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Tomlinson EJ, Schnitker LM, Casey PA. Exploring Antipsychotic Use for Delirium Management in Adults in Hospital, Sub-Acute Rehabilitation and Aged Care Settings: A Systematic Literature Review. Drugs Aging 2024; 41:455-486. [PMID: 38856874 PMCID: PMC11193698 DOI: 10.1007/s40266-024-01122-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND International guidelines discourage antipsychotic use for delirium; however, concerns persist about their continued use in clinical practice. OBJECTIVES We aimed to describe the prevalence and patterns of antipsychotic use in delirium management with regard to best-practice recommendations. Primary outcomes investigated were prevalence of use, antipsychotic type, dosage and clinical indication. METHODS Eligibility criteria: studies of any design that examined antipsychotic use to manage delirium in adults in critical care, acute care, palliative care, rehabilitation, and aged care were included. Studies of patients in acute psychiatric care, with psychiatric illness or pre-existing antipsychotic use were excluded. INFORMATION SOURCES we searched five health databases on 16 August, 2023 (PubMed, CINAHL, Embase, APA PsycInfo, ProQuest Health and Medical Collection) using MeSH terms and relevant keywords, including 'delirium' and 'antipsychotic'. Risk of bias: as no included studies were randomised controlled trials, all studies were assessed for methodological quality using the Mixed Methods Appraisal Tool. SYNTHESIS OF RESULTS descriptive data were extracted in Covidence and synthesised in Microsoft Excel. RESULTS Included studies: 39 studies published between March 2004 and August 2023 from 13 countries (n = 1,359,519 patients). Most study designs were retrospective medical record audits (n = 16). SYNTHESIS OF RESULTS in 18 studies, participants' mean age was ≥65 years (77.79, ±5.20). Palliative care had the highest average proportion of patients with delirium managed with antipsychotics (70.87%, ±33.81%); it was lower and varied little between intensive care unit (53.53%, ±19.73%) and non-intensive care unit settings [medical, surgical and any acute care wards] (56.93%, ±26.44%) and was lowest in in-patient rehabilitation (17.8%). Seventeen different antipsychotics were reported on. In patients aged ≥65 years, haloperidol was the most frequently used and at higher than recommended mean daily doses (2.75 mg, ±2.21 mg). Other antipsychotics commonly administered were olanzapine (mean 11 mg, ±8.54 mg), quetiapine (mean 64.23 mg, ±43.20 mg) and risperidone (mean 0.97 mg, ±0.64 mg). CONCLUSIONS The use of antipsychotics to manage delirium is strongly discouraged in international guidelines. Antipsychotic use in delirium care is a risk for adverse health outcomes and a longer duration of delirium, especially in older people. However, this study has provided evidence that clinicians continue to use antipsychotics for delirium management, the dose, frequency and duration of which are often outside evidence-based guideline recommendations. Clinicians continue to choose antipsychotics to manage delirium symptoms to settle agitation and maintain patient and staff safety, particularly in situations where workload pressures are high. Sustained efforts are needed at the individual, team and organisational levels to educate, train and support clinicians to prioritise non-pharmacological interventions early before deciding to use antipsychotics. This could prevent delirium and avert escalation in behavioural symptoms that often lead to antipsychotic use.
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Affiliation(s)
- Emily J Tomlinson
- Deakin University, Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Geelong, Victoria, Australia.
- Deakin University, School of Nursing and Midwifery, Geelong, Victoria, Australia.
| | - Linda M Schnitker
- School of Nursing, Queensland University of Technology, Kelvin Grove, Brisbane, QLD, Australia
- Bolton Clarke Research Institute, Kelvin Grove, Brisbane, QLD, Australia
| | - Penelope A Casey
- Deakin University, School of Nursing and Midwifery, Geelong, Victoria, Australia
- Deakin University, Centre for Quality and Patient Safety Research-Eastern Health Partnership, Geelong, Victoria, Australia
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Alghadeer S, Almesned RS, Alshehri EA, Alwhaibi A. Evaluation of the Efficacy and Safety of Quetiapine in the Treatment of Delirium in Adult ICU Patients: A Retrospective Comparative Study. J Clin Med 2024; 13:802. [PMID: 38337497 PMCID: PMC10856481 DOI: 10.3390/jcm13030802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/11/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
Background: Quetiapine is commonly prescribed off-label to manage delirium in intensive care unit (ICU) patients. However, limited studies comparing its efficacy and safety to those of other antipsychotics exist in the literature. Method: A retrospective, single-center chart review study was conducted on adults admitted to the ICU between January 2017 and August 2022, who were diagnosed with delirium and treated with a single antipsychotic and had no neurological medical conditions, active alcohol withdrawal, or prior use of antipsychotics. Data were analyzed using SPSS software version 28, with p-values of <0.05 indicating statistical significance. Results: In total, 47 patients were included, of whom 22 (46.8%), 19 (40.4%), 4 (8.5%), and 2 (4.3%) were on quetiapine, haloperidol, risperidone, and olanzapine, respectively. The median number of hours needed to resolve delirium were 12 (21.5), 23 (28), 13 (13.75), and 36 (10) (p = 0.115) for quetiapine, haloperidol, risperidone, and olanzapine, respectively, with haloperidol being used for a significantly shorter median number of days than quetiapine (3 (2.5) days vs. 7.5 (11.5) days; p = 0.007). Of the medication groups, only quetiapine-treated patients received a significantly higher median maintenance compared to the initiation dose (50 (50) mg vs. 50 (43.75) mg; p = 0.039). For the length of stay in the ICU and hospital, delirium-free days, % of ICU time spent in delirium, ventilator-free days, the difference between the highest and baseline QTc intervals, and ICU and hospital mortalities, no significant difference was observed between the groups. Conclusions: Overall, the use of quetiapine in our retrospective study seems to not be advantageous over the other drugs in terms of efficacy and safety outcomes.
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Affiliation(s)
- Sultan Alghadeer
- Department of Clinical Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia; (S.A.); (E.A.A.)
| | - Rahaf S. Almesned
- Pharmacy Department, King Saud University Medical City (KSUMC), King Saud University, Riyadh 11411, Saudi Arabia;
| | - Emad A. Alshehri
- Department of Clinical Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia; (S.A.); (E.A.A.)
| | - Abdulrahman Alwhaibi
- Department of Clinical Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia; (S.A.); (E.A.A.)
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Kim DH, Lee H, Pawar A, Lee SB, Park CM, Levin R, Metzger E, Bateman BT, Ely EW, Pandharipande PP, Pisani MA, Hohmann SF, Marcantonio ER, Inouye SK. Trends in use of antipsychotics and psychoactive drugs in older patients after major surgery. J Am Geriatr Soc 2023; 71:3755-3767. [PMID: 37676699 PMCID: PMC10841351 DOI: 10.1111/jgs.18580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/05/2023] [Accepted: 07/13/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Professional society guidelines recommend limiting the use of antipsychotics in older patients with postoperative delirium. How these recommendations affected the use of antipsychotics and other psychoactive drugs in the postoperative period has not been studied. METHODS This retrospective cohort study included patients 65 years or older without psychiatric diagnoses who underwent major surgery in community hospitals (CHs) and academic medical centers (AMCs) in the United States. The outcome was the rate of hospital days exposed to antipsychotics, antidepressants, antiepileptics, benzodiazepines, hypnotics, and selective alpha-2 receptor agonist dexmedetomidine in the postoperative period by hospital type. RESULTS The study included 4,098,431 surgical admissions from CHs (mean age 75.0 [standard deviation, 7.1] years; 50.8% female) during 2008-2018 and 2,310,529 surgical admissions from AMCs (75.0 [7.4] years; 49.4% female) during 2009-2018. In the intensive care unit (ICU) setting, the number of exposed days per 1000 hospital-days declined for haloperidol (CHs: 33-21 days [p < 0.01]; AMCs: 24-15 days [p < 0.01]) and benzodiazepines (CHs: 261-136 days [p < 0.01]; AMCs: 150-77 days [p < 0.01]). The use of atypical antipsychotics, antidepressants, antiepileptics, and dexmedetomidine increased, while hypnotic use varied by the hospital type. In the non-ICU setting, the rate declined for haloperidol in CHs but not in AMCs (CHs: 10-6 days [p < 0.01]; AMCs: 4-3 days [p = 0.52]) and for benzodiazepines in both settings (CHs: 126-56 days [p < 0.01]; AMCs: 30-27 days [p < 0.01]). The use of antiepileptics and antidepressants increased, while the use of atypical antipsychotics and hypnotics varied by the hospital type. CONCLUSIONS The use of haloperidol and benzodiazepines in the postoperative period declined at both CHs and AMCs. These trends coincided with the increasing use of other psychoactive drugs.
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Affiliation(s)
- Dae Hyun Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Hemin Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA
| | - Ajinkya Pawar
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA
| | - Su Been Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA
| | - Chan Mi Park
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA
| | - Eran Metzger
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Harvard Medical School, Boston, MA
| | - Brian T. Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - E. Wesley Ely
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN
| | - Pratik P. Pandharipande
- Departments of Anesthesiology and Surgery, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Margaret A. Pisani
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Samuel F. Hohmann
- Vizient, Inc. and Department of Health Systems Management, Rush University, Chicago, IL
| | - Edward R. Marcantonio
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sharon K. Inouye
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
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Reppas-Rindlisbacher C, Wiesenfeld L, Stall NM. Antipsychotiques pour les personnes âgées hospitalisées atteintes de délirium. CMAJ 2023; 195:E1561-E1562. [PMID: 37984934 PMCID: PMC10662490 DOI: 10.1503/cmaj.230227-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023] Open
Affiliation(s)
- Christina Reppas-Rindlisbacher
- Divisions de médecine interne générale et de gériatrie (Reppas-Rindlisbacher, Stall), Système de santé Sinaï et Réseau universitaire de santé; Institut de recherche de l'Hôpital Women's College (Reppas-Rindlisbacher, Stall); Départements de médecine (Reppas-Rindlisbacher, Stall) et de psychiatrie (Wiesenfeld), Université de Toronto; Division de psychiatrie (Wiesenfeld), Système de santé Sinaï, Toronto, Ont.
| | - Lesley Wiesenfeld
- Divisions de médecine interne générale et de gériatrie (Reppas-Rindlisbacher, Stall), Système de santé Sinaï et Réseau universitaire de santé; Institut de recherche de l'Hôpital Women's College (Reppas-Rindlisbacher, Stall); Départements de médecine (Reppas-Rindlisbacher, Stall) et de psychiatrie (Wiesenfeld), Université de Toronto; Division de psychiatrie (Wiesenfeld), Système de santé Sinaï, Toronto, Ont
| | - Nathan M Stall
- Divisions de médecine interne générale et de gériatrie (Reppas-Rindlisbacher, Stall), Système de santé Sinaï et Réseau universitaire de santé; Institut de recherche de l'Hôpital Women's College (Reppas-Rindlisbacher, Stall); Départements de médecine (Reppas-Rindlisbacher, Stall) et de psychiatrie (Wiesenfeld), Université de Toronto; Division de psychiatrie (Wiesenfeld), Système de santé Sinaï, Toronto, Ont
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Reppas-Rindlisbacher C, Wiesenfeld L, Stall NM. Antipsychotic medications for older adults with delirium admitted to hospital. CMAJ 2023; 195:E1038-E1039. [PMID: 37580070 PMCID: PMC10426344 DOI: 10.1503/cmaj.230227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Affiliation(s)
- Christina Reppas-Rindlisbacher
- Division of General Internal Medicine and Geriatrics (Reppas-Rindlisbacher, Stall), Sinai Health System and the University Health Network; Women's College Research Institute (Reppas-Rindlisbacher, Stall), Women's College Hospital; Department of Medicine (Reppas-Rindlisbacher, Stall) and of Psychiatry (Wiesenfeld), University of Toronto; Division of Psychiatry (Wiesenfeld), Sinai Health System, Toronto, Ont.
| | - Lesley Wiesenfeld
- Division of General Internal Medicine and Geriatrics (Reppas-Rindlisbacher, Stall), Sinai Health System and the University Health Network; Women's College Research Institute (Reppas-Rindlisbacher, Stall), Women's College Hospital; Department of Medicine (Reppas-Rindlisbacher, Stall) and of Psychiatry (Wiesenfeld), University of Toronto; Division of Psychiatry (Wiesenfeld), Sinai Health System, Toronto, Ont
| | - Nathan M Stall
- Division of General Internal Medicine and Geriatrics (Reppas-Rindlisbacher, Stall), Sinai Health System and the University Health Network; Women's College Research Institute (Reppas-Rindlisbacher, Stall), Women's College Hospital; Department of Medicine (Reppas-Rindlisbacher, Stall) and of Psychiatry (Wiesenfeld), University of Toronto; Division of Psychiatry (Wiesenfeld), Sinai Health System, Toronto, Ont
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Beaucage-Charron J, Rinfret J, Coveney R, Williamson D. Melatonin and Ramelteon for the treatment of delirium: A systematic review and meta-analysis. J Psychosom Res 2023; 170:111345. [PMID: 37150157 DOI: 10.1016/j.jpsychores.2023.111345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 04/21/2023] [Accepted: 04/29/2023] [Indexed: 05/09/2023]
Abstract
OBJECTIVE To assess the efficacy of melatonin and melatonergic agonist for the treatment of delirium in hospitalized patients. METHODS Embase, MEDLINE, PsycINFO, PubMed, CENTRAL, Cochrane Database of Systematic Reviews, TRIP Medical Database, ClinicalTrials.gov and Google were searched from inception to October 2022. Randomized controlled trials (RCT) and observational studies with any type of comparator evaluating melatonin or melatonergic agonist (ramelteon) enrolling any populations (ICU, surgery, geriatric) were included. Two reviewers independently selected and extracted data using the Cochrane risk of bias tools (RoB2 and ROBINSI). RESULTS Out of the 650 screened publications, three RCTs and six observational studies were included (n = 1211). All three RCTs compared melatonin to placebo, as the majority of observational studies compared melatonin or ramelteon to antipsychotics. Two RCTs reported the duration of delirium and a meta-analysis provided a statistical difference between melatonin and placebo (-1.72 days, 95% CI -2.66 to -0.77, p = 0.0004). Five observational studies reported the duration of delirium but only one reported a statistical reduction in the duration of delirium. CONCLUSION Although melatonin and ramelteon may be effective treatments for delirium, particularly to shorten the duration of delirium and to limit the use of rescue medication, current data is limited in number and in its quality. Clinicians should wait until higher quality data from ongoing RCTs are available before prescribing melatonin to delirious patients.
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Affiliation(s)
- Johannie Beaucage-Charron
- Department of Pharmacy, Hôpital Maisonneuve-Rosemont, CIUSSS de l'Est-de-l'Île-de-Montréal, Montréal, Canada.
| | - Justine Rinfret
- Department of Pharmacy, Hôpital Maisonneuve-Rosemont, CIUSSS de l'Est-de-l'Île-de-Montréal, Montréal, Canada
| | - Richard Coveney
- Direction of Education, Research and Innovation, Hôpital Maisonneuve-Rosemont, CIUSSS de l'Est-de-l'Île-de-Montréal, Montréal, Canada
| | - David Williamson
- Department of Pharmacy, Hôpital du Sacré-Cœur de Montréal, CIUSSS du Nord-de-l'Île-de-Montréal, Montréal, Canada; Faculty of Pharmacy, Université de Montréal, Montréal, Canada
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Growdon ME, Gan S, Yaffe K, Lee AK, Anderson TS, Muench U, Boscardin WJ, Steinman MA. New psychotropic medication use among Medicare beneficiaries with dementia after hospital discharge. J Am Geriatr Soc 2023; 71:1134-1144. [PMID: 36514208 PMCID: PMC10089969 DOI: 10.1111/jgs.18161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 10/21/2022] [Accepted: 11/16/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hospitalizations among people with dementia (PWD) may precipitate behavioral changes, leading to the psychotropic medication use despite adverse outcomes and limited efficacy. We sought to determine the incidence of new psychotropic medication use among community-dwelling PWD after hospital discharge and, among new users, the proportion with prolonged use. METHODS This was a retrospective cohort study using a 20% random sample of Medicare claims in 2017, including hospitalized PWD with traditional and Part D Medicare who were 68 years or older. The primary outcome was incident prescribing at discharge of psychotropics including antipsychotics, sedative-hypnotics, antiepileptics, and antidepressants. This was defined as new prescription fills (i.e., from classes not used in 180 days preadmission) within 7 days of hospital or skilled nursing facility discharge. Prolonged use was defined as the proportion of new users who continued to fill newly prescribed medications beyond 90 days of discharge. RESULTS The cohort included 117,022 hospitalized PWD with a mean age of 81 years; 63% were female. Preadmission, 63% were using at least 1 psychotropic medication; 10% were using medications from ≥3 psychotropic classes. These included antidepressants (44% preadmission), antiepileptics (29%), sedative-hypnotics (21%), and antipsychotics (11%). The proportion of PWD discharged from the hospital with new psychotropics ranged from 1.9% (antipsychotics) to 2.9% (antiepileptics); 6.6% had at least one new class started. Among new users, prolonged use ranged from 36% (sedative-hypnotics) to 63% (antidepressants); across drug classes, prolonged use occurred in 51%. Predictors of newly initiated psychotropics included length of stay (≥median vs. CONCLUSIONS Hospitalized PWD have a high prevalence of preadmission psychotropic medication use; against this baseline, discharge from the hospital with new psychotropics is relatively uncommon. Nevertheless, prolonged use of newly initiated psychotropics occurs in a substantial proportion of this population.
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Affiliation(s)
- Matthew E Growdon
- Division of Geriatrics, University of California, San Francisco, California, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California, USA
| | - Siqi Gan
- Division of Geriatrics, University of California, San Francisco, California, USA
- Northern California Institute for Research and Education, San Francisco, California, USA
| | - Kristine Yaffe
- Mental Health, San Francisco VA Medical Center, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
- Departments of Neurology and Psychiatry, University of California, San Francisco, California, USA
| | - Alexandra K Lee
- Division of Geriatrics, University of California, San Francisco, California, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California, USA
| | - Timothy S Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ulrike Muench
- Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, California, USA
| | - W John Boscardin
- Division of Geriatrics, University of California, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco, California, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California, USA
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Wang Y, Zhu J, Shan L, Wu L, Wang C, Yang W. Potentially inappropriate medication among older patients with diabetic kidney disease. Front Pharmacol 2023; 14:1098465. [PMID: 36843920 PMCID: PMC9946453 DOI: 10.3389/fphar.2023.1098465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/26/2023] [Indexed: 02/11/2023] Open
Abstract
Objective: Potentially inappropriate medications (PIM) contribute to poor outcomes in older patients, making it a widespread health problem. The study explored the occurrence and risk factors of PIM in older diabetic kidney disease (DKD) patients during hospitalization and investigated whether polypharmacy was associated with it. Methods: Retrospective analysis of the patients ≥ 65 years old diagnosed with DKD from July to December 2020; the PIM was evaluated according to the American Beers Criteria (2019). Factors with statistical significance in univariate analysis were included in Logistic multivariate analysis to explore the potential risk factors related to PIM. Results: Included 186 patients, 65.6% of patients had PIM, and 300 items were confirmed. The highest incidence of PIM was 41.7% for drugs that should be carefully used by the older, followed by 35.3% that should be avoided during hospitalization. The incidence of PIM related to diseases or symptoms, drug interactions to avoid, and drugs to avoid or reduce dose for renal insufficiency patients were 6.3%, 4.0% and 12.7%, respectively. The medications with a high incidence of PIM were diuretics (35.0%), benzodiazepines (10.7%) and peripheral ɑ1 blockers (8.7%). Compared with hospitalization, there were 26% of patients had increased PIM at discharge. Multivariate Logistic regression analysis showed that polypharmacy during hospitalization was an independent risk factor for PIM, OR = 4.471 (95% CI: 2.378, 8.406). Conclusion: The incidence of PIM in hospitalized older DKD patients is high; we should pay more attention to the problem of polypharmacy in these patients. Pharmacists identifying the subtypes and risk factors for PIM may facilitate risk reduction for older DKD patients.
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Affiliation(s)
- Yuping Wang
- Department of Pharmacy, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jie Zhu
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China,Guangdong-Hong Kong-Macao Joint University Laboratory of Metabolic and Molecular Medicine, Guangzhou, China,Department of Gastrointestinal Surgery, The Second People’s Hospital of Yibin, Yibin, Sichuan, China
| | - Luchen Shan
- College of Pharmacy, Jinan University, Guangzhou, China
| | - Ling Wu
- Department of Pharmacy, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Cunchuan Wang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China,Guangdong-Hong Kong-Macao Joint University Laboratory of Metabolic and Molecular Medicine, Guangzhou, China,*Correspondence: Cunchuan Wang, ; Wah Yang,
| | - Wah Yang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China,Guangdong-Hong Kong-Macao Joint University Laboratory of Metabolic and Molecular Medicine, Guangzhou, China,*Correspondence: Cunchuan Wang, ; Wah Yang,
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Tozer T, MacKenzie M, Burgess S, Loubani O, Neville H. Opioid and Sedative Coprescription: Prescribing Patterns after an ICU Admission. Can J Hosp Pharm 2023; 76:29-39. [PMID: 36683658 PMCID: PMC9817220 DOI: 10.4212/cjhp.3245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background Opioid misuse constitutes a health care crisis in Canada, and coprescription of opioids with sedatives has been associated with adverse events. Opioids and sedatives are frequently administered in the intensive care unit (ICU). The rate of continuation of opioid-sedative combinations after an ICU admission at the study institution was unknown. Objectives To determine the rates of opioid and sedative coprescriptions following an ICU admission and to identify factors associated with continuation of hospital-initiated opioid-sedative coprescriptions at ICU transfer and hospital discharge. Methods This retrospective chart review involved patients admitted to ICUs at a tertiary care centre between April 1, 2018, and March 31, 2019. Baseline characteristics were obtained from a clinical database and medication information from medication reconciliation forms. An opioid coprescription was defined as prescription of an opioid in combination with a sedative (benzodiazepine, z-drug, gabapentinoid, tricyclic antidepressant, or antipsychotic), and hospital-initiated coprescriptions encompassed various predefined scenarios of therapy started or modified before ICU transfer. Factors associated with hospital-initiated opioid coprescription were analyzed by multivariable logistic regression. Results A total of 735 patients met the inclusion criteria. At ICU transfer, 23.0% (169/735) of the patients had an opioid coprescription, and 87.0% (147/169) of these coprescriptions were hospital-initiated. At hospital discharge, 8.6% (44/514) of the patients had an opioid coprescription, and 56.8% (25/44) of these coprescriptions were hospital-initiated. Male sex, home opioid coprescription, surgical patient, prolonged hospital stay, and in-hospital death were significantly associated with hospital-initiated opioid coprescription at the time of ICU transfer. Home opioid coprescription was significantly associated with opioid coprescription at the time of hospital discharge. Conclusions Hospital-initiated opioid coprescriptions accounted for the majority of opioid coprescriptions at ICU transfer and hospital discharge. Pharmacists should assess all opioid coprescriptions to determine whether discontinuation and/or dose reduction is appropriate.
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Muacevic A, Adler JR, Burke H, Spurling B, Czuma R, Varghese R, Cohen A, Hartney K, Sullivan G, Kozel FA, Maldonado JR. A Retrospective Analysis of Guanfacine for the Pharmacological Management of Delirium. Cureus 2023; 15:e33393. [PMID: 36751225 PMCID: PMC9899070 DOI: 10.7759/cureus.33393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2023] [Indexed: 01/07/2023] Open
Abstract
Background Delirium is a syndrome of acute brain failure that represents a change from an individual's baseline cognitive functioning characterized by deficits in attention and multiple aspects of cognition that fluctuate in severity over time. The symptomatic management of delirium's behavioral manifestations remains difficult. The alpha-2 agonists, dexmedetomidine and clonidine, are efficacious, but their potential cardiovascular adverse effects limit their utilization. Guanfacine is an oral alpha-2 agonist with a lower potential for such adverse outcomes; however, its use in delirium has not been studied. Methods A retrospective descriptive analysis of guanfacine for managing hyperactive or mixed delirium at Tampa General Hospital from January 2020 to October 2020 was conducted. The primary outcome was the time reduction in acute sedative administration. Secondary outcomes included renewed participation in physical therapy or occupational therapy (PT/OT), decreased opioid use, and an incidence of cardiovascular adverse effects. Results One hundred forty-nine patients were identified as having received guanfacine for managing delirium during the study period. All experienced a reduction in acute sedative use after the initiation of guanfacine. In 93 patients receiving PT/OT and no longer participating due to behavioral agitation, 74% had a documented renewal of services within four days. Of 112 patients on opioids, 70% experienced a 25% reduction in opioid administration within four days. No patients experienced consecutive episodes of hypotension that required a change in their clinical care. Two patients experienced a single episode of consecutive bradycardia that led to the discontinuation of guanfacine. Conclusions Based on our retrospective study, guanfacine is a well-tolerated medication for the management of delirium. Even in medically and critically ill patients, cardiovascular adverse events were rare with guanfacine. Patients treated with guanfacine experienced decreased acute sedative use for behavioral agitation. Additionally, patients treated with guanfacine received fewer opioids and were better able to participate in PT/OT. Future studies with prospective, randomized, placebo-controlled designs are warranted to evaluate this promising intervention for delirium further.
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11
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Riester MR, Goyal P, Jiang L, Erqou S, Rudolph JL, McGeary JE, Rogus-Pulia NM, Madrigal C, Quach L, Wu WC, Zullo AR. New Antipsychotic Prescribing Continued into Skilled Nursing Facilities Following a Heart Failure Hospitalization: a Retrospective Cohort Study. J Gen Intern Med 2022; 37:3368-3379. [PMID: 34981366 PMCID: PMC9550891 DOI: 10.1007/s11606-021-07233-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Multimorbidity and polypharmacy are common among individuals hospitalized for heart failure (HF). Initiating high-risk medications such as antipsychotics may increase the risk of poor clinical outcomes, especially if these medications are continued unnecessarily into skilled nursing facilities (SNFs) after hospital discharge. OBJECTIVE Examine how often older adults hospitalized with HF were initiated on antipsychotics and characteristics associated with antipsychotic continuation into SNFs after hospital discharge. DESIGN Retrospective cohort. PARTICIPANTS Veterans without prior outpatient antipsychotic use, who were hospitalized with HF between October 1, 2010, and September 30, 2015, and were subsequently discharged to a SNF. MAIN MEASURES Demographics, clinical conditions, prior healthcare utilization, and antipsychotic use data were ascertained from Veterans Administration records, Minimum Data Set assessments, and Medicare claims. The outcome of interest was continuation of antipsychotics into SNFs after hospital discharge. KEY RESULTS Among 18,008 Veterans, antipsychotics were newly prescribed for 1931 (10.7%) Veterans during the index hospitalization. Among new antipsychotic users, 415 (21.5%) continued antipsychotics in skilled nursing facilities after discharge. Dementia (adjusted OR (aOR) 1.48, 95% CI 1.11-1.98), psychosis (aOR 1.62, 95% CI 1.11-2.38), proportion of inpatient days with antipsychotic use (aOR 1.08, 95% CI 1.07-1.09, per 10% increase), inpatient use of only typical (aOR 0.47, 95% CI 0.30-0.72) or parenteral antipsychotics (aOR 0.39, 95% CI 0.20-0.78), and the day of hospital admission that antipsychotics were started (day 0-4 aOR 0.36, 95% CI 0.23-0.56; day 5-7 aOR 0.54, 95% CI 0.35-0.84 (reference: day > 7 of hospital admission)) were significant predictors of continuing antipsychotics into SNFs after hospital discharge. CONCLUSIONS Antipsychotics are initiated fairly often during HF admissions and are commonly continued into SNFs after discharge. Hospital providers should review antipsychotic indications and doses throughout admission and communicate a clear plan to SNFs if antipsychotics are continued after discharge.
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Affiliation(s)
- Melissa R Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA.
| | - Parag Goyal
- Division of Cardiology and Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Lan Jiang
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Sebhat Erqou
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - James L Rudolph
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - John E McGeary
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, RI, USA
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, USA
| | - Nicole M Rogus-Pulia
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, USA
- Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Caroline Madrigal
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Lien Quach
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Wen-Chih Wu
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
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12
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The role of experiential knowledge in hospital nurses’ management of pain-related agitation in people with dementia: an expert performance simulation study. Int J Nurs Stud 2021; 127:104160. [DOI: 10.1016/j.ijnurstu.2021.104160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 12/08/2021] [Accepted: 12/10/2021] [Indexed: 11/19/2022]
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13
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Mart MF, Williams Roberson S, Salas B, Pandharipande PP, Ely EW. Prevention and Management of Delirium in the Intensive Care Unit. Semin Respir Crit Care Med 2021; 42:112-126. [PMID: 32746469 PMCID: PMC7855536 DOI: 10.1055/s-0040-1710572] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Delirium is a debilitating form of brain dysfunction frequently encountered in the intensive care unit (ICU). It is associated with increased morbidity and mortality, longer lengths of stay, higher hospital costs, and cognitive impairment that persists long after hospital discharge. Predisposing factors include smoking, hypertension, cardiac disease, sepsis, and premorbid dementia. Precipitating factors include respiratory failure and shock, metabolic disturbances, prolonged mechanical ventilation, pain, immobility, and sedatives and adverse environmental conditions impairing vision, hearing, and sleep. Historically, antipsychotic medications were the mainstay of delirium treatment in the critically ill. Based on more recent literature, the current Society of Critical Care Medicine (SCCM) guidelines suggest against routine use of antipsychotics for delirium in critically ill adults. Other pharmacologic interventions (e.g., dexmedetomidine) are under investigation and their impact is not yet clear. Nonpharmacologic interventions thus remain the cornerstone of delirium management. This approach is summarized in the ABCDEF bundle (Assess, prevent, and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment). The implementation of this bundle reduces the odds of developing delirium and the chances of needing mechanical ventilation, yet there are challenges to its implementation. There is an urgent need for ongoing studies to more effectively mitigate risk factors and to better understand the pathobiology underlying ICU delirium so as to identify additional potential treatments. Further refinements of therapeutic options, from drugs to rehabilitation, are current areas ripe for study to improve the short- and long-term outcomes of critically ill patients with delirium.
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Affiliation(s)
- Matthew F. Mart
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
| | - Shawniqua Williams Roberson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Bioengineering, Vanderbilt University, Nashville, Tennessee
| | - Barbara Salas
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Pratik P. Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Division of Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E. Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- VA Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center (GRECC), Nashville, Tennessee
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14
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Does Recent Hospitalization Increase Antipsychotic Initiation Among Community Dwellers With Alzheimer's Disease? J Am Med Dir Assoc 2021; 22:1543-1547.e3. [PMID: 33460619 DOI: 10.1016/j.jamda.2020.12.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 12/09/2020] [Accepted: 12/11/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Antipsychotics are often prescribed to persons with cognitive impairment in the hospital, but it is not known whether recent hospital care increases the risk of antipsychotic initiation in community dwellers with Alzheimer's disease (AD). We studied whether hospital care during the previous 2 weeks is associated with antipsychotic initiation in persons with AD. DESIGN Register-based study. PARTICIPANTS AND SETTING The nationwide Medication use and Alzheimer's disease (MEDALZ) cohort containing Finnish community dwellers with AD between 2005 and 2011 (N = 70,718) was used. METHODS Incident antipsychotic use was identified with a 1-year washout period. Each new initiator was matched with noninitiator according to age, sex, and time since AD diagnosis (n = 22,281 matched pairs). The use of antipsychotics was identified from the Prescription Register. Information on hospital discharge within the past 2 weeks of antipsychotic initiation was extracted from the Hospital Discharge Register. RESULTS Antipsychotic initiators were 5 times more likely to have recently been discharged from the hospital compared with the matched noninitiators (29.8% and 5.3%, respectively). In adjusted regression analyses, a hospital stay longer than a week and especially more than 2 months [odds ratio (OR) 4.40, 95% confidence interval (CI) 3.51-5.53], use of benzodiazepines and related drugs (OR 1.66, 95% CI 1.44-1.92), and memantine (OR 1.30, 95% CI 1.12-1.52) were associated with antipsychotic initiation. Older age (OR 0.77, 95% CI 0.62-0.95), asthma or chronic obstructive pulmonary disease (OR 0.73, 95% CI 0.60-0.89), diabetes (OR 0.82, 95% CI 0.69-0.97), and cardiovascular disease (OR 0.82, 95% CI 0.72-0.94) were associated with a lower risk of initiation. CONCLUSIONS AND IMPLICATIONS Recent hospital care seems to be a risk factor for antipsychotic initiation in community-dwelling persons with AD. The need of antipsychotic treatment must be carefully assessed at the time of discharge. Well planned hospital discharge and home care might reduce antipsychotic initiation.
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15
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Walsh B, Dahlke S, O'Rourke H, Hunter KF. Nurses' decision-making related to administering as needed psychotropic medication to persons with dementia: an empty systematic review. Int J Older People Nurs 2021; 16:e12350. [PMID: 33438810 DOI: 10.1111/opn.12350] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/29/2020] [Accepted: 09/08/2020] [Indexed: 11/28/2022]
Abstract
Behavioural and psychological symptoms of dementia occur in approximately 75% of people with dementia admitted to acute care. Acute care nurses' decision-making regarding administering 'as needed' (pro re nata or PRN) psychotropic medications to persons with dementia are not well understood. This is an important clinical concern because 'as needed' medications are given at the discretion of the nurse. A comprehensive, systematic search and screen for studies that explored nurses' decision-making related to administering as needed psychotropic medication to persons with dementia in acute care settings was conducted. No studies that reported nurses' decision-making related to administration of as needed psychotropic medications to hospitalized persons with dementia were identified. In light of this, we present a discussion based on a narrative review of what is known on this topic from other settings, based on papers found in our original review. We will briefly explore what is needed in future research to address the gap in knowledge about nurse' decision-making related to administering as needed psychotropic medications. IMPLICATIONS FOR PRACTICE: Research is needed to understand and inform the decision-making process in the administration of as needed psychotropic medications to hospitalized persons with dementia.
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Affiliation(s)
- Brittany Walsh
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Sherry Dahlke
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Hannah O'Rourke
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
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16
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Walsh B, Dahlke S, O'Rourke H, Hunter KF. Exploring acute care nurses' decision-making in psychotropic PRN use in hospitalised people with dementia. J Clin Nurs 2020; 31:2024-2035. [PMID: 32860272 DOI: 10.1111/jocn.15477] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 07/30/2020] [Accepted: 08/19/2020] [Indexed: 12/01/2022]
Abstract
AIMS AND OBJECTIVES To understand how acute care nurses make decisions about administering "as-needed" (PRN) psychotropic medications to hospitalised people with dementia (PWD). BACKGROUND Behavioural and psychological symptoms of dementia occur in approximately 75% of PWD admitted to acute care. Despite this, few studies provide insight into the use and prevalence of psychotropic use in acute care. DESIGN A qualitative descriptive design was used to explore acute care nurses' decision-making about PRN psychotropic medication administration to PWD. METHODS Semi-structured interviews were conducted with eight nurses from three acute care medical units in a large tertiary hospital in Western Canada. Conventional content analysis was used to develop three themes that reflect nurses' decision-making related to administering PRNs to hospitalised PWD. COREQ guidelines were followed. RESULTS Three themes of legitimising control, making the patient fit and future telling were developed. Legitimising control involved medicating undesirable behaviours to promote the nurses' perceptions of safety. Making the patient fit involved maintaining routine and order. Future telling involved pre-emptively medicating to prevent undesirable behaviours from escalating. Nurses provided little to no mention of assessing for physical causes contributing to behaviours. PRNs were seen as a reasonable alternative to physical restraints and were frequently used. Additionally, organisational and unit routines greatly influenced nurses' decision-making. CONCLUSIONS These findings provide an initial understanding of how nurses make decisions to administer PRN medications to hospitalised older people and may inform prescribing practices. There were novel findings about the lack of assessment prior to PRN administration, and the nurses' collective response in decision-making. More research is needed to better understand the complexities of nurses' decision-making, to assist in the development of interventions for nursing practice.
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Affiliation(s)
- Brittany Walsh
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Sherry Dahlke
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Hannah O'Rourke
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
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Abstract
The use of psychotropic drugs (antipsychotics, benzodiazepines and benzodiazepine-related drugs, and antidepressants) is common, with a prevalence estimates range of 19-29% among community dwelling older adults. These drugs are often prescribed for off-label use, including neuropsychiatric symptoms. The older adult population also has high rates of pneumonia and some of these cases may be associated with adverse drug events. In this narrative review, we summarize the findings from current observational studies on the association between psychotropic drug use and pneumonia in older adults. In addition to studies assessing the use of psychotropics, we included antiepileptic drugs, as they are also central nervous system-acting drugs, whose use is becoming more common in the aging population. The use of antipsychotics, benzodiazepine, and benzodiazepine-related drugs are associated with increased risk of pneumonia in older adults (≥ 65 years of age), and these findings are not limited to this age group. Minimal and conflicting evidence has been reported on the association between antidepressant drug use and pneumonia, but differences between study populations make it difficult to compare findings. Studies regarding antiepileptic drug use and risk of pneumonia in older persons are lacking, although an increased risk of pneumonia in antiepileptic drug users compared with non-users in persons with Alzheimer's disease has been reported. Tools such as the American Geriatric Society Beers Criteria and the STOPP/START criteria for potentially inappropriate medications aids prescribers to avoid these drugs in order to reduce the risk of adverse drug events. However, risk of pneumonia is not mentioned in the current criteria and more research on this topic is needed, especially in vulnerable populations, such as persons with dementia.
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Affiliation(s)
- Blair Rajamaki
- School of Pharmacy, Faculty of Health Sciences, Kuopio Campus, University of Eastern Finland, P.O. Box 1627, 70211, Kuopio, Finland
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland
| | - Sirpa Hartikainen
- School of Pharmacy, Faculty of Health Sciences, Kuopio Campus, University of Eastern Finland, P.O. Box 1627, 70211, Kuopio, Finland
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland
| | - Anna-Maija Tolppanen
- School of Pharmacy, Faculty of Health Sciences, Kuopio Campus, University of Eastern Finland, P.O. Box 1627, 70211, Kuopio, Finland.
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.
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18
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Morris NP. Antipsychotics for delirium-the consent conundrum. Lancet Psychiatry 2020; 7:e5. [PMID: 31981540 DOI: 10.1016/s2215-0366(19)30522-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 12/12/2019] [Accepted: 12/12/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Nathaniel P Morris
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford University, Palo Alto, CA 94305-5717, USA.
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19
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Baruth JM, Gentry MT, Rummans TA, Miller DM, Burton MC. Polypharmacy in older adults: the role of the multidisciplinary team. Hosp Pract (1995) 2020; 48:56-62. [PMID: 31900000 DOI: 10.1080/21548331.2019.1706995] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Patients over the age 65 are a quickly expanding segment of the US population and represent a large percentage of patients requiring inpatient care. Older adults are more likely to experience polypharmacy and adverse drug effects. This review explains the risks of polypharmacy and potentially inappropriate medications in the elderly. Specific classes of medications frequently used in older adults in acute care settings are examined, including anticholinergic, sedative hypnotics, and antipsychotic medications. We discuss strategies aimed at addressing polypharmacy in this population including a drug regimen review (which is distinct from medication reconciliation), screening tools, pharmacist-led interventions, and computer-based strategies in the context of current literature and research findings. We provide a summary of general guidelines that may be helpful for geriatricians and hospitalists in improving patient care and clinical outcomes.
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Affiliation(s)
- Joshua M Baruth
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Melanie T Gentry
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Teresa A Rummans
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA.,Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL, USA
| | - Donna M Miller
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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20
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Basciotta M, Zhou W, Ngo L, Donnino M, Marcantonio ER, Herzig SJ. Antipsychotics and the Risk of Mortality or Cardiopulmonary Arrest in Hospitalized Adults. J Am Geriatr Soc 2019; 68:544-550. [PMID: 31743435 DOI: 10.1111/jgs.16246] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 10/06/2019] [Accepted: 10/07/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Prior studies in outpatient and long-term care settings demonstrated increased risk for sudden death with typical and atypical antipsychotics. To date, no studies have investigated this association in a general hospitalized population. We sought to evaluate the risk of death or nonfatal cardiopulmonary arrest in hospitalized adults exposed to antipsychotics. DESIGN Retrospective cohort study. SETTING Large academic medical center in Boston, Massachusetts. PARTICIPANTS All hospitalizations between 2010 and 2016 were eligible for inclusion. We excluded those admitted directly to the intensive care unit (ICU), obstetric and gynecologic or psychiatric services, or with a diagnosis of a psychotic disorder. INTERVENTION Typical and atypical antipsychotic administration, defined by pharmacy charges. MEASUREMENTS The primary outcome was death or nonfatal cardiopulmonary arrest during hospitalization (composite). RESULTS Of 150 948 hospitalizations in our cohort, there were 691 total events (515 deaths, 176 cardiopulmonary arrests). After controlling for comorbidities, ICU time, demographics, admission type, and other medication exposures, typical antipsychotics were associated with the primary outcome (hazard ratio [HR] = 1.6; 95% confidence interval [CI] = 1.1-2.4; P = .02), whereas atypical antipsychotics were not (HR = 1.1; 95% CI = .8-1.4; P = .5). When focusing on adults age 65 years and older, however, both typical and atypical antipsychotics were associated with increased risk of death or cardiopulmonary arrest (HR = 1.8; 95% CI = 1.1-2.9; and HR = 1.4; 95% CI = 1.1-2.0, respectively). Sensitivity analyses using a propensity score approach and a cohort of only patients with delirium both yielded similar results. CONCLUSION In hospitalized adults, typical antipsychotics were associated with increased mortality or cardiopulmonary arrest, whereas atypical antipsychotics were only associated with increased risk among adults age 65 years and older. Providers should be thoughtful when prescribing antipsychotic medications, especially to older adults in settings where data regarding benefit are lacking. J Am Geriatr Soc 68:544-550, 2020.
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Affiliation(s)
- Matthew Basciotta
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Hospital Medicine, North Shore Medical Center, Salem, Massachusetts.,Tufts University School of Medicine, Boston, Massachusetts
| | - Wenxiao Zhou
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Long Ngo
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Michael Donnino
- Harvard Medical School, Boston, Massachusetts.,Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Edward R Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Shoshana J Herzig
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med 2019; 46:e825-e873. [PMID: 30113379 DOI: 10.1097/ccm.0000000000003299] [Citation(s) in RCA: 1750] [Impact Index Per Article: 350.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU. DESIGN Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017. METHODS Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified. RESULTS The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation. CONCLUSIONS We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.
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22
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Pahwa AK, Qureshi I, Cumbler E. Things We Do For No Reason™: Use of Antipsychotic Medications in Patients with Delirium. J Hosp Med 2019; 14:565-567. [PMID: 30897059 DOI: 10.12788/jhm.3166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 12/23/2018] [Accepted: 01/07/2019] [Indexed: 01/24/2023]
Abstract
Inspired by the ABIM Foundation's Choosing Wisely® campaign, the "Things We Do for No Reason™" (TWDFNR™) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR™ series do not represent "black and white" conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.
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Affiliation(s)
- Amit K Pahwa
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Imran Qureshi
- Johns Hopkins Hospital Department of Pharmacy, Baltimore, Maryland
| | - Ethan Cumbler
- University of Colorado School of Medicine, Denver, Colorado
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Phan SV, Lugin Y, Morgan K. Rates of new antipsychotic prescriptions and continuation at discharge from a medical unit in a community teaching hospital serving rural counties. Ment Health Clin 2019; 9:88-92. [PMID: 30842916 PMCID: PMC6398354 DOI: 10.9740/mhc.2019.03.088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Introduction Antipsychotics are commonly used during hospitalization to manage a variety of acute indications and may be inadvertently continued at discharge. The purpose of this study was to identify the rate at which patients admitted to nonpsychiatric units were continued on newly prescribed antipsychotics at discharge from a rural community teaching hospital. Methods This study was a retrospective chart review of adult patients admitted to a large community teaching hospital and initiated on an antipsychotic from August 1, 2016, to August 31, 2017. Exclusion criteria were patients admitted to psychiatric or obstetrics/gynecology services, with a diagnosis of a psychotic disorder, or on an antipsychotic prior to hospitalization. The primary outcome measure was the number of new antipsychotic prescriptions during hospitalization that were continued at discharge. Secondary outcomes included antipsychotic characteristics and initiation indications. Descriptive statistics were used to describe antipsychotic use and demographic data. Results Of 100 patients included, 3 patients were discharged on an antipsychotic. Two patients had questionable indications, and 1 patient had a new psychotic disorder diagnosis. Of all antipsychotics newly initiated during hospitalization, haloperidol was the most commonly prescribed antipsychotic. The majority of doses were scheduled as 1-time or as-needed doses. Approximately 20% of antipsychotics were administered orally. No relevant indication was found for 35% of patients newly initiated on antipsychotics, and documented indications included agitation, psychosis, delirium, and anxiety. Discussion In an institution that largely serves a rural population, antipsychotic prescribing at discontinuation was not worse than what has been previously reported in other regions of the United States. Limitations for this study include the retrospective nature, single-center study, and small sample size. Although there was a lack of continuation after discharge, there was also a deficit of documentation with 35% of the antipsychotic initiations having no documented indication.
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Devlin JW, Smithburger P, Kane JM, Fraser GL, Skrobik Y. Intended and Unintended Consequences of Constraining Clinician Prescribing: The Case of Antipsychotics. Crit Care Med 2018; 44:1805-7. [PMID: 27635480 DOI: 10.1097/ccm.0000000000002103] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- John W Devlin
- School of Pharmacy Northeastern University Boston, MASchool of Pharmacy University of Pittsburgh Pittsburgh, PADepartment of Pediatrics University of Chicago Comer Children's Hospital Chicago, ILDepartments of Pharmacy and Critical Care Medicine Maine Medical Center Portland, MEDepartment of Medicine McGill University Montreal, PQ, Canada
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Kim DH, Mahesri M, Bateman BT, Huybrechts KF, Inouye SK, Marcantonio ER, Herzig SJ, Ely EW, Pisani MA, Levin R, Avorn J. Longitudinal Trends and Variation in Antipsychotic Use in Older Adults After Cardiac Surgery. J Am Geriatr Soc 2018; 66:1491-1498. [PMID: 30125337 PMCID: PMC6217828 DOI: 10.1111/jgs.15418] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 03/22/2018] [Accepted: 03/27/2018] [Indexed: 01/07/2023]
Abstract
OBJECTIVES To evaluate temporal trends and between-hospital variation in off-label antipsychotic medication (APM) use in older adults undergoing cardiac surgery. DESIGN Retrospective cohort study. SETTING National administrative database including 465 U.S. hospitals. PARTICIPANTS Individuals aged 65 and older without known indications for APMs who underwent cardiac surgery from 2004 to 2014 (N=293,212). MEASUREMENTS Postoperative exposure to any APMs and potentially excessive dosing were examined. Hospital-level APM prescribing intensity was defined as the proportion of individuals newly treated with APMs in the postoperative period. RESULTS The rate of APM use declined from 8.8% in 2004 to 6.2% in 2014 (p<.001). Use of haloperidol (parenteral 7.0% to 4.5%, p<.001; oral: 1.9% to 0.5%, p<.001), and risperidone (1.1% to 0.3%, p<.001) declined, whereas quetiapine use tripled (0.6% to 1.9%, p=.03). Hospital APM prescribing intensity varied widely, from 0.3% to 35.6%, across 465 hospitals. Treated individuals at higher-prescribing hospitals were more likely to receive APMs on the day of discharge (highest vs lowest quintile: 15.1% vs 9.6%; p<.001) and for a longer duration (4.8 vs 3.7 days; p<.001) than those at lower-prescribing hospitals. Delirium was the strongest risk factor for APM exposure (odds ratio=9.73, 95% confidence interval=9.02-10.5), whereas none of the hospital characteristics were significantly associated. The rate of potentially excessive dosing declined (60.7% to 44.9%, p<.001), and risk factors for potentially excessive dosing were similar to those for any APM exposure. CONCLUSIONS Our findings suggest highly variable prescribing cultures and raise concerns about inappropriate use, highlighting the need for better evidence to guide APM prescribing in hospitalized older adults after cardiac surgery.
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Affiliation(s)
- Dae Hyun Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Mufaddal Mahesri
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Brian T. Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Krista F. Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Sharon K. Inouye
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Edward R. Marcantonio
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Shoshana J. Herzig
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - E. Wesley Ely
- Division of Allergy, Pulmonology, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Veterans Affairs Tennessee Valley Geriatric Research Education Clinical Center, Nashville, TN
| | - Margaret A. Pisani
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale-New Haven Hospital, New Haven, CT
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Jerry Avorn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
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Herzig SJ, LaSalvia MT, Naidus E, Rothberg MB, Zhou W, Gurwitz JH, Marcantonio ER. Antipsychotics and the Risk of Aspiration Pneumonia in Individuals Hospitalized for Nonpsychiatric Conditions: A Cohort Study. J Am Geriatr Soc 2017; 65:2580-2586. [PMID: 29095482 DOI: 10.1111/jgs.15066] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND/OBJECTIVES Off-label use of antipsychotics is common in hospitals, most often for delirium management. Antipsychotics have been associated with aspiration pneumonia in community and nursing home settings, but the association in hospitalized individuals is unexplored. We aimed to investigate the association between antipsychotic exposure and aspiration pneumonia during hospitalization. DESIGN Retrospective cohort study. SETTING Large academic medical center. PARTICIPANTS All adult hospitalizations between January 2007 and July 2013. We excluded outside hospital transfers, hospitalizations shorter than 48 hours, and psychiatric hospitalizations. MEASUREMENTS Antipsychotic use defined as any pharmacy charge for an antipsychotic medication. Aspiration pneumonia was defined according to a discharge diagnosis code for aspiration pneumonia not present on admission and validated using chart review. A generalized estimating equation was used to control for 43 potential confounders. RESULTS Our cohort included 146,552 hospitalizations (median age 56; 39% male). Antipsychotics were used in 10,377 (7.1%) hospitalizations (80% atypical, 35% typical, 15% both). Aspiration pneumonia occurred in 557 (0.4%) hospitalizations. The incidence of aspiration pneumonia was 0.3% in unexposed individuals and 1.2% in those with antipsychotic exposure (odds ratio (OR) = 3.9, 95% confidence interval (CI) = 3.2-4.8). After adjustment, antipsychotic exposure was significantly associated with aspiration pneumonia (adjusted OR = (aOR) = 1.5, 95% CI = 1.2-1.9). Similar results were demonstrated in a propensity-matched analysis and in an analysis restricted to those with delirium or dementia. The magnitude of the association was similar for typical (aOR = 1.4, 95% CI = 0.94-2.2) and atypical (aOR = 1.5, 95% CI = 1.1-2.0) antipsychotics. CONCLUSION Antipsychotics were associated with greater odds of aspiration pneumonia after extensive adjustment for participant characteristics. This risk should be considered when prescribing antipsychotics in the hospital.
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Affiliation(s)
- Shoshana J Herzig
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Mary T LaSalvia
- Harvard Medical School, Boston, Massachusetts.,Division of Infectious Disease, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Elliot Naidus
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Michael B Rothberg
- Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Wenxiao Zhou
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jerry H Gurwitz
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group and Fallon Community Health Plan, Worcester, Massachusetts.,University of Massachusetts Medical School, Worcester, Massachusetts
| | - Edward R Marcantonio
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Abstract
RATIONALE Vasopressin may be used to treat vasodilatory hypotension in septic shock, but it is not recommended by guidelines as a first- or second-line agent. Little is known about how often the drug is used currently in septic shock. OBJECTIVES We conducted this study to describe patterns of vasopressin use in a large cohort of U.S. adults with septic shock and to identify patient and hospital characteristics associated with vasopressin use. METHODS This was a retrospective cohort study of adults admitted to U.S. hospitals with septic shock in the Premier healthcare database (July 2008 to June 2013). We performed multilevel mixed-effects logistic regression with hospitals as a random effect to identify factors associated with use of vasopressin alone or in combination with other vasopressors on at least 1 day of hospital admission. We calculated quotients of Akaike Information Criteria (AIC) to determine relative contributions of patient and hospital characteristics to observed variation. MEASUREMENTS AND MAIN RESULTS Among 584,421 patients with septic shock in 532 hospitals, 100,923 (17.2%) received vasopressin. A total of 6.1% of patients receiving vasopressin received vasopressin alone, and 93.9% received vasopressin in combination with other vasopressors (up to five vasopressors in 15 different combinations). The mean monthly rate of vasopressin use increased from 14.5 to 19.6% over the study period, representing an average annual relative increase of 8% (P < 0.001). The median hospital rate of vasopressin use for septic shock was 11.7% (range, 0-69.7%). Patient demographic and clinical characteristics, including patient age (adjusted odds ratio, 0.71 for age > 85 yr compared with the reference group of age < 50 yr; 95% confidence interval, 0.69-0.74) and acute respiratory dysfunction (adjusted odds ratio, 3.25; 95% confidence interval, 3.20-3.31), were responsible for the majority of observed variation in vasopressin use (quotient of AICs, 0.56). However, hospital of admission also contributed substantially to observed variation (quotient of AICs, 0.37). CONCLUSIONS Approximately one-fifth of patients with septic shock received vasopressin, but rarely as a single vasopressor. The use of vasopressin has increased over time. The likelihood of receiving vasopressin was strongly associated with the specific hospital to which each patient was admitted.
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Johnson KG, Fashoyin A, Madden-Fuentes R, Muzyk AJ, Gagliardi JP, Yanamadala M. Discharge Plans for Geriatric Inpatients with Delirium: A Plan to Stop Antipsychotics? J Am Geriatr Soc 2017; 65:2278-2281. [DOI: 10.1111/jgs.15026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kim DH, Lee J, Kim CA, Huybrechts KF, Bateman BT, Patorno E, Marcantonio ER. Evaluation of algorithms to identify delirium in administrative claims and drug utilization database. Pharmacoepidemiol Drug Saf 2017; 26:945-953. [PMID: 28485014 DOI: 10.1002/pds.4226] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 04/03/2017] [Accepted: 04/18/2017] [Indexed: 11/08/2022]
Abstract
PURPOSE To evaluate the performance of delirium-identification algorithms in administrative claims and drug utilization data. METHODS We used data from a prospective study of 184 older adults who underwent aortic valve replacement at a single academic medical center to evaluate the following delirium-identification algorithms: (1) International Classification of Diseases (ICD) diagnosis codes for delirium; (2) antipsychotics use; (3) either ICD diagnosis codes or antipsychotics use; and (4) both ICD diagnosis codes and antipsychotics use. These algorithms were evaluated against a validated bedside assessment, the Confusion Assessment Method, and a validated delirium severity scale, the CAM-S. RESULTS Delirium occurred in 66 patients (36%), of which 14 (21%) had hyperactive or mixed features and 15 (23%) had severe delirium. ICD diagnosis codes for delirium were present in 15 patients (8%). Antipsychotics were used in 13 patients (7%). ICD diagnosis codes alone and antipsychotics use alone had comparable sensitivity (18% vs. 18%) and specificity (98% vs. 99%). Defining delirium using either ICD diagnosis codes or antipsychotics use, sensitivity improved to 30% with little change in specificity (97%). This algorithm showed higher sensitivity for hyperactive or mixed delirium (64%) and severe delirium (73%). Requiring both ICD diagnosis codes and antipsychotics use resulted in perfect specificity but low sensitivity (6%). CONCLUSION Delirium-identification algorithms in claims data have low sensitivity and high specificity. Defining delirium using ICD diagnosis codes or antipsychotics use performs better than considering either type of information alone. This information should inform the design and interpretation of claims-based comparative effectiveness and safety research. Copyright © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Dae Hyun Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jung Lee
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Caroline A Kim
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Edward R Marcantonio
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Garpestad E, Devlin JW. Polypharmacy and Delirium in Critically Ill Older Adults: Recognition and Prevention. Clin Geriatr Med 2017; 33:189-203. [PMID: 28364991 DOI: 10.1016/j.cger.2017.01.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Among older adults, polypharmacy is a sequelae of admission to the intensive care unit and is associated with increased medication-associated adverse events, drug interactions, and health care costs. Delirium is prevalent in critically ill geriatric patients and medications remain an underappreciated modifiable risk for delirium in this setting. This article reviews the literature on polypharmacy and delirium, with a focus on highlighting the relationships between polypharmacy and delirium in critically ill, older adults. Discussed are clinician strategies on how to recognize and reduce medication-associated delirium and recommendations that help prevent polypharmacy when interventions to reduce the burden of delirium in this vulnerable population are being formulated.
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Affiliation(s)
- Erik Garpestad
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, 200 Washington Street, Boston, MA 02111, USA
| | - John W Devlin
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, 200 Washington Street, Boston, MA 02111, USA; School of Pharmacy, Northeastern University, 360 Huntington Avenue 140TF RD218F, Boston, MA 02115, USA.
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