Reducing opioid use for chronic pain in older adults.

PURPOSE: Implementation of the SAFE PAIN algorithm for reducing opioid use for chronic pain in older adults is described. SUMMARY: A multidisciplinary team at Sheppard Pratt Health System, the largest private provider of psychiatric care in Maryland, used lean methodology to identify the root causes for noncompliance to evidence-based practices for patients in the geropsychiatry unit treated for osteoarthritis or chronic back pain. The team collaborated to develop a facility-specific treatment algorithm, called SAFE PAIN (Sheppard Pratt Health System Algorithm For Elderly Patient Centered Analgesia Interdisciplinary Nagara), was based on the Center for Disease Control and Prevention's evidence-based recommendations that included nonpharmacologic interventions as a first-line therapy for patients with osteoarthritis or chronic back pain. Rates of prescribing new opioids and prescribing evidence-based alternative medications via the SAFE PAIN algorithm were evaluated from March 1 to September 30, 2017 and compared with baseline (2012-2016). The lean methodology interventions led to zero new opioid orders during the study period, a significant decrease compared with previous years (p < 0.01). The rates of prescribing evidence-based alternative medications increased significantly from the baseline period to postimplementation (p < 0.01). Lean methodology interventions also decreased waste in several processes. CONCLUSION: The prescribing rate of new opioids for osteoarthritis and chronic back pain decreased and the prescribing rate for evidence-based medications increased after implementation of the SAFE PAIN algorithm in a geropsychiatry unit.

Lean Methodology Reduces Inappropriate Use of Antipsychotics for Agitation at a Psychiatric Hospital.

OBJECTIVE: To Evaluate the Effects of Applying Lean Methodology-Improving Quality Increasing Efficiency by Eliminating Waste and Reducing Costs-An Approach To Decrease the Prescribing Frequency of Antipsychotics for The Indication of Agitation. DESIGN: Historically Controlled Study. SETTING: Bheppard Pratt Health System is the Largest Private Provider of Psychiatric Care in Maryland With a Total Bed Capacity of 300. There Were 4 337 Patient Days From November 1 2012 to October 31 2013 on the Dementia Unit. PATIENTS: All Patients Admitted on the Dementia Unit Were 65 Years of Age and Older with a Primary Diagnosis of Dementia. INTERVENTION: our Multidisciplinary Team Used Lean Methodology to Identify the Root Causes and Interventions Necessary to Reduce Inappropriate Antipsychotic Use. MAIN OUTCOME MEASURES: The Primary Outcome Was Rate of Inappropriately Indicating Agitation as the Rationale When Prescribing Antipsychotic Medications. RESULTS: There Was a 90% (P < 0.001) Reduction in Rate Of Antipsychotic Prescribing with an Indication of Agitation. CONCLUSION: The Lean Methodology Interventions Led To A 90% (P < 0.001) Reduction in the Rate of Antipsychotic Prescribing with an Indication of Agitation and a 10% Rate Reduction in Overall Antipsychotic Prescribing. Key Words: Agitation Alzheimer's Antipsychotics Behavioral and Psychological Symptoms of Dementia Centers For Medicare & Medicaid Services Dementia Root-cause Analysis. ABBREVIATIONS: BPSD = Behavioral and Psychological Symptoms of Dementia CATIE-AD = Clinical Antipsychotic Trials of Intervention Effectiveness in Alzheimer's Disease EMR = Electronic Medical Records GAO = Government Accountability Office GNCIS = Geriatric Neuropsychiatric Clinical Indicator Scale.

ECT in the treatment of a patient with catatonia: consent and complications.

Acute catatonia in an adolescent or young adult can present complex clinical challenges. Prominent issues include those involving diagnosis, timely and effective treatment, and diminished capacity to provide consent. The authors describe a 19-year-old woman presenting initially with manic excitement followed by a lengthy period of mutism, immobility, and food and fluid refusal. Elevated temperature, an elevated creatine phosphokinase level, and autonomic dysfunction led to consideration of a malignant catatonic syndrome. The patient manifested rigidity accompanied by posturing and waxy flexibility. Neurologic, medical, and laboratory evaluations failed to identify an organic cause for the likely catatonia. Treatment with amantadine, bromocriptine, and lorazepam was unsuccessful. ECT was deemed appropriate but required emergency guardianship because of the patient's inability to provide consent. At the initial ECT session, the elicited seizure was followed by an episode of torsade de pointes requiring immediate cardioversion. In reviewing the ECT complication, it appeared that muscle damage due to catatonic immobility led to acute hyperkalemia with the administration of succinylcholine. Discussions were held with the patient's guardian outlining the clinical issues and the risks of additional ECT. The patient responded to eight subsequent ECT sessions administered with rocuronium, a nondepolarizing muscle relaxant. The authors provide a brief review of the diagnosis and treatment of catatonia and address issues surrounding ECT, cardiac effects, use of muscle relaxants, and the consent process.

Electroconvulsive therapy in the setting of implantable cardioverter-defibrillators.

Electroconvulsive therapy has potent cardiovascular effects, which may pose a challenge in treating patients with preexisting cardiac disease. Although it is well studied in the treatment of refractory depression, there are still pitfalls to overcome when treating those with comorbid cardiovascular disease. The synergistic effects of depression and cardiovascular disease in affecting the morbidity and mortality of patients make treatment a significant issue. The authors discuss 3 elderly patients treated for major depression, all of whom previously had implantable cardioverter-defibrillators placed. All 3 patients were effectively treated, with no major adverse effects. The cases illustrate how taking the appropriate preventative measures allow even the most medically challenging patient to undergo effective treatment and highlight the debate surrounding the intraoperative management of implantable cardioverter-defibrillator devices.

Long-term weekly continuation electroconvulsive therapy: a case series.

Despite best efforts with continuation pharmacotherapy, many patients relapse after a successful course of electroconvulsive therapy (ECT). Although maintenance ECT can be a useful and cost-effective treatment modality, there is considerable heterogeneity on how it is used. The authors report a case series of 3 patients ages 68, 43, and 81 years with diagnosis of schizoaffective disorder, bipolar disorder, and major depression with psychotic features who required weekly ECT treatments for several years. All attempts to space treatments led to rapid decompensation. None of the patients experienced clinical evidence of any treatment related cognitive or physical morbidity.

Treatment of psychiatric symptoms associated with neurosyphilis.

There is currently no consensus on how to manage the psychiatric manifestations of neurosyphilis, despite the resurgence of this condition. The authors present five cases of neurosyphilis in inpatient psychiatric settings that manifested with predominantly psychiatric symptoms and were appropriately diagnosed and successfully treated with psychotropic medication concurrent with antibiotic therapy. A review of available data reveals that presently there are no specific guidelines to address psychiatric symptomatology in neurosyphilis. The authors see merit in the prudent use of psychotropic medication to achieve symptom stabilization.

Racial and socioeconomic differences in psychiatric symptoms in nursing home residents: a minimum data set-based pilot study.

BACKGROUND: Little research has explored racial and socioeconomic differences in the presence, detection, and treatment of neuropsychiatric symptoms in nursing home residents. OBJECTIVE: To evaluate racial and socioeconomic differences on mood and behavior Minimum Data Set (MDS) recorded symptoms, MDS recorded psychiatric diagnoses, and MDS identified psychotropic medication use. METHODS: Data were obtained through a cross-sectional review of MDS data of 290 African-American and white residents of 2 nursing homes. The association between age, gender, race, and pay status with mood and behavior patterns, psychiatric diagnoses, and use of psychotropic medication was evaluated. RESULTS: White residents were more likely than African American residents to have MDS recorded psychiatric diagnoses (odds ratio, OR = 3.24), but there were no significant racial differences in recorded mood or behavior symptomatology or in the pharmacologic treatment of mental illness. Medicaid recipients were more likely than nonrecipients to have behavior symptoms (OR = 2.09), have a psychiatric diagnosis (OR = 2.91), and receive psychotropic medications in the absence of a psychiatric diagnosis (OR = 3.62). CONCLUSION: Pay status was associated with recorded symptoms, diagnoses, and medications, but racial differences were found only for recorded diagnoses.

Challenging the quality of the quality indicator, "depression without treatment".

OBJECTIVE: To assess the validity of the Minimum Data Set (MDS)-based quality indicator, "depression without treatment," and examine whether a nonphysician-based educational intervention can improve the accuracy of MDS questions regarding depression and its treatment. SUBJECTS: All residents of a 538-bed urban, university affiliated, long-term-care (LTC) facility. Nursing and social work staff involved in completing the mood and behavior items on the MDS. DESIGN: Two retrospective chart review of psychotropic medications, psychiatric diagnoses, mental health evaluation, and treatment of all residents who were identified as displaying the MDS quality indicator, depression without treatment, before and 2 months after an educational intervention. The education consisted of three 1 1/2-hour sessions led by a psychiatric clinical nurse specialist to educate registered nurse assessment coordinators and social workers about psychotropic medications, clinical characteristics of psychiatric diagnoses, chart review, and coordination of resident medical care. RESULTS: The first MDS identified 66 residents as having depression without treatment. Clinical record review revealed that 11 of these residents were receiving an antidepressant. Twenty-two others were receiving a psychotropic medication consistent with their psychiatric diagnosis. Twenty-five of the remaining residents had not received mental health assessment for greater than 1 year. Two months after the educational intervention, 36 residents were identified as depression without treatment. Four of these residents were receiving an antidepressant; eight others were receiving a psychotropic medication consistent with their psychiatric diagnosis. Thirteen of the remaining residents had not received mental health assessment for greater than 1 year. CONCLUSIONS: This preliminary study reveals that the presence of the quality indicator, depression without treatment, may not accurately capture clinically depressed LTC residents in need of mental health intervention. An educational intervention may be able to assist staff in more accurately completing MDS questions regarding depression and its treatment.