In the elderly, Potentially Inappropriate Prescriptions (PIPs) are quite common and connected with adverse drug events (ADEs), hospital stays, increased medical acuities, and inefficacious healthcare. Benzodiazepines as a class have been identified as an independent risk factor for ADE's and shown to be associated with sedation and impairments in cognition, memory, and balance, lending to an increased risk for falls. Clinically inappropriate medications continue to be prescribed and preferred by many clinicians over non-pharmacological strategies despite continued evidence demonstrating poor outcomes in older adults. Due to the increasing evidence in positive elderly outcomes through the reduction in use of inappropriate drugs, medication reduction strategies are now required policy components in the Centers for Medicare and Medicaid Services regulations along with Medicare Part D. Quality measures now focus on extensive drug reviews with reduction strategies that incorporate use of: the Beers Criteria; multidisciplinary approaches; involving patients and caregivers; and de-prescribing strategies. Case StudyEdna Smith is a 68-year-old female who presents to clinic for poststroke rehabilitation follow-up. She initially received physiotherapy treatments including activities focused on strengthening motor skills, mobility training, constraint-induced therapy, and range of motion therapy three times weekly for 4 months. Due to improvements in physical functioning, her treatment frequency was reduced to twice weekly 12 weeks ago and once weekly 1 month ago. At her last visit, she was ambulating without assistance or noticeable deficits.At this visit, Ms. Smith and her husband report new concerns. In recent weeks Ms. Smith has experienced intermittent and increasing occurrences of disorientation, poor balance, and several falls. She reports her Primary Care Provider (PCP) initiated lorazepam therapy approximately 6 weeks ago for complaint of insomnia.
Gabapentin was first approved by the US Food and Drug Administration in 1993 as an adjunct treatment of epilepsy. In 2004, an additional indication of pain associated with post-herpetic neuralgia was added. Misuse of gabapentinoids dates back to 2010 while surging recently to the tenth most commonly prescribed medication in 2016. Abuse can be as high as 65% for even those who legally obtained the medication through a prescription. It is used off-label up to 95% of the time despite limited evidence of its efficacy particularly with multiple pain types. The surge in misuse can be attributed not only to off-label use but also an assumption of no abuse potential coupled with clinicians seeking alternative treatment options to the opioids. More common side-effects include sedation, dizziness, and cognitive difficulties. However, even normal dosing can produce side-effects similar to other addictive substances including: euphoria, talkativeness, and increased energy (opioids); sedation (opioids, benzodiazepines); and dissociation (hallucinogens). In fact, a few states including Kentucky, Ohio, and West Virginia will or have already added gabapentin to the controlled substance rosters even though no federal designation is in place. Identified risks for gabapentin misuse in the literature are limited with the exception of a history of or current substance abuse, particularly opioids. Unfortunately, gabapentin is often co-prescribed with opioids lending to a heightened risk of opioid-related mortality. Clinicians must understand that gabapentin is not effective for a variety of pain conditions nor is a routine substitute for opioids. In addition, close monitoring practices often associated with opioids and benzodiazepines (i.e., regular monitoring for aberrant drug taking behaviors, limits on supply, guarded dose titration) should be applied to that of gabapentin.
Introduction: The Centers for Disease Control and Prevention estimates that approximately 20% of the United States population lives with at least one mental health issue. The most common mental illnesses affecting older Americans include anxiety, cognitive, and mood disorders. These patients may exhibit behaviors indicating agitation or anxiety during necessary hospital stays that warrant de-escalation techniques and appropriate medications to help manage emergent symptoms. Aims: This quality improvement intervention was intended to demonstrate enhancement of the nursing assessment and reassessment of patients demonstrating symptoms of agitation and anxiety requiring intervention. Method: Assessment of the established nursing practice demonstrated compromised patient safety and led to planning and implementation of a new practice standard that incorporated an evidence-based tool. Nurses utilized a protocol that employed the Pittsburgh Agitation Scale to augment documentation of the nursing assessment for patients exhibiting symptoms of marked anxiety and agitation. Results: Following a 3-month trial, chart audits were completed to assess results of the protocol’s implementation. Significant improvement was noted in the nursing assessment process as evidenced in required documentation of nursing assessment and reassessment including use of the protocol. Conclusions: Implementing standards to guide nursing care can support both patient safety and professional practice.
Nearly four percent of the global population consumes cannabis with the highest prevalence among young people. Proponents of its use boast a myriad of benefits, including relief of pain, depression, anxiety, and insomnia. Pharmacologic research on cannabidiol (CBD) first occurred in the late 1970s, and more recently has garnered expanded focus due to mounting consumption despite a dearth of evidence in health efficacies. Tetrahydrocannabinol (THC) is deemed to be the intoxicating component of the flowering plant, lending to psychoactive outcomes, including euphoria and psychosis. Conversely, CBD is not thought to be psychotropic in nature. While there are a number of considerations regarding the utilization of CBD, emphasis is placed on the fact that medical-use indication is limited to its anti-seizure effects. In addition, high-grade evidence-based research data regarding the use of CBD for other medical diseases is deficient. Negative health consequences for consumers who may be unaware that inaccurate labeling and dose variability across the product backdrop is problematic. All things considered, counsel against the use of CBD products may be a judicious clinical approach.
Spirituality is an essential component of any healthcare assessment and plan, yet it is not clear how to best integrate spirituality in an interprofessional practice. Bronstein's Model for Interdisciplinary Collaboration served as a guide to address this problem and to design a quality improvement project for and provision of spiritual care to adolescents was facilitated in a local residential psychiatric facility. Professional staff members of the Interprofessional treatment teams (IPTT) were invited to participate in educational programming that was based on textbook reviews, interviews with a nursing curriculum designer and residential chaplain, and surveys of IPTT member baseline knowledge of the relationship between spirituality and mental health. Eighteen participants took both the pre-test and post-test survey. A two-tailed Wilcoxon signed ranks test was run on the scores of those who took both tests, revealing there was a significant difference between the scores (p = .002), indicating an increase in general knowledge regarding matters of spirituality and its relationship to mental health. Finally, a process and structural evaluation of the discussion meetings revealed content of these meetings was generally helpful and positively contributed to the knowledge and skillsets of interprofessional treatment team members in recognizing spiritual distress and meeting spiritual needs. The role of pastoral care was affirmed and even celebrated by members of the interprofessional treatment team.
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