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Jaworska N, Moss SJ, Krewulak KD, Stelfox Z, Niven DJ, Ismail Z, Burry LD, Fiest KM. A scoping review of perceptions from healthcare professionals on antipsychotic prescribing practices in acute care settings. BMC Health Serv Res 2022; 22:1272. [PMID: 36271347 PMCID: PMC9587627 DOI: 10.1186/s12913-022-08650-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 10/09/2022] [Indexed: 11/24/2022] Open
Abstract
Background Antipsychotic medications are frequently prescribed in acute care for clinical indications other than primary psychiatric disorders such as delirium. Unfortunately, they are commonly continued at hospital discharge and at follow-ups thereafter. The objective of this scoping review was to characterize antipsychotic medication prescribing practices, to describe healthcare professional perceptions on antipsychotic prescribing and deprescribing practices, and to report on antipsychotic deprescribing strategies within acute care. Methods We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and Web of Science databases from inception date to July 3, 2021 for published primary research studies reporting on antipsychotic medication prescribing and deprescribing practices, and perceptions on those practices within acute care. We included all study designs excluding protocols, editorials, opinion pieces, and systematic or scoping reviews. Two reviewers screened and abstracted data independently and in duplicate. The protocol was registered on Open Science Framework prior to data abstraction (10.17605/OSF.IO/W635Z). Results Of 4528 studies screened, we included 80 studies. Healthcare professionals across all acute care settings (intensive care, inpatient, emergency department) perceived prescribing haloperidol (n = 36/36, 100%) most frequently, while measured prescribing practices reported common quetiapine prescribing (n = 26/36, 76%). Indications for antipsychotic prescribing were delirium (n = 48/69, 70%) and agitation (n = 20/69, 29%). Quetiapine (n = 18/18, 100%) was most frequently prescribed at hospital discharge. Three studies reported in-hospital antipsychotic deprescribing strategies focused on pharmacist-driven deprescribing authority, handoff tools, and educational sessions. Conclusions Perceived antipsychotic prescribing practices differed from measured prescribing practices in acute care settings. Few in-hospital deprescribing strategies were described. Ongoing evaluation of antipsychotic deprescribing strategies are needed to evaluate their efficacy and risk. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08650-7.
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Affiliation(s)
- Natalia Jaworska
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada. .,Alberta Health Services, Calgary, AB, Canada.
| | - Stephana J Moss
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Karla D Krewulak
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Calgary, AB, Canada
| | - Zara Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Zahinoor Ismail
- Alberta Health Services, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Department of Psychiatry, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Lisa D Burry
- Departments of Pharmacy and Medicine, Leslie Dan Faculty of Pharmacy, Sinai Health System, University of Toronto, Toronto, Canada
| | - Kirsten M Fiest
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Department of Psychiatry, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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Cook EA, Duenas M, Harris P. Polypharmacy in the Homebound Population. Clin Geriatr Med 2022; 38:685-692. [PMID: 36210084 PMCID: PMC9468911 DOI: 10.1016/j.cger.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The number of homebound elders has risen dramatically in the past decade and was accelerated by the Sars-Cov-2 COVID-19 pandemic. These individuals generally have 5 or more chronic conditions, take 6 or more medications, and are at elevated risk for functional decline. Polypharmacy constitutes a major burden for these individuals, putting them at risk for medication nonadherence, medication errors, medication interactions, and reduced quality of life. A team-based approach may help these elders manage medications more effectively.
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Affiliation(s)
- Erin Atkinson Cook
- UCLA Division of Geriatrics, 10945 Le Conte Avenue, Suite 2339, Los Angeles, CA 90095, USA
| | - Maria Duenas
- UCLA Department of Medicine, Division of Geriatrics, 10945 Le Conte Avenue, Suite 2339, Los Angeles, CA 90095, USA
| | - Patricia Harris
- UCLA Division of Geriatrics, 10945 Le Conte Avenue, Suite 2339, Los Angeles, CA 90095, USA.
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Halavonich L, Robert S, McGraw D, Weeda E, Mullinax K, Bass B. Management of delirium at an academic medical center: Plans for antipsychotic prescribing upon discharge. Ment Health Clin 2020; 10:25-29. [PMID: 31942275 PMCID: PMC6956973 DOI: 10.9740/mhc.2020.01.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Introduction Delirium is an acute, fluctuating change in mental status, often associated with behavioral manifestations such as agitation. Literature suggests that many patients who continue on antipsychotics for extended management of delirium are not provided instructions for discontinuation. However, there is a positive correlation between consult services and instructions for discontinuation. The objective of this study was to determine the frequency at which patients with delirium were prescribed an antipsychotic at hospital discharge and to characterize discharge antipsychotic prescribing for psychiatric consult and nonconsult cohorts. Methods This study was a retrospective chart review of adult patients with an International Classification of Diseases 10th revision code of delirium who received at least 1 dose of antipsychotic during their admission. Inclusion criteria were all patients aged 18 years or older with a diagnosis of or relating to delirium who were administered antipsychotics during their admission. Results A total of 152 patients were included, of which 43 received a psychiatric consult. Antipsychotics were prescribed at discharge for management of delirium for 52 (34.2%) of 152 total patients. More patients in the psychiatric consult cohort were discharged with an antipsychotic as compared to those in the nonconsult cohort (53.3% vs 26.6%, P = .02). Discussion Compared to previous studies, patients in this retrospective review were more likely to be discharged on an antipsychotic that was initiated during admission for management of delirium. Findings from this study also align with prior research demonstrating a positive association between antipsychotic discharge instructions and specialty consult recommendations.
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Schwerthöffer D, Förstl J, Fatke B. [Antipsychotic pharmacotherapy for delirious syndrome - only temporary, symptom- oriented and considering QTc time (short version)]. MMW Fortschr Med 2019; 161:50-52. [PMID: 31631300 DOI: 10.1007/s15006-019-1009-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Dirk Schwerthöffer
- Klinikum rechts der Isar, Klinik für Psychiatrie und Psychotherapie, Schlafmedizinisches Zentrum, Ismaninger Straße 22, D-81675, München, Deutschland.
| | - Johannes Förstl
- Klinikum rechts der Isar, Klinik für Psychiatrie und Psychotherapie, Schlafmedizinisches Zentrum, Ismaninger Straße 22, D-81675, München, Deutschland
| | - Bastian Fatke
- Klinikum rechts der Isar, Klinik für Psychiatrie und Psychotherapie, Schlafmedizinisches Zentrum, Ismaninger Straße 22, D-81675, München, Deutschland
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Schwerthöffer D, Förstl H, Fatke B. [Antipsychotic pharmacotherapy for delirious syndromes - only temporary, symptom-oriented and considering QTc time]. MMW Fortschr Med 2019; 161:1-6. [PMID: 31313266 DOI: 10.1007/s15006-019-0743-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 01/16/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND QTc prolongation is a common and serious side effect of antipsychotics in the treatment of delirium. Nevertheless, the occurrence of ventricular tachycardia is rarely reported, so that the clinical relevance of a QTc prolongation triggered in this way remains unclear. METHOD The focus of this review is on the antipsychotic pharmacotherapy of delirium. RESULTS AND CONCLUSIONS In individual cases, before the prescription of an antipsychotic due to a delirium, a risk-benefit assessment must be made for the patient. For this purpose, patient and substance-specific risk factors for QTc prolongation must be checked and, if possible, reduced. A specific recommendation for an antipsychotic with assured low QTc interference can not be given because all antipsychotics for delirium treatment are potentially QTc-prolonging. Antipsychotic delirium treatment should be monitored, especially in patients with a high risk profile, for QTc prolongation by regular ECG controls.
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Affiliation(s)
- Dirk Schwerthöffer
- Klinikum rechts der Isar, Klinik für Psychiatrie und Psychotherapie, Schlafmedizinisches Zentrum, 81675, München, Deutschland.
| | - Hans Förstl
- Klinikum rechts der Isar, Klinik für Psychiatrie und Psychotherapie, Schlafmedizinisches Zentrum, 81675, München, Deutschland
| | - Bastian Fatke
- Klinikum rechts der Isar, Klinik für Psychiatrie und Psychotherapie, Schlafmedizinisches Zentrum, 81675, München, Deutschland
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Kalisch Ellett LM, Pratt NL, Apajee J, Roughead EE. Initiation and continuation of antipsychotic medicines in older people following non-psychiatric hospital admission. Int J Clin Pharm 2019; 41:1341-1347. [PMID: 31240552 DOI: 10.1007/s11096-019-00866-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 06/17/2019] [Indexed: 11/27/2022]
Abstract
Background Internationally, antipsychotics are frequently initiated during hospital admission for older patients and use often continues post-discharge without indication. We located no Australian studies on this topic. Objective to identify the hospital admissions (excluding psychosis) associated with antipsychotic initiation and continuation in older Australians. Setting Australian Government Department of Veterans' Affairs. Method Retrospective analysis of administrative claims data for people admitted to hospital from 1 January 2014 to 31 December 2014, aged ≥ 65 years, who were antipsychotic naïve. Main outcome measure number of admissions associated with antipsychotic initiation, and the major diagnosis groups for these admissions. Where antipsychotics were initiated, we determined the time to cessation of antipsychotics after discharge. Results There were 142,009 hospital admissions for 66,415 people with a median age of 86 years. 921 (0.65%) admissions were associated with antipsychotic initiation, most commonly where the primary diagnoses were for mental and behavioural disorders excluding psychosis (17.8%) and injuries (16%). Fourteen percent of antipsychotic initiations were for primary diagnoses of delirium or dementia. When secondary diagnoses were considered, 55% of antipsychotic initiations were associated with delirium, dementia or both. The median duration of use among people who used antipsychotics was 132 days, and 40% continued use until death or one year follow-up. Conclusion Initiation of antipsychotics during hospital admissions was not frequent in this Australian population. Amongst those who did initiate antipsychotics, for almost half no diagnosis corresponding with an approved indication for use was recorded and long-term use of up to one year was common.
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Affiliation(s)
- Lisa M Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia.
| | - Nicole L Pratt
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia
| | - Jemisha Apajee
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia
| | - Elizabeth E Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia
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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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