Putting seniors on off-label medications with black box labels like Remeron for safety reasons?
A sibling and mother's pcm endorse putting my mother on medications like Remeron for safety reasons. Per my sibling who lives in the home and the caregiver, my mother is very active and can be during the night. But she has 24/7 care in her home; isn't that why we pay for them?
I cannot find any evidenced-based studies on PubMed endorsing the use of Remeron and others; I understand MDs have been using them off-label for years. I question if they have been around for years why any studies aren't there supporting use of it. I also question if Remeron is used a lot as it is the cheapest generic drug in the formulary.
Sadly, the PCM In the past has allowed my brother with no authority (is not HCP) to consent to the drug, My brother just happens to be at the appointment. I have asked the PCM not to do this and to go through proper channels.
The New York Times recently had an article on the misuse of Remeron in the senior population.
Any experiences or advice? Are they better (ideally FDA approved drugs) that are better choices. My mother has a beautiful mind. When she was put on Remeron in the past by mistake in a physical therapy rehabilitation facility eventually it totally knocked her out and took away her full cognition. Once she got back home, we stopped the medication, and she became fully clear again.
Ideally, I want all off-label, black box warning use of psychiatric drugs to be prescribed by a specialist like a neurologist or geriatrician, not a PCM just two years out of her residency. I hear there some pharmacists trained in this specialty can be a possible good resource.
11 Answers
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Well, does your mother have a neurologist? If that's what you want, then by all means, take her to a neurologist or a geriatrician and get a second opinion about this medication.
Is there another medication you think your mom should be on?
I agree that often times, cost is a big factor in why meds are prescribed. But for many people, that HAS to be the case, because they can't afford to pay for the medication out of pocket, and/or their insurance will not cover other, more expensive medications. And these various programs that pharmaceutical companies provide - ie."need help paying for your medication? XXX can help..." are usually only for a brief period of time for a medication that will likely be a long-term treatment.
You say mom is "active" at night - well, active to one person is agitated to another. It could be that the people who are with your mom overnight are seeing her behavior as agitation rather than activity. It is somewhat of a judgement call, and I would imagine the doctor who is prescribing the medication is weighing the benefits against the risks and has decided that the benefits outweigh the concerns. But you are within your right to seek a second opinion, if you feel like this is not the right course of action for your mom.
- it was maybe not being dosed/adjusted for her, which is process that doesn't happen overnight and requires oversight and communication between her MR and her PCP.
- it was maybe interacting with other medications she could have also been on. This would be a conversation beforehand with her PCP and then a discussion with the pharmacist when the drug was picked up.
- it was maybe not a medication that would ever work for her since many prescription drugs don't promise 100% efficacy in 100% of its users. Every body is unique and the blood-brain barrier is very tricky to bypass.
From our family's personal experience, it took many tries to adjust my MIL's meds for depression and anxiety. We had a very diligent medical staff at her facility give us lots of feedback and suggestions during this process. Once it seemed like we achieved an optimal prescription and dosage it has stayed the same ever since (2018). There was no neurologist involved, just people that were willing to stay on top of it.
I encourage you to keep insisting that her medical team go through the proper PoA channels for her care decisions.
Nighttime is primetime for seniors to become disoriented, get out of bed and fall. Even the best-staffed facilities cannot keep up with who is wandering at night. My own Aunt with dementia still managed to escape out of her in-home bed "fortress", fall and break her hip on her carpeted floor. I wish you much success in managing your Mom's care.
Family members certainly know a great deal about their elders, but what drug to prescribe is probably not within their area of expertise. It is a blessing to be able to weigh in in on what has worked in the past, what allergic and other untoward reactions have occurred in the past, both with the patient and first degree relatives, but if an elder with dementia is in psychic pain (my mom was) and is becoming impossible to deal with, considering meds to treat their broken brain seems quite reasonable to me.
There are some really good articles out there how use of Remeron and other anti-psychotic demands proper consenting (falls under medical ethics), something which is not always properly done. Pubmed also contains a lot of research articles questioning its use.
Is this person a doctor (PCP) or a Nurse practioner. I agree, if you are Moms Healthcare proxy, then you should be talked to concerning her health. Also, since she has had trouble with this med before, then it should not be given to her.
Thank God I was well aware of my Moms health history. I stopped a doctor from doing a dye test on Mom when she said "we have to check her kidney function first". I then told the doctor that Mom had one kidney working 50% capacity. If the test had been done, it could have damaged the existing kidney.
You do need to be an advocate for Mom. Brother may not like it but ur Moms healthcare proxy. All questions concerning her health wellbeing should go thru you. If you can, give this person a copy of the proxy.
They share a reporting system if informed consent was no properly obtained.
“They Want Docile”: How Nursing Homes in the United States Overmedicate People with Dementia | HRW
In other words, lead, follow or get out of the way.
My mom's doctor tried mirtazapine to help her sleep at night and for us it was a miraculous god send, not only did it help her sleep at night it made her more her old self during the day. It is also supposed to increase appetite which I never noticed, but that would have been a positive too. I do remember some of mom's meds had an adjustment period where the side effects were very noticeable (sinemet knocked her right out), but since she only took the mirtazapine in the evening any sedating effect wasn't a problem.
Is she on any other antidepressants?
Have you spoken to the prescribing doc/APRNs?
This has been discussed often with you, D.
I cannot imagine why you cause so much angst over these issues when there is nothing to be done about them and it is just discomfitting to all.
Angst is advocacy not just of my mother but the vulnerable population of seniors in the United States.