Faculty Bibliography

BACKGROUND:A computerized physician order entry (CPOE) system provides opportunity for real-time alerts to prescribers. Winthrop University Hospital began using CPOE in 2009. OBJECTIVE:We sought to improve prescribing among older hospitalized patients by adding alerts to the CPOE system for potentially inappropriate medications. METHODS:In January 2011, informational alerts were integrated into the CPOE system for selected high-risk medications: diphenhydramine, metoclopramide, and all antipsychotics. We evaluated the effect of these alerts on prescribing frequency by comparing the number of prescriptions during the second quarters of 2010 ("pre-alert") with the second quarters of 2011 through 2013 ("post-alert"). Prescribing patterns were evaluated through a pharmacy database of medication orders. Frequency of prescribing was adjusted for total discharges. A comparison was made to ages 18-64 years, and comparing "as needed" vs standing orders. RESULTS:In the 65 years of age and older group, there were significant reductions in prescription rates pre-alert vs post-alert for diphenhydramine (p < 0.001) and metoclopramide (p < 0.001). There was no decrease in prescription rates for antipsychotics in older patients (p = 0.80). In the younger comparison group, no decreases in prescription rates for those drugs were observed. Our analysis is based on numbers of written prescriptions and not actual doses administered; therefore, no conclusions concerning the effect of these alerts on communication or documentation of risk/benefits of these medications can be ascertained. CONCLUSION/CONCLUSIONS:The data suggest that prescribing rates for drugs with the least efficacy and potential for harm and with alternative agents (i.e., diphenhydramine and metoclopramide) can be modified by CPOE alerts for older patients.

PURPOSE/OBJECTIVE:To assess the impact of the current curriculum for physician assistant (PA) students in palliative medicine and end-of-life care. METHODS:PA students were invited to participate in an anonymous online survey evaluating seven domains of knowledge in palliative medicine coupled with a self-assessment in competence. Participants were also asked to identify current and desired educational formats in palliative medicine education. There were 1,313 emailed surveys with 139 total responses. RESULTS:Our results demonstrate that a year of clinical training only resulted in minimal improvement in factual knowledge. This suggests that there is insufficient exposure to palliative medicine education during their clinical training. CONCLUSION/CONCLUSIONS:PA students recognize their knowledge gaps and lack of exposure in palliative medicine. A more focused curriculum is needed in training experiences for PA students.

OBJECTIVES/OBJECTIVE:To use a nationwide survey to assess changes in antipsychotic utilization patterns and usage policies in nursing homes (NHs) in the United States since the introduction of the black box warning by the FDA. DESIGN/SETTING/PARTICIPANTS/METHODS:A survey was distributed online and was completed by 250 directors of nursing of NH. The directors of nursing answered questions concerning policies about and use of antipsychotic medications. MEASUREMENTS/RESULTS/RESULTS:The most commonly reported intervention to manage symptoms in residents with dementia since the black box warning was to lower doses of antipsychotics. Over half of facilities report obtaining more frequent psychiatry/psychology consults. One-hundred seven facilities have a policy regarding informing family members of residents about the black box warning. Most facilities (63.6%) with a policy require family to sign consent. In the NH setting, the presence or absence of a policy did not correlate with the reported change in use of antipsychotics or types of alternative interventions. CONCLUSION/CONCLUSIONS:Notably, a large number of NH facilities have policies regarding informed consent on the use of antipsychotics. However, in our study, the rate of use of antipsychotics did not change in many facilities since the black box warning. In addition, having a policy did not correlate with decreased antipsychotic use or with use of alternate agents or nonpharmacologic methods to address symptoms. The results of this survey suggest that NH administrators should worry less about the legal exposure of using antipsychotics and focus on actions that result in improved patient care.

The purpose of this study is to determine the prevalence of tobacco use in patients diagnosed with dementia or cognitive impairment in an outpatient setting as they may be unsafe smokers and present safety risks to themselves and others. We conducted a retrospective chart review of new patients between 1/06 and 8/07 who were diagnosed with dementia or cognitive impairment in a geriatric outpatient practice. The data collected included age, gender, tobacco use patterns and mini-mental state examination (MMSE) score. Data was analyzed using SAS 9.1 for Windows (SAS Institute, Cary, NC). Former tobacco use rates in our study were similar to nationwide published rates for elderly over 65 (39.9% vs. 39.5%, respectively, p=0.99). However, only two patients in our study (1.32%, 95%CI=0.16-4.70) were current tobacco users compared with published census data that 10.2% of those over 65 are current smokers nationwide (p<0.001). Our study revealed a much lower rate of current tobacco use in our series of cognitively impaired patients. Further research is needed to explore the reasons for decreased smoking in those with cognitive impairment and its clinical implications.

PURPOSE/OBJECTIVE:The Accreditation Council for Graduate Medical Education requires that internal medicine (IM) core curricula include end-of-life care and pain management concepts and that fellows in hematology/oncology, pulmonary/critical care, and geriatrics should receive formal instruction and clinical experience in palliative and end-of-life care. We aimed to assess the effectiveness of current teaching methods for housestaff in these fields. METHOD/METHODS:All of the IM residents, geriatric medicine fellows, hematology/oncology fellows, and pulmonary/critical care fellows from four regional graduate medical education sites were asked to participate in an online survey at the beginning and end of the 2008-2009 academic year. We evaluated seven domains of knowledge of palliative care and pain management with a self-assessment of competence in these areas. We also asked participants to describe their current curriculum and training in palliative medicine. RESULTS:There were 326 e-mailed survey invitations. There were 180 responses for the start-year survey and 102 responses for the end-year survey. All sites were represented in the responses. The only learners to significantly improve their palliative knowledge during a year of training were PGY-1s and PGY-4s. The majority of housestaff surveyed report that their current palliative medicine training is inadequate. The vast majority (84.6%) said a dedicated palliative medicine rotation would be "useful" or "very useful." CONCLUSIONS:Housestaff recognize their lack of experience and training in palliative medicine and are interested in many teaching venues to improve their skills. A more focused curriculum in palliative and end-of-life care is required at both resident and subspecialty fellowship levels.

The palliative medicine literature consistently documents that physicians are poorly prepared to help patients experience a "good death" and are often unaware of their ill patients' preferences for end-of-life care. The present study, enrolling 150 physicians, sought to improve their communication skills for end-of-life care. We found significant attitudinal changes and a greater degree of self-rated competence in delivering end-of-life care for those in the intervention group. This study used a novel approach to train physicians to be better equipped to conduct difficult goals of care conversations with patients and their families at end-of-life.

Delusions, hallucinations and other psychotic symptoms can accompany a number of conditions in late life. As such, elderly patients are commonly prescribed antipsychotic medications for the treatment of psychosis in both acute and chronic conditions. Those conditions include schizophrenia, bipolar disorder, depression and dementia. Elderly patients are at an increased risk of adverse events from antipsychotic medications because of age-related pharmacodynamic and pharmacokinetic changes as well as polypharmacy. Drug selection should be individualized to the patient's previous history of antipsychotic use, current medical conditions, potential drug interactions, and potential side effects of the antipsychotic. Specifically, metabolic side effects should be closely monitored in this population. This paper provides a review of aripiprazole, a newer second generation antipsychotic agent, for its use in a variety of psychiatric disorders in the elderly including schizophrenia, bipolar disorder, dementia, Parkinson's disease and depression. We will review the pharmacokinetics and pharmacodynamics of aripiprazole as well as dosing, diagnostic indications, efficacy studies, and tolerability including its metabolic profile. We will also detail patient focused perspectives including quality of life, patient satisfaction and adherence.