Results of a Continuous Quality Improvement Initiative of the Contemporaneous Model of Service Delivery.

The Contemporaneous Model of service delivery serves to manage behavioral expression in residents of long-term care homes with a diagnosis of advanced neurocognitive disorder. Its effectiveness is benchmarked in preventing the residents, on its active caseload, from seeking assistance in the emergency department and the dementia behavioral inpatient units for behavioral risks. The results of the three years of operation of the Contemporaneous Model of service delivery, for the years 2017-2018, 2018-2019, and 2019-2020, are presented here. These results are supportive of this model of service delivery as an effective way to reduce the burden of patients with advanced neurocognitive disorder with behavioral expressions on the emergency departments and specialized dementia behavioral services. It has the potential for becoming the gold standard model of service delivery in the Canadian health care system.

Evidence-Informed Approach to De-Prescribing of Atypical Antipsychotics (AAP) in the Management of Behavioral Expressions (BE) in Advanced Neurocognitive Disorders (NCD): Results of a Retrospective Study.

The LuBAIR™ Paradigm is a novel approach to ascribe meaning to behavioral expressions in advanced neurocognitive disorders when the reliability of a clinical assessment is limited. The meaning ascribed to each behavioral category was used to identify those which are likely to respond to the use of atypical antipsychotics, in their management. De-prescribing was attempted on patients who qualified to enter this retrospective study. De-prescribing was defined as successful if individuals were completely withdrawn from AAP and remained off them for 60 days, without the re-emergence of behaviors. The LuBAIR™ Inventory was filled on two occasions. The data collected on the second occasion, in the successful and failed de-prescribed groups, were compared in this retrospective study. MANOVA, Chi-Square paired t-test statistical analyses were used to detect the differences in the behavioral categories between the two cohorts. Cohen d was used to measure effect size. Patients who did not have Mis-Identification and Goal-Directed Expressions were more likely to successfully de-prescribe: X2 (1, N = 40) = 29.119 p < 0.0001 and X2 (1, N = 40) = 32.374, p < 0.0001, respectively. Alternatively, the same behavioral categories were more likely to be present in patients who failed de-prescribing: MANOVA and paired t-test (p < 0.0001). Atypical antipsychotics, in their role as an antipsychotic and mood stabilizer, may be used to manage Mis-Identification and Goal-Directed Expressions, respectively.

COVID-19 associated mucormycosis: A Descriptive Multisite Study from India.

BACKGROUND AND AIMS: Mucormycosis is an invasive fungal infection and carries a significant morbidity and mortality. A number of cases of mucormycosis have been reported in association with COVID-19. In this study, a consortium of clinicians from various parts of India studied clinical profile of COVID-19 associated mucormycosis (CAM) and this analysis is presented here. METHODS: Investigators from multiple sites in India were involved in this study. Clinical details included the treatment and severity of COVID-19, associated morbidities, as well as the diagnosis, treatment and prognosis of mucormycosis. These data were collected using google spreadsheet at one centre. Descriptive analysis was done. RESULTS: There were 115 patients with CAM. Importantly, all patients had received corticosteroids. Diabetes was present in 85.2% of patients and 13.9% of patients had newly detected diabetes. The most common site of involvement was rhino-orbital. Mortality occurred in 25 (21.7%) patients. On logistic regression analysis, CT scan-based score for severity of lung involvement was associated with mortality. CONCLUSION: Universal administration of corticosteroids in our patients is notable. A large majority of patients had diabetes, while mortality was seen in ∼1/5th of patients, lower as compared to recently published data.

Glycemic parameters in patients with new-onset diabetes during COVID-19 pandemic are more severe than in patients with new-onset diabetes before the pandemic: NOD COVID India Study.

BACKGROUND AND AIMS: It is not known if new onset diabetes during Coronavirus-19 disease (COVID-19; NOD COVID) is phenotypically or biochemically different than new onset diabetes before COVID-19 (NOD). METHODS: All adults diagnosed with new onset diabetes from during the time of COVID-19 were compared with new onset diabetes prior to COVID-19 from two tertiary care hospitals in Chennai and Delhi. RTPCR test for SARS-CoV-2 virus was done as appropriate, and COVID-19 antibody test was done in all other NOD COVID patients. RESULT: A total of 555 patients with new onset diabetes were included in the study (282 NOD and 273 NOD COVID patients). Patients with NOD COVID had higher fasting and post prandial blood glucose and glycated hemoglobin levels vs. NOD patients. Both the groups had high average body mass index; ∼28 kg/m2. Interestingly, fasting C-peptide levels were significantly higher in the NOD COVID group vs. NOD group. There was no difference in C-peptide levels or glycemic parameters between the COVID-19 antibody positive and negative NOD COVID cases. CONCLUSION: Individuals who were diagnosed with diabetes during COVID-19 epidemic (NOD COVID) do not significantly differ from those diagnosed before COVID-19 in symptomatology, phenotype, and C-peptide levels but they had more severe glycemia.

Discontinuation of antipsychotics treatment for elderly patients within a specialized behavioural unit: a retrospective review.

Background Best practice guidelines recommend regular evaluation of antipsychotics in managing behaviours for dementia patients with a view to de-prescribing, given its significant mortality and adverse outcomes (Reus et al. in Am J Psychiatry 173(5):543-546, 2016, Deprescribing Guidelines and Algorithms in https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ , 2019). The relationship between the dose of antipsychotic and the probability of discontinuation remains unknown in hospitalized dementia patients. Objectives This study aims to examine the relationship between high dose antipsychotic (greater than 62 mg chlorpromazine equivalent daily dose) and antipsychotics discontinuation in hospitalized dementia patients. Setting Specialized Dementia Behavioral Health Program in Hamilton, Ontario, Canada. Method A retrospective chart review was completed from August to December of 2019. A univariate logistic regression model was applied to antipsychotic doss (in chlorpromazine equivalent) and antipsychotic discontinuation outcome at 60 days (Narayan and Nishtala in Eur J Clin Pharmacol 73(12):1665-1672, 2017). A multivariant model was used to assess potential confounders, including other psychiatric medication exposure and Medicines Comorbidity Index (Luthra in J Gerontol Geriatr Res 4(260):2, 2015). Regression and dose-response models were utilized to identify the threshold dose (maximum daily dose). Main outcome measures Antipsychotic discontinuation at 60 days after the last dose. Results A total of 42 patients were eligible for outcome analysis. High dose antipsychotic was associated with worse discontinuation outcomes in both unadjusted (odds ratio, 0.09; 95% confidence interval, 0.02-0.37; p < 0.01) and adjusted generalized estimation equation models (odds ratio 0.65; 95% confidence interval, 0.59-0.72; p = 0.01). There were no statistically significant associations between baseline comorbidities (Medicines Comorbidity Index) (p = 0.68), mood stabilizer (p = 0.14), benzodiazepines (p = 0.93) and antidepressant exposure (p = 0.68) with antipsychotic discontinuation. The logistic regression model identified 40.7 mg of quetiapine, 1.7 mg of olanzapine and 0.51 mg of risperidone as the threshold dose, balancing sensitivity and specificity. The dose-response model also identified similar doses of 42 mg of quetiapine, 1.76 mg of olanzapine and 0.53 mg of risperidone. Conclusion The use of high dose antipsychotics is associated with worse discontinuation outcomes in hospitalized dementia patients. Therefore, our results suggest not exceeding a daily dose of 50 mg of quetiapine, 1.75 mg of olanzapine and 0.5 mg of risperidone when used for responsive behaviours and reassess the benefits and risks for each patient regularly.