Factors Associated With Benzodiazepine and Antipsychotic Prescribing in Hospice: A Qualitative Study of Hospice Prescribers.

OBJECTIVES: Benzodiazepine and antipsychotic medications are common components of the hospice toolkit and are routinely prescribed for behavioral symptom management at end of life. These medications have significant associated risks but, despite their frequent use, little is known about how clinicians weigh prescribing decisions for individuals in hospice. In this qualitative study, we examined the key factors that influence the decision to initiate a benzodiazepine and antipsychotic medication for management of behavioral symptoms at end of life. DESIGN: A qualitative study using semi-structured interviews and descriptive qualitative analysis. SETTING AND PARTICIPANTS: We conducted semi-structured interviews with prescribing hospice physicians and nurse practitioners working in hospice settings across the United States. METHODS: Hospice clinicians were asked to describe factors that influence prescribing decisions to initiate benzodiazepine and antipsychotic medications for the management of behavioral symptoms. Data from audio-recorded sessions were transcribed, coded to identify relevant concepts, and reduced to determine major themes. RESULTS: We completed 23 interviews with hospice physicians and nurse practitioners. On average, participants had worked in a hospice setting for a mean of 14.3 years (SD: 10.9); 39% had geriatrics training. Major themes related to benzodiazepine and antipsychotic prescribing were (1) caregiving factors strongly influence the use of medications, (2) patient and caregiver stigma and concerns regarding medication use limit prescribing, (3) medications are initiated to avoid hospitalization or transition to a higher level of care, and (4) nursing home hospice care brings unique challenges. CONCLUSION AND IMPLICATIONS: Caregiver factors and the setting of hospice care strongly influence clinician decisions to initiate benzodiazepines and antipsychotics in hospice. Caregiver education about medication use at end of life and support in managing challenging behaviors may help promote optimal prescribing.

Right Brain: Oriented to Self.

In medical school, students learn to view the world through a biomedical lens. While necessary clinically, this lens can be impersonal. For example, the mental status examination (MSE) evaluates cognitive function through a brief assessment of alertness and orientation to person, place, time, and situation. While clinically useful, the MSE often neglects to capture a person's individuality. Visiting my grandmother who has Alzheimer disease highlighted this tension. I juxtaposed the impersonality of our MSE orientation scale with my grandmother's lived experiences. My grandmother is identified using a pseudonym. Informed consent was obtained from her health care power of attorney and family.Birds twitter and chirp as they flit into the shade,the covered patio a respite from the morning's heat.I sit with Joanna and show her a painting:an apple, red peppers, a garlic clove, and a grapefruitrest on a white napkin.Produce so vibrant the napkin is stainedwith their vivid reflections.The wrinkles around her eyes deepen as she squints at the picture.She always liked to see my artwork.Bright colors illuminate the lines of confusion on her face.Where did you get all this food?We're rationing for the war to stop Hitler.I have evaluated dementia:limited treatment options, behavioral interventions.Cognitive changes alterorientation to self,place, time, situation.Joanna and I sit on the memory care patio.The birdfeeder dances in the humid summer air.I've shared my artwork with Grandma Jofrom crayons' waxy scrawlto crisp acrylic colors.Today a t-shirt replaces my white coat.The war is over, grandma.The produce is from a grocery store.I redirect with another painting.This is a bridge in a park-She smiles: it's New York City, I miss going there.In the middle of Central Park,a cement bridge in a grassy parkspans a wide, still pond.Today, the colors of the bridge,reflected on the water,spark a glimmer of my grandmother.This time she knows the memory is in the past,as she tells me about New York in the Forties.With the beating of sparrow wings,the moment of clarity endsas past and present are blended again.When the sun sinks, my visit will fade.I clutch what happenedoutside, away from the clinical setting.What we cannot quantifywith A&O x1: oriented to self.

Postoperative Delirium Severity and Recovery Correlate With Electroencephalogram Spectral Features.

BACKGROUND: Delirium is an acute syndrome characterized by inattention, disorganized thinking, and an altered level of consciousness. A reliable biomarker for tracking delirium does not exist, but oscillations in the electroencephalogram (EEG) could address this need. We evaluated whether the frequencies of EEG oscillations are associated with delirium onset, severity, and recovery in the postoperative period. METHODS: Twenty-six adults enrolled in the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES; ClinicalTrials.gov NCT02241655) study underwent major surgery requiring general anesthesia, and provided longitudinal postoperative EEG recordings for this prespecified substudy. The presence and severity of delirium were evaluated with the confusion assessment method (CAM) or the CAM-intensive care unit. EEG data obtained during awake eyes-open and eyes-closed states yielded relative power in the delta (1-4 Hz), theta (4-8 Hz), and alpha (8-13 Hz) bands. Discriminability for delirium presence was evaluated with c-statistics. To account for correlation among repeated measures within patients, mixed-effects models were generated to assess relationships between: (1) delirium severity and EEG relative power (ordinal), and (2) EEG relative power and time (linear). Slopes of ordinal and linear mixed-effects models are reported as the change in delirium severity score/change in EEG relative power, and the change in EEG relative power/time (days), respectively. Bonferroni correction was applied to confidence intervals (CIs) to account for multiple comparisons. RESULTS: Occipital alpha relative power during eyes-closed states offered moderate discriminability (c-statistic, 0.75; 98% CI, 0.58-0.87), varying inversely with delirium severity (slope, -0.67; 98% CI, -1.36 to -0.01; P = .01) and with severity of inattention (slope, -1.44; 98% CI, -2.30 to -0.58; P = .002). Occipital theta relative power during eyes-open states correlated directly with severity of delirium (slope, 1.28; 98% CI, 0.12-2.44; P = .007), inattention (slope, 2.00; 98% CI, 0.48-3.54; P = .01), and disorganized thinking (slope, 3.15; 98% CI, 0.66-5.65; P = .01). Corresponding frontal EEG measures recapitulated these relationships to varying degrees. Severity of altered level of consciousness correlated with frontal theta relative power during eyes-open states (slope, 11.52; 98% CI, 6.33-16.71; P < .001). Frontal theta relative power during eyes-open states correlated inversely with time (slope, -0.05; 98% CI, -0.12 to -0.04; P = .002). CONCLUSIONS: Presence, severity, and core features of postoperative delirium covary with spectral features of the EEG. The cost and accessibility of EEG facilitate the translation of these findings to future mechanistic and interventional trials.

Convergent Validity of Three Methods for Measuring Postoperative Complications.

BACKGROUND: Anesthesiologists need tools to accurately track postoperative outcomes. The accuracy of patient report in identifying a wide variety of postoperative complications after diverse surgical procedures has not previously been investigated. METHODS: In this cohort study, 1,578 adult surgical patients completed a survey at least 30 days after their procedure asking if they had experienced any of 18 complications while in the hospital after surgery. Patient responses were compared to the results of an automated electronic chart review and (for a random subset of 750 patients) to a manual chart review. Results from automated chart review were also compared to those from manual chart review. Forty-two randomly selected patients were contacted by telephone to explore reasons for discrepancies between patient report and manual chart review. RESULTS: Comparisons between patient report, automated chart review, and manual chart review demonstrated poor-to-moderate positive agreement (range, 0 to 58%) and excellent negative agreement (range, 82 to 100%). Discordance between patient report and manual chart review was frequently explicable by patients reporting events that happened outside the time period of interest. CONCLUSIONS: Patient report can provide information about subjective experiences or events that happen after hospital discharge, but often yields different results from chart review for specific in-hospital complications. Effective in-hospital communication with patients and thoughtful survey design may increase the quality of patient-reported complication data.