PRN Medication Research Articles

Pro re nata (as needed) psychotropic medication use in patients with borderline personality disorder and subjects with other personality disorders over 14 years of prospective follow-up.

The use of pro re nata (PRN; as needed) psychotropic medication in patients with borderline personality disorder (BPD) has not been well characterized. This study had 3 purposes, which are as follows: (1) to describe the prevalence of PRN psychotropic medication use among patients with BPD and comparison subjects with other personality disorders (OPD) over 14 years of prospective follow-up, (2) to examine the rates reported by patients with BPD who ever recovered and never recovered, and (3) to examine the reasons for taking PRN medication reported by these patients. Overall, the prevalence of PRN psychotropic medication use was initially approximately 3 times higher among patients with BPD than comparison subjects with OPD, with a significant one-third decline in the use of PRN medication reported by patients with BPD over time. In analyses restricted to patients with BPD, patients with BPD who never recovered were approximately twice as likely to use PRN medication than patients with BPD who ever recovered over time. In reasons for use, the rates of PRN medication use to decrease agitation for both diagnostic groups declined significantly over time, whereas they remained significantly higher among patients with BPD. Likewise, patients with BPD who never recovered reported higher use of PRN medication to decrease agitation than patients with BPD who ever recovered over time. The results of this study indicate that PRN psychotropic medication is widely used for the treatment of patients with BPD, particularly those who have not achieved a recovery in both the symptomatic and psychosocial realms. They also suggest that patients with BPD use proportionally more PRN medication to decrease agitation than comparison subjects with OPD, with lower proportional use to reduce agitation found among recovered patients with BPD.

A study of the use of sedative PRN medication in patients at a secure hospital

We have investigated the use of ‘as required’ (PRN), sedative psychotropic medication in 242 forensic rehabilitation patients at a UK secure psychiatric hospital. In total, 176 (73%) patients were prescribed PRN medication and 90 (37%) received a total of 542 doses in the preceding two weeks. The principle indication for use was agitation. Oral benzodiazepines, particularly Lorazepam, were most commonly prescribed and administered followed by Haloperidol. Although high-dose antipsychotics and polypharmacy due to PRN prescribing were common (11 and 20%, respectively), on only 6% of the days studied did patients actually receive PRN antipsychotic medication. Using univariate analyses, PRN administration was associated with younger age, female gender, emotionally unstable personality disorder, shorter length of stay and detention in medium security. Case note documentation of PRN administration was often absent (44%) or vague. Further research, both quantitative and qualitative, is needed into the precise circumstances under which PRN is administered.

(101) Standardized analgesia protocol led by nurses: efficacy maintained when based on hetero-evaluation

Pediatric pain remains sub-optimally controlled. Use of standardized protocol is one key for better analgesia. We have been using an algorithm in our center for over 10 years for the 5 to 18 YO hospitalized children. Nurses asked for such an algorithm for the 1 to 7 YO children. To do so, we had to first implement a hetero-evaluation scale (EVENDOL). Thirty minute training sessions were provided to nurses about EVENDOL’s applicability. Subsequently, all children 1 to 7 YO admitted for painful medical or surgical conditions were evaluated using EVENDOL. Pain values and analgesia were noted for each patient by electronic and paper charting. Satisfaction and practice changes within the nursing staff were evaluated. Forty children were included. 24 children were under surgical care and 16 under medical care. A total of 260 pain measurements were documented. Overall 95% of this cohort received multimodal analgesia which is two or more types of pain medication. More than 50% of prescribed PRN medications were given on a regular basis. Only 12 of 260 pain assessments were in the severe pain category and they received an appropriate and timely analgesia. 85% of pain scores on day 2 were in the mild pain category. These scores were comparable to those obtained with the 5-18 year old cohort (96%) post implementation of the pain algorithm. Ease of EVENDOL use was rated at 9.3 of 10. Global satisfaction score about the scale was 6.7/10. We stopped the recruitment for the control group prior to implementation of the algorithm because nurses spontaneously transposed the pre-existing 5 to 18 year old standardised analgesia protocol, and used it in the 1-7 year old group. This may explain the excellent pain control despite the absence of a standardised analgesic pain protocol in this age group. Supported by Foundation of Stars.

A REGIONAL RE-AUDIT OF THE SYMPTOMATIC MANAGEMENT OF NAUSEA & VOMITING IN THE MEDICAL MANAGEMENT OF MALIGNANT BOWEL OBSTRUCTION

BackgroundThe medical management of symptoms associated with malignant bowel obstruction remains a clinical challenge in palliative care. Where surgical intervention is not appropriate, thorough clinical assessment should guide treatments for...

DRUGS AT THE END OF LIFE: AN APPROPRIATE CONCERN?

BackgroundThe Independent Review of the Liverpool Care Pathway (LCP) described concerns about use of opioid and sedative drugs at the end of life. Baroness Neuberger reiterated the importance of appropriate...

The administration of psychotropic PRN medication in Scottish psychiatric intensive care units

Information concerning the administration of psychotropic PRN medication in Scottish PICUs is scarce. The medical notes and prescription charts of all patients (n = 75) admitted during the study period were consulted to determine the frequency and nature of PRN practice. 65% of patients (n = 49) were administered up to 11 drugs comprising of antipsychotics (n = 8), benzodiazepines (n = 2) and zopiclone. The most frequently administered PRN medicines were lorazepam, haloperidol and zuclopenthixol. The mean dose administered for oral and intramuscular (IM) forms of both lorazepam and haloperidol were very similar. The mean number of PRN administrations per patient per day was 0.4. 40% of psychotropic PRN administrations were initiated by the nurse with the majority of doses administered at bedtime. Ten patients received an IM injection. Four patients were restrained during these administrations. Documentation pertaining to the rationale for IM administrations and of pre and post rapid tranquillisation physical health monitoring was lacking. This study highlights variation in practice between units, inadequate monitoring and documentation, a possible lack of understanding by prescribers of the differences in bioavailability between oral and injectable forms of medication and relatively limited use of newer drugs.

A study of the prescription and administration of sedative PRN medication to older adults at a secure hospital

There is a paucity of research into PRN medication use in older psychiatric inpatients. This is an important topic given the risks of polypharmacy, adverse drug reactions, and high dose medication. In 2013, we carried out a cross-sectional survey of the prescription and administration of sedative PRN medication to older adult inpatients on seven wards at a UK tertiary referral centre. We compared them with 242 patients of working age. Of the 92 patients studied, 56 (60.9%) were prescribed PRN sedation and 25 (27.2%) had received one or more doses in the previous fortnight. In total, 70 doses had been administered; all by mouth and all but one as single doses. Lorazepam was by far the most commonly prescribed and administered PRN drug. Agitation was the main indication, although violence was the most commonly cited reason for administration but documentation of antecedents, non-pharmacological strategies and outcome including side effects was uniformly poor with only 37 (52.9%) doses recorded in the case notes. Those with organic disorders were just as likely to receive PRN as those with functional illnesses. Patients very rarely actually received high dose antipsychotics or antipsychotic polypharmacy as a result of PRN prescriptions. Older patients were less likely than adults of working age to be prescribed PRN and dosages were smaller. Prospective studies of PRN prescription and administration are needed to better understand the reasons underpinning its use and to gain objective data upon its effectiveness or otherwise in this vulnerable patient group.

Use of PRN medication in people with intellectual disabilities

Purpose – The purpose of this paper is to identify psychotropic medication being prescribed for people with intellectual disability “as and when required” (PRN); the indications, frequency of use, rate of poly-pharmacy and contribution of PRN medication towards this. The paper also aimed to identify individual and environmental factors associated with PRN medication prescribing. Design/methodology/approach – Data were collected from nursing and medical records for the 119 service users in the acute assessment and treatment unit and NHS residential care settings managed by specialist intellectual disability services covering Leicester, Leicestershire and Rutland over a month period. Data were analysed using descriptive statistics and logistic regression to calculate adjusted odds ratios for predictor variables. Findings – In total, 72 per cent of the service users were prescribed and 25 per cent were administered PRN medication over the study period. The most common indications for PRN prescribing were aggression and agitation. Lorazepam and chlorpromazine were the most frequently prescribed PRN medications. The rate of poly-pharmacy was 41 and 38 per cent of this was attributable to PRN medication. Male gender and history of challenging behaviour were found to be significant factors associated with PRN medication prescribing. Originality/value – PRN medications are commonly prescribed in people with intellectual disabilities and contribute to poly-pharmacy. Whilst PRN medication continues to remain an effective therapeutic option in situations where environmental and behavioural approaches are proving insufficient, their use should always be in conjunction with effective review mechanisms.

TIC ATTACKS IN TOURETTE SYNDROME

IntroductionTourette syndrome (TS) is a childhood–onset neurodevelopmental disorder characterised by chronic multiple motor and vocal tics associated with other co–morbidities in most cases. The natural course is for symptoms to...

Identification of the “Minimal Triangle” and Other Common Event-to-Event Transitions in Conflict and Containment Incidents

Although individual conflict and containment events among acute psychiatric inpatients have been studied in some detail, the relationship of these events to each other has not. In particular, little is known about the temporal order of events for individual patients. This study aimed to identify the most common pathways from event to event. A sample of 522 patients was recruited from 84 acute psychiatric wards in 31 hospital locations in London and the surrounding areas during 2009–2010. Data on the order of conflict and containment events were collected for the first two weeks of admission from patients’ case notes. Event-to-event transitions were tabulated and depicted diagrammatically. Event types were tested for their most common temporal placing in sequences of events. Most conflict and containment occurs within and between events of the minimal triangle (verbal aggression, de-escalation, and PRN medication), and the majority of these event sequences conclude in no further events; a minority transition to other, more severe, events. Verbal abuse and medication refusal were more likely to start sequences of disturbed behaviour. Training in the prevention and management of violence needs to acknowledge that a gradual escalation of patient behaviour does not always occur. Verbal aggression is a critical initiator of conflict events, and requires more detailed and sustained research on optimal management and prevention strategies. Similar research is required into medication refusal by inpatients.

Development of a Psychotropic PRN Medication Evaluative Tool

This article describes a psychotropic PRN Evaluative Tool developed by interprofessional clinicians to address inconsistent reporting and assessment of the effectiveness of PRN medications used for people who are developmentally disabled. Fifty-nine participants (37 males, 22 females), ages 16 to 60 years, were included in the review, all diagnosed with an intellectual disability and a serious mental illness. Participants' range of intellectual disability varied from severe to mild. The review was conducted over a 2-year period. Data was evaluated by comparing differences in a number of patient pre and post behaviors after having received PRN medication. Results indicated a statistically significant decrease in the total number of post-PRN behavior variables observed compared with the pre-PRN behavior variables. This tool has improved patient outcomes through the reduction of unnecessary and/or ineffective PRNs by providing a more thorough assessment of the effectiveness of PRN medications and thereby reducing subjective and ambiguous language.

Medication Management in Assisted Living

Psychotropic medications administered on an as-needed basis, often designated as pro re nata (or PRN, hereafter as-needed), can alleviate acute symptoms and facilitate deprescribing, although as-needed use is associated with negative outcomes such as polypharmacy and drug interactions. The aim of this study was to examine the extent to which PRN psychotropic medications are prescribed and administered to assisted living (AL) residents, overall and in relation to resident- and community-level characteristics.Cross-sectional study.All AL residents and select staff in 250 AL communities in 7 states.Data regarding prescribing and administration of 5 types of PRN psychotropic medications in the prior 7 days (antipsychotics, mood stabilizers and antiepileptics, antidepressants, anxiolytics/hypnotics, and cognitive enhancers) were abstracted and compared across resident and community characteristics.Prescribing of PRN psychotropics in AL is low (10.3%). Of prescribed PRN medications, 2.5% of residents were administered a PRN and 8% had PRN that was not administered in the previous 7 days. Anxiolytics were administered PRN more commonly compared with antipsychotics (2.0% vs 0.2%). Of all PRN psychotropic prescriptions (n = 1039), 70.5% had a written indication describing the reason for administration. Among PRN medications administered (n = 242), the proportion with an indication was lower (62.0%). PRN psychotropic medication prescribing was higher among residents with dementia and a psychiatric diagnosis, and in larger AL communities and those with a higher proportion of dementia care beds.The prescribing and administration of PRN psychotropic medications in AL is relatively rare, although more common among residents with dementia. Emerging psychotropic medication policies should be expanded to address mental health care, anxiolytic/hypnotic use for residents living with dementia, PRN prescribing in chart review, and the use of detailed indications for PRN use, especially when medications are administered by unlicensed care staff.

Polypharmacy Among Hospitalized Children

Source: Feudtner C, Dingwei D, Hexem KR, et al. Prevalence of polypharmacy exposure among hospitalized children in the United States. Arch Pediatr Adolesc Med. 2012; 166(1): 9– 16; doi: 10.1001/archpediatrics.2011.161Investigators at the Children’s Hospital of Philadelphia and the University of Pennsylvania examined the pattern of exposure to drugs and therapeutic agents among children hospitalized in 2006, excluding healthy newborns. The goals of the study were to determine the most commonly used drugs and therapeutic agents, measure the daily and cumulative medication exposures during a hospital stay, and identify potential differences in the use of drugs and therapeutic agents in children’s hospitals versus general hospitals based on patient characteristics such as age, gender, diagnosis, and length of stay. Data were extracted from two databases, the Pediatric Health Information System and the Perspective Data Warehouse, which provided detailed information on pharmacy activity on each day of hospitalization.Data collected from 52 children’s hospitals and 411 general hospitals on 587,427 children younger than 18 years (equivalent to 20% of pediatric admissions across the country in 2006) were analyzed. The most prevalent drugs and therapeutic agents to which hospitalized children were exposed were intravenous fluids, analgesics, anti-infectives, anesthetics, and gastrointestinal drugs. Stratified by age, heparin and ampicillin were the most common drug exposures in children younger than 1 year in children’s and general hospitals, respectively; acetaminophen was the most common exposure in children 1 to 9 years old in both children’s and general hospitals; and ondansetron and fentanyl were the most common in children aged 10 to 17 years in children’s and general hospitals, respectively. On day 1 of hospitalization, the median level of exposure was four distinct medications for children younger than 1 year in children’s hospitals and three distinct medications at general hospitals. For children 1 year or older, the median level of first-day exposure was five distinct medications in both children’s and general hospitals. In children’s hospitals, the cumulative number of medications received for the median patient younger than 1 year was 25 by hospital day 30, and for the patient 1 year or older was 42 by hospital day 30. In general hospitals, the cumulative number of medications received increased to 21 and 25, respectively, for children younger than 1 year and those 1 year or older. Patients in children’s hospitals were estimated to be exposed to 1.34 times more medications than patients in general hospitals, but after adjusting for patient characteristics, this was not a significant difference.The authors conclude that a large number of hospitalized children are exposed to polypharmacy, raising patient safety concerns.Dr Riedmann has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.There are limitations to this study, many identified by the authors, which potentially bias its findings. First, the retrospective nature of the study eliminated the ability to verify that the patients actually received the medications that were prescribed and billed. Second, the data sources used were also limited because PRN medications may have been inaccurately billed for but not received. Third, unaccounted-for confounding may have skewed the comparisons of medications used for pediatric patients admitted to children’s hospitals versus the general hospitals. For example, adolescent females who were admitted for childbirth rather than an acute illness/ injury would be found exclusively in general hospitals, as evidenced by the amount of oxytocin administered at general hospitals versus children’s hospitals. In addition, children needing specialists for more complex medical conditions would more likely be admitted to a children’s hospital, as evidenced by the finding of a higher percentage of disease-specific medications (cardiovascular, neoplastic, etc.) prescribed at children’s hospitals.However, the results of this study are important. There is a clear association between polypharmacy and the risk of adverse drug effects in adults.1 Previous studies of the risk of adverse drug reactions in hospitalized children, particularly children admitted to intensive care units, suggest similar risks.2 In addition, many medications have not been thoroughly studied in the pediatric population for their safety.3 Since the amount of polypharmacy increases with the length of hospitalization, patients with complex medical problems requiring a prolonged hospital stay are at a greater risk for adverse effects. Studies dedicated to the effects of polypharmacy in children would be beneficial to establishing goals to limit adverse effects and create standards of care for pediatric patients admitted to the hospital. Finally, as pointed out in an editorial accompanying the main study,4 polypharmacy in children is an increasing problem in the outpatient setting as well, with a different set of issues requiring further study.

Regional audit on the symptomatic management of nausea & vomiting in the medical management of malignant bowel obstruction

BackgroundMalignant bowel obstruction is a recognised complication of advanced malignancy. Surgery is not always suitable therefore antiemetics are the mainstay of symptomatic management. There is little evidence for any specific...

The First National Survey of Medication Aides

A survey was developed with the goal of providing insight into the work settings, education, supervision, and work roles of medication aides. Results, which typically varied by work setting and regulatory agency, included 46% of respondents reporting that medication aide training needed to be more challenging and 8% reporting they had no supervision. Of medication aides who had supervision, 19% said their supervisor was never on site. When asked about work roles, 21% said they were not given a job description that addressed the scope of their duties, 33% needed more information about their authorized duties, and 21% thought some of the tasks that they performed were beyond their scope. In terms of job duties, 29% indicated they were allowed to administer injectable medications, 80% were allowed to administer the first dose of a new medication, 67% were allowed to administer prn medication without an assessment by a licensed nurse, 49% were allowed to administer medications when the patient's condition was unstable or had changing nursing needs, and 59% were allowed to crush medications without authorization by a licensed nurse. Study implications are discussed.

Management of disturbed behaviour in a psychiatric intensive care unit: views of staff on options for intervention

Aims and method: NICE guidelines provide a framework for decision making with regard to the management of disturbed or violent behaviour in inpatient mental health settings, although also point to the fact that there is a limited evidence base for the use of more high risk interventions such as rapid tranquillisation, restraint, and seclusion. The current study sought to elicit the views of a team of PICU staff regarding their preference for management strategies for such behaviour. Results: Forty-three staff assigned ranks to five intervention options: restraint to administer medication, restraint without medication, seclusion, individual counselling, and offering PRN medication. The results revealed a clear preference for individual counselling as the first choice of intervention, and offering PRN medication as a second choice. The three remaining options could not be statistically separated. Clinical implications: The results indicate that respondents viewed the choice of intervention beyond counselling and the offer of PRN medication as an issue of clinical judgement, dependent on a range of factors relevant to the presenting clinical situation. As such they offer support for the current NICE guidelines. The results are discussed with reference to the NICE guidelines, and areas for further study are highlighted.

The Use of Pro Re Nata or Statim Medications for Behavioral Control: A Summary of Experience at a Tertiary Care Children's Mental Health Center

The present study aims to identify patterns for use of medication given pro re nata (PRN or "on an as needed [preordered] basis") or statim (STAT [a new order] or "at once, immediately") and their efficacy in controlling aggressive behavior in the mental health (MH) services environment. PRN and STAT medication data were combined and referred to as PRN throughout this article, as the data were not collected in a manner required to differentiate between PRN and STAT medication administration. Analyzed data were extracted from the clinical records of a sample of children and youth admitted for the first time to a tertiary MH center. MH Program patients (characterized by at least one Axis I psychiatric diagnosis [Axis I group]) were compared to Dual Diagnosis Program patients (characterized by an Axis I diagnosis in addition to an Axis II diagnosis of mental retardation [Axis II group]). Age, gender, Program (Axis I or II group), and the length of stay for treatment produced significant differences in the use of PRNs between the two groups. Further, the study investigated the precipitating factors leading to use of PRNs, in conjunction with the level of supervision and the de-escalation techniques used to avoid the use of PRNs. Axis I patients were more likely to endanger others, whereas Axis II patients were more likely to endanger themselves. Both groups of patients demonstrated a need for an increased level of supervision prior to the crisis. Olanzapine, chlorpromazine, and lorazepam were effective in calming patients and preventing further aggressive outbursts.

Characteristics of Admissions to a Recently Opened Psychiatric Emergency Care Centre

The Psychiatric Emergency Care Centre (PECC) is a relatively recent service development that aims to improve emergency care of psychiatric patients. The goal of this paper was to report on the characteristics of admissions to a recently established PECC. Several key characteristics of admissions to the PECC were documented for each of 376 patients in the first 6 months of its operation. These characteristics were then compared to the characteristics of admissions of 299 patients in the 'virtual' PECC (a PECC within the general emergency department) in the 6 months prior to the opening of the PECC. The most common presenting symptom in the PECC was suicidal ideation (47.6%, n = 179) and the most frequent diagnosis made in the PECC was adjustment disorder (35.9%, n = 135). When comparing admissions to the 'virtual' PECC, PECC admissions were characterized by a significantly less frequent use of physical restraint and haloperidol and midazolam as pro re nata (prn) medications. Although further study is needed, one possible advantage of the PECC may be a less frequent use of physical restraint and certain prn medications (i.e. haloperidol and midazolam) for agitated and aggressive patients.

Weekend Prescribing Practices and Subsequent Seclusion and Restraint in a Psychiatric Inpatient Setting

Weekend Prescribing Practices and Subsequent Seclusion and Restraint in a Psychiatric Inpatient Setting

The Effects of Molindone as a Concomitant Medication on Aggressive Behavior

Background: After noting a significant reduction in aggression and agitation in treatment-refractory patients with molindone augmentation in severely aggressive inpatients, the authors conducted a retrospective medical records review to assess the possible anti-aggressive role of molindone treatment in a larger cohort of treatment-refractory inpatients. Method: Twenty-four weeks of data from thirty inpatients who were consecutively augmented with molindone, including progress notes, orders for seclusion, chemical restraint, and scores on the Agitation-Calmness Evaluation Scale (ACES) were systematically collected. The number of seclusions, number of as-needed medications (PRNs) and ACES scores were used to tabulate the frequency of aggression and agitation episodes during the 8-week period before, 8 weeks after, and 9 through 16 weeks after the initiation of molindone augmentation treatment. Results: Over the observation period of twenty-four weeks, the number of episodes of PRN medication administration ...