Assessing agitation, preventing escalation

LEVEL OF CARE DEPENDENCY AND FUNCTIONAL STATUS AMONG PATIENTS WITH ALZHEIMER'S DISEASE AND AGITATION/AGGRESSION SYMPTOMS

SEVERITY OF AGITATION IN ALZHEIMER'S DISEASE: PROPORTION OF INDIVIDUALS TRANSITIONING TO LONG-TERM RESIDENTIAL CARE USING US NATIONAL ALZHEIMER'S COORDINATING CENTER DATA

COVID-19 has been a major challenge for the healthcare sector, but also an opportunity for innovation and learning. The training and education of healthcare professionals during viral epidemics are crucial to ensure their safety, competence, and confidence. These innovations have the potential to improve the quality and efficiency of healthcare delivery, not only during the pandemic but also beyond. Published data on the training of healthcare professionals were obtained and reviewed to produce this article. The review analyses the various innovation that was adopted in the training of healthcare professionals during the COVID-19 pandemic. The COVID-19 pandemic has globally amplified the utilization of information technology in education. The limited physical access to classrooms and healthcare facilities triggered an immediate surge in the adoption of digital platforms to cater to the educational requirements of students across all healthcare disciplines. During the COVID-19 pandemic, healthcare professionals witnessed several significant changes in their training. In conclusion, the COVID-19 pandemic has acted as a powerful catalyst for innovation in the training of healthcare professionals. Here are the key takeaways: adaptive solutions, remote monitoring, embracing innovation, collaboration and research and resilience and adaptability. As we move forward, these innovations will continue to shape healthcare education, ensuring that professionals are well-prepared to face future challenges.

Agitation-Sedation (A-S) cycling in critically ill intensive care unit (ICU) patients is damaging to health. Sedation quality is assessed by nurses and may suffer from subjectivity in their judgement and lead to sub-optimal sedation. Therefore, the use of quantitative modelling to enhance understanding of the A-S system is a key tool for optimising sedation management. Inadequate assessment of the agitation associated with clinical outcomes may lead to under or over-sedation and harm a patient's wellbeing. Empirical distributions of the nurses ratings of a patients pain and/or agitation levels and the administered dose of sedative are often positively skewed and if the joint distribution is non-elliptical, then the high nurses ratings of a patients agitation levels may not correspond to the occurrences of patients A-S profile with large infusion dose. Copulas measure nonlinear dependencies capturing the dependence between skewed distributions. Therefore, the aim is to use a copula-based dependence measure between the nurses rating of patients agitation level, and the automated sedation dose to identify patient-specific thresholds that separate the regions of mild, moderate, and severe agitation intensities. Delineating the occurrences with different agitation intensities allows us to establish the regions where nurses rating has stronger or weaker correlation with the automated sedation dose. This pilot study modelled agitation-sedation profiles of two patients collected at Christchurch Hospital, Christchurch School of Medicine and Health Sciences, NZ, from the pool of 37 patients. Classification of patients into poor and good trackers based on Wavelet Probability Bands (WPB). One of the patients is a poor tracker and the other patient is a good tracker. The best-fitting c opula s hows t hat t he dependency structure between the nurses rating of a patients agitation level and the administered dose of sedative for both patients has an upper and lower tail. Mo

Psychomotor agitation in subjects hospitalized for an acute exacerbation of Schizophrenia

Pharmacological treatments for agitation and aggression in patients with Alzheimer's disease have shown limited efficacy. The authors assessed the heterogeneity of response to citalopram in the Citalopram for Agitation in Alzheimer Disease (CitAD) study to identify individuals who may be helped or harmed. In this double-blind parallel-group multicenter trial of 186 patients with Alzheimer's disease and clinically significant agitation, participants were randomly assigned to receive citalopram or placebo for 9 weeks, with the dosage titrated to 30 mg/day over the first 3 weeks. Five planned potential predictors of treatment outcome were assessed, along with six additional predictors. The authors then used a two-stage multivariate method to select the most likely predictors; grouped participants into 10 subgroups by their index scores; and estimated the citalopram treatment effect for each. Five covariates were likely predictors, and treatment effect was heterogeneous across the subgroups. Patients for whom citalopram was more effective were more likely to be outpatients, have the least cognitive impairment, have moderate agitation, and be within the middle age range (76-82 years). Patients for whom placebo was more effective were more likely to be in long-term care, have more severe cognitive impairment, have more severe agitation, and be treated with lorazepam. Considering several covariates together allowed the identification of responders. Those with moderate agitation and with lower levels of cognitive impairment were more likely to benefit from citalopram, and those with more severe agitation and greater cognitive impairment were at greater risk for adverse responses. Considering the dosages used and the association of citalopram with cardiac QT prolongation, use of this agent to treat agitation may be limited to a subgroup of people with dementia.

BackgroundPrimary healthcare in many Western countries faces increased patient care needs due to shorter hospital stays and an ageing population suffering from complex conditions. A shortage of qualified professionals jeopardises the quality of care in primary healthcare settings. Literature indicates that the quality of care and the occurrence of adverse events are linked to the observational competencies of healthcare professionals. In Norway, patient safety competence programmes, such as ClinObsMunicipality, have been developed to improve healthcare professionals’ observational competencies in recognising and responding to clinical deterioration, thereby ensuring safety in primary healthcare. In this study, we aimed to explore and describe how healthcare professionals experienced and perceived learning and training in this competence-building programme. Specifically, we focused on their reflections on its applicability in clinical practice.DesignAqualitative study was conducted. In preparing the manuscript, we applied the checklist guidelines for the Consolidated Criteria for Reporting Qualitative Research.MethodThe study is based on 17 individual interviews with healthcare professionals from different primary healthcare settings. Data were analysed using Malteruds’ systematic text condensation, a thematic cross-case analysis.ResultsWe identified three categories illustrating how healthcare professionals experienced learning and training in the competence-building programme and its applicability for clinical practice: (1) Shared base of competence through practice-based group-learning with colleagues; (2) Enhanced clinical communication: The impact and applicability of standardised language; (3) From Colleagues to team: Increased autonomy and collaboration.ConclusionThis study highlights that healthcare professionals experienced learning and training in the competence programme as applicable to their clinical practice. Group-learning activities fostered a supportive environment where participants could engage with cases and scoring tools relevant to their clinical settings. This approach enhanced their observational competencies, deepened their understanding of team roles and strengthened interprofessional communication and collaboration, which may positively impact patient care and safety in primary healthcare settings. While the programme empowered healthcare professionals through increased autonomy, it also uncovered hesitance in critical situations among some participants, suggesting complex awareness and the urgency of timely interventions.

While the Western diet has evolved to become increasingly high in saturated fat, cholesterol, protein, sugar, and salt intake, nutrition education and training of health care professionals to counsel their patients on the hazards of such a diet has trailed behind. Primary care physicians have an opportunity to bridge the gap by providing nutrition and dietary counseling as key components in the delivery of preventive services. Increasing research points to the value of a whole-foods plant-based diet in combating chronic disease, yet the knowledge of health professionals about the topic is comparable to that of the general public. This education crisis is apparent in medical training with restricted time for dedicated lectures on nutrition, physical activity, restorative sleep, emotional well-being, and avoidance of risky substance use. Together, educators and learners are valuable catalysts for culture change in medical education, training, and clinical practice. Barriers to physician ability to counsel about lifestyle are many, but one that stands out is lack of training and comfort with counseling. This has implications for the training of health care professionals. American College of Lifestyle Medicine has a committee, Professionals in Training, composed of interprofessional and multidisciplinary students, residents, and fellows nationally and worldwide who are committed to expanding exposure to lifestyle medicine and implementation of lifestyle medicine in parallel curriculum and personal care.

Patient Safety: Grantmakers Join The Effort To Reduce Medical Errors

SummaryTreatment of psychotic agitation is an area that is very poorly evidenced, principally because research evidence from patients with moderate agitation may not generalise to the more severely agitated patients. There is a significant gap between current treatment recommendations and what is seen in clinical practice. There are also big differences in clinical practice between different units treating seemingly similar patient groups. This commentary considers possible reasons for these findings and also discusses non-pharmacological interventions, which probably contribute more to the management of psychotic agitation than does the choice of one antipsychotic drug over another.

Core competencies in osteopathy: Italian register of osteopaths proposal

ObjectiveThis study aimed to explore patients' experiences of their involvement in the design and delivery of interprofessional education interventions focussing on mental ill‐health for students studying in undergraduate healthcare and healthcare‐related programmes.DesignA qualitative methodology using a Grounded Theory approach was used to undertake an iterative series of focus groups with members of a university's Patient, Carer and Public Involvement (PCPI) Group who have a history of mental ill‐health and were involved in the development and delivery of educational interventions for students on undergraduate healthcare and healthcare‐related programmes. Their experiences of being involved in teaching and learning activities, collaboration with academic staff and integration into the academic faculty were explored. Constant comparative analysis facilitated the identification and prioritisation of salient themes.ResultsFive salient inter‐related themes emerged from the data: (1) reduced stigma and normalisation of experience of illness; (2) enhanced self‐worth; (3) improved well‐being; (4) community and connection; and (5) enduring benefits.ConclusionsA supportive university community and a designated academic PCPI co‐ordinator facilitate a supportive environment for patients and carers to develop as educators, contribute to the training of future healthcare professionals and improve their own personal well‐being. Appropriately resourced and well‐supported initiatives to integrate patients, carers and the public into the functions of an academic faculty can result in tangible benefits to individuals and facilitate meaningful and enduring connections between the university and the wider community within which it is situated.Patient and Public InvolvementPatients have been involved in the design of the teaching and learning initiatives that this study was primarily focused on. Patients were given autonomy in determining how their experiences should be incorporated into teaching and learning experiences.

Objective: Studies suggest that healthcare professionals often feel unprepared to deal with mental health issues in refugees and asylum seekers. The aim of this qualitative study was to examine the experiences of refugees and asylum seekers in relation to mental health and healthcare, to inform cultural competency training for undergraduate medical students. Method: Focus groups were conducted with 16 refugees and asylum seekers and staff from relevant charity organisations in Wales. We explored participants’ experiences in relation to mental health and healthcare, and training for healthcare professionals. The data were thematically analysed using an inductive approach. Results: Three overarching themes were identified: (1) recognition of the specific mental health needs of refugees and asylum seekers, (2) barriers preventing effective mental healthcare delivery for refugees and asylum seekers and (3) authentic learning experiences for medical students. Conclusion: To our knowledge, this is the first study to actively involve refugees and asylum seekers, along with individuals who work closely with this population, in considering the development of cultural competency training for healthcare students and professionals in relation to mental health. If we are to reduce the risks of exclusion from healthcare for refugees and asylum seekers, training in this area is essential. Findings from this study have informed the development of a guide for healthcare educators with a focus on refugee and asylum seeker mental health.

Sedation or anesthesia is used to facilitate many cases of an estimated 45 million diagnostic and therapeutic medical procedures in the United States. Preclinical studies have called attention to the possibility that sedative-hypnotic drugs can increase pain perception, but whether this observation holds true in humans and whether pain-modulating effects are agent-specific or characteristic of IV sedation in general remain unclear. To study this important clinical question, the authors recruited 86 healthy volunteers and randomly assigned them to receive one of three sedative drugs: midazolam, propofol, or dexmedetomidine. The authors asked participants to rate their pain in response to four experimental pain tasks (i.e., cold, heat, ischemic, or electrical pain) before and during moderate sedation. Midazolam increased cold, heat, and electrical pain perception significantly (10-point pain rating scale change, 0.82 ± 0.29, mean ± SEM). Propofol reduced ischemic pain and dexmedetomidine reduced both cold and ischemic pain significantly (-1.58 ± 0.28, mean ± SEM). The authors observed a gender-by-race interaction for dexmedetomidine. In addition to these drug-specific effects, the authors observed gender effects on pain perception; female subjects rated identical experimental pain stimuli higher than male subjects. The authors also noted race-drug interaction effects for dexmedetomidine, with higher doses of drug needed to sedate Caucasians compared with African Americans. The results of the authors' study call attention to the fact that IV sedatives may increase pain perception. The effect of sedation on pain perception is agent- and pain type-specific. Knowledge of these effects provides a rational basis for analgesia and sedation to facilitate medical procedures.

Self-emulsification is considered a formulation technique that has proven capacity to improve oral drug delivery of poorly soluble drugs by advancing both solubility and bioavailability. The capacity of these formulations to produce emulsions after moderate agitation and dilution by means of water phase addition provides a simplified method to improve delivery of lipophilic drugs, where prolonged drug dissolution in the aqueous environment of the gastro-intestinal (GI) tract is known as the rate-limiting step rendering decreased drug absorption. Additionally, spontaneous emulsification has been reported as an innovative topical drug delivery system that enables successful crossing of mucus membranes as well as skin. The ease of formulation generated by the spontaneous emulsification technique itself is intriguing due to the simplified production procedure and unlimited upscaling possibilities. However, spontaneous emulsification depends solely on selecting excipients that complement each other in order to create a vehicle aimed at optimizing drug delivery. If excipients are not compatible or unable to spontaneously transpire into emulsions once exposed to mild agitation, no self-emulsification will be achieved. Therefore, the generalized view of excipients as inert bystanders facilitating delivery of an active compound cannot be accepted when selecting excipients needed to produce self-emulsifying drug delivery systems (SEDDSs). Hence, this review describes the excipients needed to generate dermal SEDDSs as well as self-double-emulsifying drug delivery systems (SDEDDSs); how to consider combinations that complement the incorporated drug(s); and an overview of using natural excipients as thickening agents and skin penetration enhancers.