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An audit of lithium prescribing practices in an old age psychiatry service highlighting renal impairment in this cohort
- Leia Valentine, John Cannon, Siobhan Marmion, Michelle Corcoran, Marguerite Cryan, Geraldine McCarthy, Catherine Dolan
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S109-S110
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Aims
To compare Lithium prescribing practices in a Psychiatry of Old Age (POA) Service in the North-West of Ireland among adults aged 65 years and over with best practice guidelines.
MethodReview of the literature informed development of audit standards for Lithium prescribing. These included National Institute for Clinical Excellent (NICE) 2014 guidelines, The British National Formulary (2019) and Maudsley Prescribing Guidelines (2018). Data were collected retrospectively, using an audit-specific data collection tool, from clinical files of POA team caseload, aged 65 years or more and prescribed Lithium over the past one year.
ResultAt the time of the audit in February 2020, 18 patients were prescribed lithium, 67% female, average age 74.6 years. Of those prescribed Lithium; 50% (n = 9) had a depression diagnosis, 44% (n = 8) had bipolar affective disorder (BPAD) and 6% (n = 1) had schizoaffective disorder.
78% (n = 14) of patients were on track to meet, or had already met, the NICE standard of 3-monthly serum lithium level. Lithium levels were checked on average 4.5 times in past one year, average lithium level was 0.61mmol/L across the group and 39% (n = 7) had lithium level within recommended therapeutic range (0.6-0.8mmol/L).
83% (n = 15) of patients met the NICE standards of 3 monthly renal tests, thyroid function test was performed in 89% (n = 16) and at least one serum calcium level was documented in 63% (n = 15). Taking into consideration most recent blood test results, 100% (n = 18) had abnormal renal function, 78% (n = 7) had abnormal thyroid function and 60% (n = 9) had abnormal serum calcium.
Half (n = 9) were initiated on lithium by POA service and of these, 56% (n = 5) had documented renal impairment prior to initiation. Of patients on long term lithium therapy at time of referral (n = 9), almost half (n = 4) had a documented history of lithium toxicity.
ConclusionThe results of this audit highlight room for improvement in lithium monitoring of older adults attending POA service. Furthermore, all patients prescribed lithium had impaired renal function, half had abnormal calcium and two fifths had abnormal thyroid function. This is an important finding given the associations between those admitted to hospital with COVID-19 and comorbid kidney disease and increased risk of inpatient death.
Our findings highlight the need for three monthly renal function monitoring in older adults prescribed lithium given the additive adverse effects of increasing age and lithium on the kidney. Close working with specialised renal services to provide timely advice on renal management for those with renal impairment prescribed lithium is important to minimise adverse patient outcomes.
Measuring access to primary healthcare services after stroke: A spatial analytic approach
- Emma Finch, Yan Liu, Michele Foster, Tegan Cruwys, Jennifer Fleming, Linda Worrall, Ian Williams, Darshan Shah, Philip Aitken, Jonathan Corcoran
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- Journal:
- Brain Impairment / Volume 20 / Issue 3 / December 2019
- Published online by Cambridge University Press:
- 28 May 2019, pp. 240-250
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Objective:
To determine accessibility of the primary healthcare system for patients with stroke recently discharged from hospital.
Methods:This project mapped retrospective patient location data and the location of primary healthcare services in the same region. Patient location data were from all patients with stroke (N = 1595: January 2011–January 2017) discharged from one metropolitan hospital to the local Primary Health Network. Geographic Information System technology was used to map the patient discharge locations and the spatial distribution of primary healthcare services (general practitioner, pharmacy, allied health) across the region. Road network data were used to measure the level of access from each patient’s discharge location to the services.
Results:Access to primary healthcare services was variable. Areas with larger proportions of patients with stroke did not necessarily have good service access. With an increase in travel time, the number of services accessible to patients also increased. However, the spatial variation of access to services remained largely unchanged.
Conclusion:Access to primary healthcare services for patients with stroke varies spatially, with a trend towards relatively low levels of accessibility for many patients. There is an urgent need for future planning to consider geographical access to primary healthcare services for patients with stroke.
Effects of general medical health on Alzheimer's progression: the Cache County Dementia Progression Study
- Jeannie-Marie S. Leoutsakos, Dingfen Han, Michelle M. Mielke, Sarah N. Forrester, JoAnn T. Tschanz, Chris D. Corcoran, Robert C. Green, Maria C. Norton, Kathleen A. Welsh-Bohmer, Constantine G. Lyketsos
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- Journal:
- International Psychogeriatrics / Volume 24 / Issue 10 / October 2012
- Published online by Cambridge University Press:
- 12 June 2012, pp. 1561-1570
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Background: Several observational studies have suggested a link between health status and rate of decline among individuals with Alzheimer's disease (AD). We sought to quantify the relationship in a population-based study of incident AD, and to compare global comorbidity ratings to counts of comorbid conditions and medications as predictors of AD progression.
Methods: This was a case-only cohort study arising from a population-based longitudinal study of memory and aging, in Cache County, Utah. Participants comprised 335 individuals with incident AD followed for up to 11 years. Patient descriptors included sex, age, education, dementia duration at baseline, and APOE genotype. Measures of health status made at each visit included the General Medical Health Rating (GMHR), number of comorbid medical conditions, and number of non-psychiatric medications. Dementia outcomes included the Mini-Mental State Examination (MMSE), Clinical Dementia Rating – sum of boxes (CDR-sb), and the Neuropsychiatric Inventory (NPI).
Results: Health status tended to fluctuate over time within individuals. None of the baseline medical variables (GMHR, comorbidities, and non-psychiatric medications) was associated with differences in rates of decline in longitudinal linear mixed effects models. Over time, low GMHR ratings, but not comorbidities or medications, were associated with poorer outcomes (MMSE: β = –1.07 p = 0.01; CDR-sb: β = 1.79 p < 0.001; NPI: β = 4.57 p = 0.01).
Conclusions: Given that time-varying GMHR, but not baseline GMHR, was associated with the outcomes, it seems likely that there is a dynamic relationship between medical and cognitive health. GMHR is a more sensitive measure of health than simple counts of comorbidities or medications. Since health status is a potentially modifiable risk factor, further study is warranted.
Benzodiazepine and Z-drug Prescribing for Elderly People in a General Hospital: A Complete Audit Cycle
- Catherine Dolan, Sami Omer, Deirdre Glynn, Michelle Corcoran, Geraldine McCarthy
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- Journal:
- Irish Journal of Psychological Medicine / Volume 29 / Issue 2 / 2012
- Published online by Cambridge University Press:
- 13 June 2014, pp. 128-131
- Print publication:
- 2012
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Background: Use of benzodiazepines and Z-drugs in the elderly is associated with adverse outcomes such as increased risk of falls and fractures and cognitive impairment. We aimed to assess the prescribing practice of benzodiazepine and Z-drugs in those aged over 65 years in a general hospital against evidence based standards and to examine the effects of multidisciplinary feedback, as well as determine the prevalence of usage.
Methods: All case-notes and medication charts of patients over the age of sixty five on surgical and medical wards in Sligo General Hospital (SGH) were retrieved and analysed over a two-day period in 2008. Data was collected in relation to benzodiazepine and Z-drug prescribing. We followed up on this initial data collection by screening discharge summaries at six weeks to assess benzodiazepine and Z-drug prescribing on discharge. Audit results were disseminated together with consensus guidelines on the prescribing of these medications in older adult population to all general practitioners in County Sligo. Educational sessions were held for both doctors and nurses in SGH. The audit cycle was completed by a re-audit of benzodiazepine and Z-drug prescribing six months from original study using identical methods.
Results: We found a high prevalence of benzodiazepine and Z-drug use in original audit, 54% (38/70) of the group audited. The prevalence fell to 46% (32/70) at the re-audit post intervention. This result was not statistically significant. The percentage of patients commenced on benzodiazepine and Z-drugs prior to admission fell from 36% (25/70) at the initial audit to 23% (16/70) at the re-audit.
Conclusion: Prescribing practices were not in keeping with consensus guidelines as highlighted by this relatively basic audit cycle. Multidisciplinary feedback and letters to GPs resulted in some reduction in the number of patients prescribed benzodiazepines and Z-drugs. Ongoing educational strategies aimed at relevant health care workers with regular audit of medication use within the general hospital setting is pertinent to further improve prescribing practice.
Problem-solving ability and repetition of deliberate self-harm: a multicentre study
- CARMEL McAULIFFE, PAUL CORCORAN, HELEN S. KEELEY, ELLA ARENSMAN, UNNI BILLE-BRAHE, DIEGO De LEO, SANDOR FEKETE, KEITH HAWTON, HEIDI HJELMELAND, MARGARET KELLEHER, AD J.F.M. KERKHOF, JOUKO LÖNNQVIST, KONRAD MICHEL, ELLINOR SALANDER-RENBERG, ARMIN SCHMIDTKE, KEES VAN HEERINGEN, DANUTA WASSERMAN
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- Journal:
- Psychological Medicine / Volume 36 / Issue 1 / January 2006
- Published online by Cambridge University Press:
- 29 September 2005, pp. 45-55
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Background. While recent studies have found problem-solving impairments in individuals who engage in deliberate self-harm (DSH), few studies have examined repeaters and non-repeaters separately. The aim of the present study was to investigate whether specific types of problem-solving are associated with repeated DSH.
Method. As part of the WHO/EURO Multicentre Study on Suicidal Behaviour, 836 medically treated DSH patients (59% repeaters) from 12 European regions were interviewed using the European Parasuicide Study Interview Schedule (EPSIS II) approximately 1 year after their index episode. The Utrecht Coping List (UCL) assessed habitual responses to problems.
Results. Factor analysis identified five dimensions – Active Handling, Passive-Avoidance, Problem Sharing, Palliative Reactions and Negative Expression. Passive-Avoidance – characterized by a pre-occupation with problems, feeling unable to do anything, worrying about the past and taking a gloomy view of the situation, a greater likelihood of giving in so as to avoid difficult situations, the tendency to resign oneself to the situation, and to try to avoid problems – was the problem-solving dimension most strongly associated with repetition, although this association was attenuated by self-esteem.
Conclusions. The outcomes of the study indicate that treatments for DSH patients with repeated episodes should include problem-solving interventions. The observed passivity and avoidance of problems (coupled with low self-esteem) associated with repetition suggests that intensive therapeutic input and follow-up are required for those with repeated DSH.