per year (PPPY) when healthcare providers made congruent decisions in patients 65 years of age or older. Congruence with the GeneSight® test recommendations, resulted in total medication cost savings of $4,114 PPPY for PCPs (p = 0.026) and $120 PPPY for psychiatrists (p = 0.719) compared to incongruence. Specific to psychiatric medications, PPPY cost savings were $1,738 PPPY for PCPs (p = 0.001) and $514 PPPY for psychiatrists (p = 0.397). The greatest cost savings was for GAD patients where congruent medication selection decisions resulted in $9,367 PPPY compared to incongruent decision making (p = 0.045). Meaningful cost savings of $5,538 PPPY (p = 0.176) were also observed for patients with MDD. Conclusions: Significant medication cost savings were observed in patients 65 years of age or older when clinicians were congruent with pharmacogenomic test recommendations. Medication cost savings occurred for a number of reasons including a reduction in polypharmacy for both psychiatric and comorbid disorders. It has been shown in several studies that relieving depression symptoms results in improvement of other comorbid conditions like diabetes. We speculate that total medication savings are partly driven by improving depression, anxiety, and other comorbid disorders in combination. This is evident from
Am J Geriatr Psychiatry 25:3S, Supplement 1
S143
2017 AAGP Annual Meeting the reduction in medication spend across CNS and non-CNS medications and the greater cost savings associated with PCP treatment compared to treatment by a psychiatrist. Psychiatrist, in contrast to PDPs, might not be willing to reduce neuropsychiatric medications due to medication trials being the primary source of treatment for patients. Understanding the genetic and phenotypic heterogeneity of patients, particularly in the over 65 age group, allows clinicians to choose optimal therapeutic treatments, avoid ADRs, and save money on medication. This research was funded by: Assurex Health.
Poster Number: NR 32
Implementation of a Screening Tool for Outpatient Palliative Care Referrals from Geriatric Psychiatry: A Quality Improvement Project Erin Zahradnik, MD1; Matthew Majeske, MD2 1
University of Chicago, Chicago, IL Icahn School of Medicine at Mount Sinai, New York, NY
2
Introduction: Geriatric psychiatry patients often have significant medical problems in addition to their mental health concerns. Diseases such as dementia frequently present with neuropsychiatric symptoms, and serious health problems are associated with increased risk of depression and anxiety. Palliative care is a specialty that focuses on the treatment of physical and psychological symptoms related to life-limiting illnesses, many of which occur in the geriatric population. This quality improvement (QI) project aimed to develop a tool to facilitate outpatient referrals from geriatric psychiatry to palliative care. Methods: The tool was developed using criteria based on palliative care and hospice eligibility, such as frequent hospitalizations, recent declining functional status, and unmet end-of-life needs. It contained both an educational component to help psychiatry providers understand specific palliative care goals, as well as a guide for determining which patients may benefit most. Patients (n = 230) were screened during their geriatric psychiatry clinic visits and then a more in-depth chart review was performed for those initially deemed good candidates (n = 13). Results: Ultimately, 11 patients were found to warrant outpatient palliative care referral. We found that the most useful criteria for facilitating these referrals was 1) presence of a life-limiting or life-threatening condition, and 2) psychiatric symptoms related to the life-threatening condition. Conclusions: The development of a palliative care screening tool and referral pathway for geriatric psychiatry patients with serious medical illnesses may help provide these patients with improved comprehensive care for their interrelated medical and psychiatric diseases.
Poster Number: NR 33
Pharmacogenetics-Guided Treatment of Mental Illness in Late-Life: A Case Series Ksenia Freeman, MD; Carl Cohen, MD; Michael Reinhardt, MD; Anup Mani, DO; Dina Ghoneim, MD SUNY Downstate, New York, NY Introduction: Psychopharmacotherapy of older adults is an exceptionally challenging and sensitive process. Safe implementation of pharmacotherapy requires: comprehensive assessment, careful person-centered planning, standardized monitoring, pharmacodynamic, and pharmacokinetic consideration. Given the complexity and high rates of adverse effects of psychopharmacotherapy in older adults, all potential tools to minimize risk and increase benefit merit investigation. Methods: Pharmacogenetic testing has undergone only minimal investigation in older adults with mental health disorders. Through evaluation of an individual’s pharmacogenetic profile, this testing offers the promise of personalized pharmacotherapy, decreased polypharmacy, and increased adherence through minimization of adverse effects. Pharmacogenetics testing analyzes medications via pharmacokinetic and pharmacodynamic genes, related to the metabolism of pharmaceutical agents commonly used in psychiatry, evaluating both single gene effects and gene drug interactions. In this study, three multicomorbid, treatment-resistant geropsychiatric cases are reviewed and the results of their pharmacogenetic testing discussed. Results: In each case, pharmacogenetic testing revealed a complex interaction between genes and drugs, potential pharmacokinetic and pharmacodynamic concerns, and suggested possible paths forwards symptom reduction or remission.
S144
Am J Geriatr Psychiatry 25:3S, Supplement 1