For many individuals with mental impairments/developmental disabilities (MR/DD) that reside in supported living centers, the potential to be placed on a myriad of psychotropic medications to manage both behavioral and neuropsychiatric disturbances exists. There are distinctive obstacles that a clinical pharmacist that works in a facility providing services to individuals with MR/DD can face as it relates the prescribing of psychotropic medications. As a result of the limited data or clinical trials on the use of psychotropic medications in this particular population, problems can be encountered when multiple psychotropic medications are prescribed.1 Based on the practice parameters for the assessment and treatment of children, adolescents, and adults with MR/DD, or other comorbid mental disorders published by the American Academy for Child and Adolescent Psychiatry, the problems can include irrational prescribing, inappropriate medication for a given diagnosis, or questionable monitoring of adverse effects. 1 The role of the clinical pharmacist in this practice setting can consist of a continuous assessment of the clinical justification and rationale for why psychotropic polypharmacy is warranted. Polypharmacy can be defined in many different ways and may differ based on the patient population being evaluated. 2 According to Fulton and Allen (2005), polypharmacy is defined as the use of medications that are not clinically indicated; and in clinical practice it is the use of more than a certain number of drugs to treat a condition regardless of its appropriateness. 3 Within an assisted living facility, periodic reviews of drug utilization can be associated with funding for the facility so the evaluation of the appropriateness of medication use, including polypharmacy, may need to be performed on a quarterly, biannual, or yearly basis.5 The co-occurring use of multiple psychoactive medications in a single patient is becoming an increasingly common and current practice in clinical psychiatry which largely based more on experience rather than evidence. 6 Any patient receiving more than one medication from a specific class (e.g. two antidepressants, two antipsychotics), should have regular reassessment to confirm the necessity of the polypharmacy.7 In general, polypharmacy is considered to a major health issue not only in primary care setting but in other practice setting as it can lead to unnecessary expenses, wasted time, and possibly mismanagement on the part of the attending clinician if the indication for psychotropic polypharmacy is not routinely evaluated.7 Furthermore, patients with MR/DD have an increased potential for drug-drug interactions, side effects of psychotropic medications such as extrapyramidal effects from antipsychotic medications and delirium from benzodiazepines, and possibly unrecognized complications.7 

As a member of the interdisciplinary team that specializes in providing care to the individual with MR/DD, the clinical pharmacist can offer recommendations on psychotropic polypharmacy management and selection. The prescribing of psychotropic medications to suppress bothersome, disruptive symptoms or behaviors is not recommended until a behavioral management program has been initially employed and is proven to be ineffective.7 When possible, behavioral interventions are the first line of treatment for all types of problematic behaviors. The development of a behavioral management program can consist of strategies for risk assessment, early intervention, control of participating factors, and acute management and after-event evaluation. The strategic process that be employed by a clinical pharmacist during routine evaluation of psychotropic polypharmacy can consist of six steps which include, 1) obtaining an accurate medication and physical history, 2) linking each prescribed medication to the psychiatric condition, 3) identifying medications that are being used to treat side effects, 4) initiating interventions to ensure adherence, 5) reconciling medications upon transfers, and 6) prevention by regularly considering the appropriated of the medication for the patient.7,8 Given the potential risks (e.g. unanticipated adverse effects, including death) that can be associated with using multiple psychiatric medications in combination, a thorough evaluation of the regimen is necessary.9 The presence of psychotropic polypharmacy can increase the likelihood of problems and places a greater responsibility on the prescriber for more intense monitoring and the ancillary support of the clinical pharmacist to assess the appropriateness of maintaining therapy. 9,10 The clinical pharmacist in a MR/DD unit can work in collaboration with the treatment team to identify environmental factors that may be contributing to the patient's disturbances and assist with modification. For instance, a MR/DD patient is started on aripiprazole 15mg by mouth at bedtime for bipolar disorder. The attending psychiatrist who routinely monitors the behavior and activities of the MR/DD patient notices that the patient is not sleeping at night, so the psychiatrist decides to initiate low-dose quetiapine 25mg by mouth at bedtime. The clinical pharmacist may be able to reduce polypharmacy in this instance by recommending morning dosing of aripiprazole given its potentially activating effects and discontinuing quetiapine.

If a determination is made on the part of the prescriber that polypharmacy may be warranted in any particular case, careful monitoring of the medication regimen must be performed by the clinical pharmacist as well as enlisting the aid of other healthcare providers to identify the development of any adverse reactions that may occur.9 The clinical pharmacist can prove to be instrumental in ensuring that prescribers are optimizing monotherapies prior to attempting polypharmacy in MR/DD patients, and in the case of frequently prescribed antipsychotic medications, there is evidence to suggest that it typically takes 16 weeks or longer for most patients display an improvement of symptoms by 30% and up to one year for other patients to improve by 60%. 11 In order to aid in the prevention and or reduction of unnecessary polypharmacy, the clinical pharmacist can routinely screen patient drug profiles, assess the effects of comorbid conditions, and review for potential drug-drug interactions that may exist with each individual patient.12 According to the State Operations Manual for Intermediate Care Facilities for Persons with Mental Retardation, psychotropic medications are to only be used within an active treatment program that is designed to eliminate specific behaviors which are thought to be drug responsive, and in addition a collaboration must exist between the physician, pharmacist, nurse, and other health staff to work together to reduce psychotropic drug utilization if an issue is identified. 13 As a result of the limited or even lack of significant data on the use of psychotropic medication in patients with diagnoses of MR/DD, clinicians can at times fall into the patterns of initiating medications by trial and error until success is achieved, but in the process a patient can be a multitude of unnecessary medications. The therapeutic endpoint with any psychotropic medication is to witness a reduction or alleviation of problematic symptoms (e.g. aggression, agitation, disruptive vocalizations). While therapeutic success can be achieved with the treatment of acute aggression, episodic aggression, and even chronic aggression, the treatment of occasional aggression rarely responds to medications and drug therapy and may even increase the risk of complications. The clinical pharmacist can assist with goal attainment by having this knowledge in mind and discussing it with all healthcare providers so they can set realistic expectations of treatment given an optimal duration of therapy.

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