TRANSITIONING PATIENTS WITH MAJOR NEUROCOGNITIVE DISORDERS FROM ANTIPSYCHOTIC MEDICATIONS TO CITALOPRAM - A PHARMACOGENETICALLY-INFORMED CASE SERIES

AAGP Annual Meeting 2019 who confirmed the DNR/DNI status could be honored as the policy had recently changed. On hospital day 28, the patient was discharged to a nursing home with hospice care, and he died nine days later. Results: Discussion: Inpatient psychiatrists and staff are not as familiar as their counterparts at a medical center in managing end-of-life care and death of patients, despite geriatric psychiatrists commonly treating patients of advanced age or with terminal illness. An increasing number of patients with advanced dementia and associated behavioral disturbances are psychiatrically hospitalized, and they represent the fastest growing group of hospice patients. This patient’s agitation needed stabilizing before he could transfer to a nursing home safely. When he began displaying autonomic instability, multiple members of his treatment team were concerned his advanced directives would not be honored if he died while on the psychiatric unit, and expressed additional concerns around the impact his death would have on staff and other patients. Conclusions: Experts suggest the final stage of Alzheimer’s disease include the inability to ambulate, speak, perform activities of daily living, and appropriately swallow. When these signs are present, it is important to recognize any limitations in the care available, involving hospice or palliative care experts if needed, to honor a patient’s end of life wishes accordingly. This research was funded by: Not applicable. Poster Number: EI - 19

TRANSITIONING PATIENTS WITH MAJOR NEUROCOGNITIVE DISORDERS FROM ANTIPSYCHOTIC MEDICATIONS TO CITALOPRAM - A PHARMACOGENETICALLYINFORMED CASE SERIES Aninditha Vengassery; Sarah Sheikh; Syed Maududi; Viktoriya Donovan; Sayan Kaishibayev; Patrick Arthur; Joseph Voigt; Carl Cohen; Michael Reinhardt SUNY Downstate Medical Center Introduction: The successful and safe psychopharmacologic management of older adults suffering with major neurocognitive disorders with behavioral disturbances and has remained a challenging therapeutic dilemma − despite recently published guidelines on the topic. Available guidelines would suggest that individuals with severe agitation, violence, or distress related to their agitation or psychosis should receive pharmacotherapy in addition to behavioral and social management. Citalopram and other SSRIs have shown promise in treating agitation and psychosis in the context of major neurocognitive disorders, however treatment with antipsychotics for this indication has not appreciably declined on the national stage despite the increased risk of morbidity and mortality associated with these medications. While the literature has given much thought to the initial choice of medication for these patients, an important question remains as to whether there are patients whom might benefit from a transition to citalopram after an antipsychotic has already been initiated. Given the high potential for symptom recurrence when transitioning from an antipsychotic, methodology that would allow some measure of individualized response prediction would be of clinical value. Interestingly, low expression alleles of the SLC6A4 (serotonin transporter) gene have been linked to decreased response to citalopram in major neurocognitive disorders. Methods: Three cases from the ambulatory Center of Excellence for Alzheimer’s Disease at SUNY Downstate are presented in which patients suffering with major neurocognitive disorders and associated neuropsychiatric symptoms were transitioned from antipsychotic medications to citalopram. Case histories and scores on the neuropsychiatric inventory and CGI scales are presented for review. Pharmacogenetic testing results are presented for the final case in which transition to citalopram was not successful. Results: Two of three cases were successfully transitioned from antipsychotic medications to citalopram, resulting in near total remission of psychosis and agitation on the CGI Agitation and Psychosis scales. The third case offers a compelling explanation for the treatment failure − pharmacogenetic polymorphisms that impacted both the metabolism (CYP2D6 ultrarapid metabolizer, CYP2C19 intermediate metabolizer) of citalopram and its effectiveness (homozygous for the short promoter of the serotonin transporter gene - SLC6A4). Conclusions: This case series presents an important treatment approach for older adults with major neurocognitive disorders that have already been started on antipsychotics for their neuropsychiatric symptoms. Transitioning from an antipsychotic to citalopram was effective in two out of three cases, limiting their exposure to a class of medications with a higher risk profile. The third case, while unsuccessful, highlights the complexities of treatment choice and the importance of a personalized approach to medicine. Given previous reports that low expression alleles of the SLC6A4 gene may be linked to decreased response to citalopram, further controlled study evaluating the transition from antipsychotic medications to citalopram utilizing pharmacogenetic testing to personalize treatment could potentially improve treatment choice in this vulnerable population. This research was funded by: This study received no outside support.

Am J Geriatr Psychiatry 27:3S, March 2019

S131