When Should Brexpiprazole Be Used for Agitation in a SNF Resident?

Brexpiprazole (Rexulti) was recently approved by the FDA for treatment of agitation in Alzheimer Dementia based on the now published phase 3 study found in JAMA Neurology, November 6, 2023. In this 12-week study of the efficacy of this medication at the 2 and 3 mg daily dose compared to placebo, a statistically significant improvement in agitation was noted vs placebo. This medication was generally well tolerated without significant safety adverse events.  Agitation was defined as 1. excessive motor activity, 2. verbal aggression, or 3. physical aggression which caused excess distress or disability and could not be safely attributed to a suboptimal care environment or another disorder.  This is a small short-term study across multiple sites and countries.  This medication should be used for this indication with great caution until further studies confirm these results and better define those who might benefit, the degree of the benefit, and if significant long term adverse events occur with more prolonged use.   This medicine has common drug interactions that warrant dose adjustment in many circumstances.  This link has the details.

Brexpiprazole is a second-generation antipsychotic.  Like other medicines in this class, it carries a black box warning for increased mortality risk in elderly patients with dementia.  The class risk for mortality is 1.7 times greater in persons with dementia who do not take this class of medicine.  This risk is measurable within the first 100 days of use.   In my experience, agitation in persons newly admitted to SNFs tends to rapidly improve as the facility addresses the potential causes of agitation and the resident becomes familiar with the facility, their caregivers, and experiences the care plan.  Medications for agitation in our setting are seldom urgently needed.  If this medicine is used, it should be restricted to those with psychosis who have the above indicators of agitation.  In addition, this medicine should be used as a temporary trial while optimizing the environment of care and identifying potential root causes for agitation.

Throughout the pandemic, your California Partnership for Improving Dementia Care has worked to support optimal dementia care in the SNF setting.  We have developed free educational presentations for your staff on Best Practices in Dementia Care, Understanding Dementia, Individualizing Care Plans, and Nonpharmacologic Interventions.  We also just released a wonderful toolkit for training new and established CNAs on the care of persons living with dementia.  Besides the toolkit, we have an introductory video that will help DSDs adapt this resource in their facility.   All these resources are available on the Leading Age website.

This year our state legislature reconsidered AB 48, the previous version of which Governor Newsom vetoed in 2022, but was modified, approved, and signed into law by our Governor this Fall.  The full text isn’t yet available, but you should expect to see more details in the future about the necessity to provide written patient education materials for obtaining informed consent for psychotropic medications in the SNF setting.  This won’t go live until 2025 after CDPH has developed the required materials, with the assistance and consultation of CALTCM content experts, and will define user expectations.

At CALTCM’s recent Annual Summit, Dr. Keith Savell presented an excellent talk on ways we can create a more homelike environment in our SNFs that may improve quality of life and the transition into your community.  We hope to make this presentation available in 2024.

JAMDA on the Go November issue interviewed Steven Posar, the Lead author of the October JAMDA issue discussing a novel and quite effective program for reducing the use of antipsychotics in nursing homes.  JAMDA podcast can be found on most podcast sites such as Podbean, Apple podcasts, or Spotify.  Click here for the link to this podcast, and click here to preview the Journal article

As we approach the holidays, I look forward to a season of hope and renewal.  I hope 2024 is a year with better staffing, less chaos, and a time when we continue to improve our care for our residents living with dementia.

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