Pillcheck: Optimizing Medication Plans for Seniors with Dementia
Seniors living with dementia in long-term care often take many medications, for memory, mood, sleep, pain, heart disease and other conditions. Each added medication increases the risk of side effects and drug interactions, and older bodies are more sensitive to both. A study funded by the Centre for Aging + Brain Health Innovation (CABHI) tested whether Pillcheck pharmacogenetic testing could help pharmacists find medications that are unlikely to work or more likely to cause harm for residents of Ontario long-term care homes.
Why are medications a challenge for seniors with dementia?
As we age, the liver and kidneys clear medications more slowly, and the brain becomes more sensitive to side effects such as drowsiness, confusion and falls. People with dementia may not be able to describe side effects, so problems can go unnoticed. Many long-term care residents also take medications for depression, anxiety, agitation, pain and sleep, several of which are affected by genes. Read more about drug metabolism and aging.
What did the Ontario long-term care study do?
The CABHI-funded project was carried out in four Ontario long-term care homes, in collaboration with Baycrest and ThinkResearch. Ninety residents had a Pillcheck pharmacogenetic test, and a pharmacist reviewed each resident's medications using the genetic results. The researchers compared the drug therapy problems found with pharmacogenetic support with those found in a standard medication review. They also compared prescribing patterns in the tested residents with those of 895 residents who were not tested, over the same period.
What did the study find?
- Many medications with genetic guidance. Residents took between 7 and 47 medications each, and 1 to 17 of them had pharmacogenetic guidance, an average of 4.6 per resident. Nearly all tested residents (94%) and most controls (84%) took two or more such medications.
- Drug therapy problems. The pharmacogenetic review identified 114 drug therapy problems in the 90 residents, and 29 of them were classified as serious.
- Depression. More than 35% of residents took antidepressants. Of these, 64% had altered CYP2C19 or CYP2D6 metabolism and could benefit from a dose change or a switch to a different antidepressant.
- Pain. One in five residents took the opioid hydromorphone. Of these, 30% carried variants in the OPRM1 gene linked to a reduced response to opioids.
The study concluded that pharmacogenetic medication optimization has clinical potential for long-term care residents, particularly for the management of depression, chronic pain, heart disease and gastrointestinal symptoms. It was an open-label study without randomization, so it identified opportunities to improve prescribing rather than measuring long-term health outcomes.
Larger trials have since measured outcomes directly. In the European U-PGx PREPARE study of nearly 7,000 patients in seven countries, genetics-guided prescribing using a 12-gene panel reduced clinically relevant drug-induced complications by about 30% over 12 weeks: they occurred in 21.5% of patients with genetics-guided treatment, compared with 28.6% with standard care.
What does this mean for depression and pain care in long-term care?
Depression is common in people with dementia, and antidepressants are among the most frequently used medications in long-term care. Many, such as citalopram, escitalopram and sertraline, are broken down by CYP2C19, and others by CYP2D6. A resident who clears an antidepressant too slowly may become drowsy, confused or unsteady, while one who clears it too quickly may get little benefit. Read more about whether antidepressant medications increase the risk of dementia in older adults.
Pain is often under-recognized in people with dementia, and opioids carry risks of drowsiness, falls and constipation. Knowing whether a resident is likely to respond poorly to an opioid, or to process pain medications unusually, can help the care team choose a safer, more effective plan.
How can families and care teams use Pillcheck?
A Pillcheck test uses a simple cheek swab, which is easy for residents with dementia. It reports CYP2D6, CYP2C19, OPRM1 and other genes that affect antidepressants, pain medications, heart medications and many others. Pillcheck reports on 24 genes, increasing coverage with new guidelines and drug labels (see the genes tab), and covers 355 medications, which account for over 70% of dispensed prescriptions. A Pillcheck pharmacist reviews the results together with all of the resident's medications and gives written recommendations for the care team and prescriber. The results last a lifetime and can guide future prescriptions as needs change.
Summary
- Seniors with dementia in long-term care often take many medications and are especially sensitive to side effects.
- In a CABHI-funded study in four Ontario long-term care homes, pharmacist reviews supported by Pillcheck found 114 drug therapy problems in 90 residents, 29 of them serious.
- Of residents taking antidepressants, 64% had altered CYP2C19 or CYP2D6 metabolism.
- Of residents taking hydromorphone, 30% carried OPRM1 variants linked to reduced opioid response.
- In the large European U-PGx PREPARE trial, genetics-guided prescribing reduced drug-induced complications by about 30%.
- Pharmacogenetic testing with a pharmacist review can help care teams make medication plans safer and more effective.
Frequently asked questions
Is the test difficult for someone with dementia?
No. Pillcheck uses a quick cheek swab, with no blood draw.
Who can order a test for a resident?
A family member with decision-making authority or the resident's care team can arrange testing. The results and pharmacist recommendations can be shared with the prescriber and the long-term care pharmacy.
Will the test change the resident's medications?
Not by itself. The pharmacist's recommendations are reviewed by the prescriber and care team, who decide whether a change is needed.
Does Pillcheck test for dementia risk?
No. Pillcheck does not diagnose dementia or predict dementia risk. It shows how a person's genes affect their response to medications.
References
Dorfman R, London Z, Metias M, Kabakchiev B, Mukerjee G, Moser A. Individualized Medication Management in Ontario Long-Term Care Clinical Impact on Management of Depression, Pain, and Dementia. J Am Med Dir Assoc. 2020;21(6):823-829.e5.
Swen JJ, van der Wouden CH, Manson LE, et al. A 12-gene pharmacogenetic panel to prevent adverse drug reactions: an open-label, multicentre, controlled, cluster-randomised crossover implementation study. Lancet. 2023;401(10374):347-356.
Centre for Aging + Brain Health Innovation (CABHI). Pillcheck: Optimizing Medication Plans for Seniors with Dementia (project summary).
