Scheduled Opioid Administration in Hospice Patients Before and After Targeted Caregiver Education.

Background: Hospice and palliative care have been shown to increase patient satisfaction and improve symptom control at the end of life. Opioid analgesics are typically given around the clock at the end of life to maintain symptom control and prevent the need for larger doses later. Many hospice patients have some degree of cognitive impairment, putting them at risk of being undertreated for pain. Methods: This was a retrospective, quasi-experimental study at a 766-bed community hospital with hospice and palliative care services. Adult patients admitted to inpatient hospice care with active orders for scheduled opioids for at least 12 hours with at least 1 dose administered were included. The primary intervention was the creation and dissemination of education to non-intensive care nursing staff. The primary outcome was the administration rate of scheduled opioid analgesics to hospice patients before and after targeted caregiver education. Secondary outcomes included the rate of use of 1-time or as-needed opioids, the rate of use-of-reversal agents, and the impact of COVID-19 infection status on administration rates of scheduled opioids. Results: A total of 75 patients were included in the final analysis. The rate of missed doses was 5% in the pre-implementation cohort and 4% in the post-implementation cohort (P = .21). The rate of delayed doses was 6% in the pre-implementation cohort and 6% in the post-implementation cohort (P = .97). Secondary outcomes were similar between the two groups with the exception of a higher rate of delayed doses in patients with confirmed COVID-19 as compared to those without COVID-19 (P = .047). Conclusion: The creation and dissemination of nursing education were not associated with a decrease in missed or delayed doses of scheduled opioids in hospice patients.

Elevated thyroid-stimulating hormone in a 65-year-old patient with phenytoin toxicity.

Phenytoin has a narrow therapeutic range and exhibits concentration-dependent kinetics within this therapeutic window. Therefore, small changes in dose or metabolism can have a large effect on serum concentrations. Therapeutic drug monitoring may be helpful in identifying drug toxicity. A 65-year-old male with a history of hydrocephalus was admitted for generalized weakness and altered mental status. Laboratory testing revealed an elevated phenytoin level, and the patient's phenytoin was discontinued. Further laboratory tests led to the diagnosis of hypothyroidism, and treatment was initiated. The complicated interaction between phenytoin and thyroid hormones is described. Pharmacists can play a role in therapeutic drug monitoring and the identification of drug-disease interactions. Pharmacist drug counseling can help patients and family members identify adverse effects and toxicity and know when to seek medical assistance.

Community-acquired methicillin-resistant Staphylococcus aureus in a group home setting.

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is an infection involving methicillin-resistant Staphylococcus aureus (MRSA) with onset in the community in an individual lacking established health care-associated MRSA risk factors. A 74-year-old group home resident with a history of hypertension and mental retardation presents with a spider bite-like lesion that rapidly progresses to multiple areas of her body. Culture results reveal MRSA. The patient's advanced age and the severity and rapidity of progression of the condition warranted treatment, and options are discussed. Pharmacists should assist in selecting antibiotics for patients with resistant infections and provide strategies for preventing the spread of resistant organisms. Current and complete medical records are critical in the group home setting. The role of the caregiver and the consultant pharmacist in this setting is discussed.

Medication sleuth: an important role for pharmacists in determining the etiology of delirium.

Delirium is characterized by disturbances of consciousness, attention, cognition, and perception and is the most common reason for acute cognitive dysfunction in hospitalized elderly patients. Causes of delirium can be multifactorial, and a careful medical and medication history can help determine the underlying cause of behavioral disturbances. A 65-year-old patient with a history of chronic pain, insomnia, and multiple medical problems, who presented with altered mental status and aggressive behavior, is described. The patient had taken an overdose of zolpidem prior to admission, and she required chemical and physical restraints and one-on-one care for safety. With time and washout of the zolpidem, the patient's behavior did not improve. On the second day of admission, medication reconciliation of this patient's medication profile helped to reveal a medication cause for this patient's delirium. A pharmacist should be included early in the process of obtaining a medication history. Recommendations for the management of chronic pain and insomnia in the elderly are presented.

A 68-year-old woman with multiple NSAID-induced adverse effects.

Common comorbid conditions such as atrial fibrillation, hypertension, congestive heart failure, and osteoarthritis put geriatric patients at risk for toxicity while using nonsteroidal anti-inflammatory drugs (NSAIDs). Concomitant medications also can contribute to complications associated with NSAID therapy. However, NSAID therapy is widely used for pain management in this patient population. This case describes a 68-year-old patient, with a history of hypertension and osteoarthritis, who presented with multiple NSAID-induced adverse effects. Upon admission to the hospital, this patient was found to have renal and hepatic failure, fluid overload, and electrocardiogram changes, most likely as a result of excessive naproxen ingestion. This patient also was taking hydrochlorothiazide and had not had any laboratory values drawn to monitor her medication regimen. Subsequently, she required hemodialysis and a long hospital course. Her hepatic failure, fluid overload, and electrocardiogram changes resolved with treatment. Multiple health care providers could have detected problems with this patient's pain management. Adverse events associated with NSAIDs can be prevented with patient monitoring and education. Health care providers also need education to learn how to optimize the pain management of their geriatric patients. Recommendations for preventing NSAID-induced adverse effects and for optimizing pain management are presented.