Risk Evaluation for Antipsychotic Agents Used in Elderly Inpatients (REPAIR).

BACKGROUND: Antipsychotics have been approved for the treatment of certain psychiatric illnesses. However, these medications are also frequently used off label, and recent studies have suggested a concerning potential increase in the risk of death when used by elderly patients with dementia. Most of the available literature focusing on off-label use of antipsychotics comes from long-term care facilities; there is a lack of quantitative data for elderly patients in the acute care setting. This study was designed to examine this scenario and to identify potential quality improvement opportunities to minimize harm. OBJECTIVES: The primary objectives were to determine the prevalence of hospital-initiated off-label use of antipsychotics for elderly inpatients and to determine the plan for these drugs upon discharge. The secondary objectives included identifying the most common diagnosis and the most common agent used. METHODS: A retrospective cohort study was performed with a convenience sample. Patients included in the analysis were elderly adults (≥ 65 years) who had been admitted to either of 2 medical units at a community hospital between September 1 and November 8, 2014. Descriptive statistics were used to examine prevalence patterns for the off-label use of antipsychotics. RESULTS: A total of 250 patients were included in the analysis. Forty-five patients (18%, 95% confidence interval [CI] 13.7%-23.2%) received a hospital-initiated antipsychotic for off-label use during the admission. For 27 (60%, 95% CI 45.5%-73.0%) of these 45 patients, the off-label therapy was discontinued upon discharge or death, and for 13 (29%, 95% CI 17.7%-43.4%), the agent was continued upon discharge without a plan in place. The most frequent diagnosis was delirium, and the agent most frequently used was haloperidol. CONCLUSIONS: Off-label antipsychotic therapy was initiated for almost 1 in every 5 elderly patients receiving care in 2 medical units at a community hospital. These findings suggest a need to monitor and reassess the off-label use of these agents, especially at the time of discharge.

CONTEXTE: Les antipsychotiques ont été approuvés pour le traitement de certains troubles psychiatriques. Or, ces médicaments sont aussi fréquemment utilisés en dérogation des directives de l'étiquette et des études récentes ont supposé une potentielle augmentation préoccupante du risque de décès lorsqu'ils sont employés pour traiter des patients âgés atteints de démence. La majeure partie de la littérature portant sur l'emploi non conforme d'antipsychotiques provient de centres d'hébergement et de soins de longue durée. Or, on constate un manque de données quantitatives sur les patients âgés dans les milieux de soins de courte durée. La présente étude a été conçue pour examiner ce scénario et découvrir de potentielles occasions d'amélioration de la qualité en vue de réduire au minimum les risques de préjudice. OBJECTIFS: Les objectifs principaux étaient de déterminer la prévalence de l'emploi non conforme d'antipsychotiques amorcé à l'hôpital chez les patients aînés et de déterminer le plan relatif à la prescription de ces médicaments au moment du congé. Les objectifs secondaires incluaient de déterminer quels étaient le diagnostic le plus fréquent et le médicament le plus utilisé. MÉTHODES: Une étude de cohorte rétrospective a été menée à l'aide d'un échantillon de commodité. Les patients retenus pour l'analyse étaient des personnes âgées (de 65 ans et plus) ayant été admises à l'une des deux unités médicales dans un hôpital communautaire entre le 1er septembre et le 8 novembre 2014. Des statistiques descriptives ont été employées pour analyser les modèles de prévalence en ce qui concerne l'emploi non conforme d'antipsychotiques. RÉSULTATS: Au total, 250 patients ont été retenus pour l'analyse. Pendant l'hospitalisation, un antipsychotique a été amorcé hors conformité chez 45 patients (18 %, intervalle de confiance [IC] de 95 % de 13,7 % à 23,2 %). Pour 27 (60 %, IC de 95 % de 45,5 % à 73,0 %) de ces 45 patients, le traitement non conforme a été arrêté au moment du congé et, pour 13 autres (29 %, IC de 95 % de 17,7 %­43,4 %), le traitement a été poursuivi au congé sans mise en place d'un plan. Le diagnostic motivant le plus souvent l'emploi non conforme de ces médicaments était le délire et le médicament le plus employé était l'halopéridol. CONCLUSIONS: Le traitement non conforme par antipsychotique a été amorcé pendant le séjour à l'hôpital pour près d'un patient âgé sur cinq qui recevait des soins dans l'une des deux unités médicales d'un hôpital communautaire. Ces résultats laissent croire qu'une surveillance de l'emploi non conforme de ces médicaments et qu'une réévaluation d'un tel traitement sont nécessaires, particulièrement au moment du congé.

The interplay of infections, function and length of stay (LOS) in newly admitted geriatric psychiatry patients.

The purpose of this study was to determine the impact of identifying and treating infections on functional outcomes and length of stay (LOS). Our retrospective naturalistic study reviewed all new admissions to a tertiary geriatric psychiatry teaching hospital from 2003 to 2007. Over this four-year period, 390 patients were admitted and discharged with 21% (85) of patients identified as having infections on admission. Those with infections were compared to the group without to determine and compare clinical characteristics. Factors included in analysis were: age, gender, diagnoses, medical comorbidity, neuropsychiatric symptoms, functional outcomes, medications and LOS. Both groups were similar in gender, psychiatric diagnoses and severity of dementia. Those requiring antibiotics for treatment of infections on admission, were older (p=0.003), had poorer baseline function (p=0.005) and higher medical comorbidity (p<0.001). At discharge, the group with infections showed greater functional improvement (p<0.001), particularly in mobility (p=0.005) and cognition (p=0.046), and had a shorter LOS (p=0.02). We conclude that a significant number of patients in tertiary geriatric services continue to have infections on admission. Early identification and treatment of infections can result in improved function and decreased LOS.

Electroconvulsive therapy clinical database: a standardized approach in tertiary care psychiatry.

Across health care disciplines research reflects the usefulness of integrating computer technology into administrative and clinical practices. Electroconvulsive therapy (ECT) researchers are often interested in examining 3 primary areas: patient characteristics, treatment characteristics, and treatment outcomes. Generating reports and conducting research analysis via the traditional patient chart review are a time-consuming and costly method. At Riverview Hospital, a tertiary care psychiatric hospital, the active use of a clinical database for patients receiving ECT allows for detailed treatment tracking and evaluation of pretreatment and posttreatment patient outcome measures. Initially, designed as part of a quality improvement process to readily access patient information and generate periodic reports, the ECT clinical database is now a central resource for ECT-specific patient, treatment, and outcome tracking. The relevance, design, content variables, and subsequent functions of the entry and storage of ECT-related administrative, treatment, outcome, and patient factors are clearly outlined and discussed. Strengths and limitations to the existing database are shared. Recommendations to other ECT services to implement this valuable documentation strategy are addressed. This approach can be an invaluable tool in providing the field of psychiatry with further contributions to ECT clinical outcomes.

Effects of an education training program on attitudes to electroconvulsive therapy.

Widespread negative attitudes toward electroconvulsive therapy (ECT) are present in the general public and among heath care professionals. However, there is evidence to suggest that clinical experience and knowledge of ECT positively improve attitudes toward this treatment. The purpose of this study was to evaluate the effects of an ECT education training program on attitudes toward ECT. Participants were 73 student nurses (91.8% women) and 21 care aid students (81.0% women) undertaking a 6-week rotation in psychiatry at a large provincial psychiatric hospital in British Columbia, Canada. The ECT education training program consisted of a brief lecture, viewing of an educational videotape, familiarization with the ECT equipment, and observation of an ECT treatment. Participants completed a short questionnaire pretraining and posttraining program. Attitudes toward ECT did not substantially differ between the 2 groups. For the entire sample, only 8.5% reported that they were well informed about ECT before the training session. More favorable attitudes were reported upon completion of the ECT education program compared with attitudes reported before training. These findings suggest that attitudes toward ECT increase favorably when individuals are provided with training and experience.

Psychometric properties and factor structure of the Neuropsychiatric Inventory Nursing Home version in an elderly neuropsychiatric population.

BACKGROUND: The Neuropsychiatric Inventory (NPI) is an interview-based instrument designed to elicit information from an informal caregiver to evaluate behavioral disturbances in persons with dementia. Minor modifications of this instrument have produced the Neuropsychiatric Inventory-Nursing Home version (NPI-NH), a version specifically designed for interviewing professional care facility staff. The purpose of this investigation is to further understand the psychometric properties of the NPI-NH by examining its reliability, validity, and factor structure in an elderly neuropsychiatric population. METHOD: Participants were 204 elderly inpatients from a large provincial neuropsychiatric hospital in British Columbia, Canada. Data were collected as part of a patient needs assessment project. RESULTS: The internal consistency reliability of the NPI-NH was alpha=0.67. An exploratory principal axis analysis with varimax rotation revealed five factors that accounted for 63.2% of the variance. These factors reflect aspects of psychiatric disturbance associated with: (a) Agitation; (b) Mood; (c) Psychosis; (d) Sleep/Motor Activity; and (e) Elevated Behavior. Convergent and discriminant validity of the five factors by correlating them with other behavioral measures was considered satisfactory. CONCLUSIONS: These results provide support for the clinical use of the NPI-NH as a screen for neuropsychiatric symptoms in an elderly neuropsychiatric population. However, additional research is encouraged to further evaluate the clinical utility of the NPI-NH in nursing home and inpatient geriatric settings.

Olanzapine associated weight gain, hyperglycemia and neuroleptic malignant syndrome: case report.

We describe here a case of olanzapine associated weight gain, hyperglycemia and neuroleptic malignant syndrome in a 64 year-old woman with a significant medical history. Eighteen weeks after initiating olanzapine, Mrs X lost glycemic control, exhibited signs and symptoms consistent with neuroleptic malignant syndrome and gained 8.9 kg. We suggest that utilization of olanzapine in the less medically stable geriatric patient be implemented with vigilant monitoring for such complications mentioned above.