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by Rose Rohloff
"The use of cardiovascular medications can have a variety of neuropsychiatric consequences." Therefore, the following highlights are good review for anyone prescribed a CV drug, especially for the elderly, those with other conditions such as liver or kidney insufficiency, and/or also being prescribed psychiatric medications. Neuropsychiatric Consequences of Cardiovascular Medicationsby Dr. Jeff C. HuffmanAssociate Professor of Psychiatry at Harvard Medical School and the Director of the Cardiac Psychiatry Research Program in the Massachusetts General Hospital (MGH) Division of Psychiatry and Medicine. Angiotensin-converting enzyme inhibitors"Bottom line: ACE inhibitors and angiotensin II receptor antagonists are associated with low rates of neuropsychiatrie side effects, though mood symptoms, psychosis, and delirium have been reported." From snake venom to ACE inhibitor - the discovery of captopril- early 1980s, hypertension conferences were routinely enlivened by the poisonous Brazilian viper, Bothrops jararaca ... captopril — the first of the angiotensin-converting enzyme inhibitors, whose effects on blood pressure mechanisms mimicked those of the snake’s venom. https://pharmaceutical-journal.com/article/news/from-snake-venom-to-ace-inhibitor-the-discovery-and-rise-of-captopril Beta-adrenergic blocking agents or Beta (β)-Blockers"Bottom line: β-Blockers as a class are not clearly associated with depression; there is the most evidence for a propranolol-depression link, but even this relationship is equivocal. In contrast, β-blockers are associated with increased rates of fatigue." Calcium channel blockers (CCBs)"Bottom line: CCBs may be associated with fatigue in some patients, but otherwise cause few neuropsychiatrie symptoms." Diuretics"Bottom line: Diuretics most often cause neuropsychiatrie symptoms indirectly, through electrolyte abnormalities (thiazides) or vitamin deficiencies (loop diuretics). Acetazolamide is associated with fatigue and with delirium in renal failure." Doctors should always monitor electrolyte levels (sodium/Na and potassium/K+) of their patients taking diuretics. Centrally acting agents - Antiadrenergic agent"Bottom line: Clonidine is consistently associated with fatigue and sedation; delirium is infrequently associated with its use. (Clonidine) is also commonly used to reduce symptoms of opiate withdrawal. Bottom line: Methyldopa is clearly associated with fatigue and sedation. In contrast to early studies linking methyldopa with depression, later reviews and studies have found this association to be relatively weak. Other neuropsychiatrie symptoms are uncommon. Bottom line: Reserpine is associated with both sedation and daytime fatigue. Incidence of depression may be elevated among patients taking reserpine. However, other (generally more recent) reports question this association." α-Adrenergic agents"Bottom line: Fatigue is the most common neuropsychiatrie side effect associated with -adrenergic antagonists; other neuropsychiatrie side effects are infrequent." Vasodialtors"Bottom line: Vasodilators are generally associated with low rates of neuropsychiatrie consequences. Hydralazine is a leading cause of drug-induced lupus, but this syndrome affects the central nervous system much less commonly than the idiopathic form of the disorder." Antiarrhythmic medications"Bottom line: Most Class I Antiarrthymic agents have been associated with psychosis and delirium in case reports. The syndrome of cinchonism associated with quinidine may include sensory changes along with delirium, and procainamide is a cause of drug-induced lupus. Bottom line: Class III Amiodarone is associated with thyroid abnormalities in 15% of patients, and untreated thyroid dysregulation can lead to a variety of mood, cognitive, and psychotic symptoms. In contrast, direct neuropsychiatrie effects of amiodarone are uncommon. Bottom line: Digoxin is associated with delirium and other cognitive effects, especially in toxicity. Visual changes and hallucinations may also occur with digoxin use, even at normal serum levels." Conclusion by Author"... numerous cardiovascular medications can have neuropsychiatrie side effects, ranging from mood symptoms to cognitive effects to psychosis, and though a given agent may not consistently cause neuropsychiatrie symptoms in the general population, idiosyncratic reactions are possible." More specific studies are needed for, "clinicians ... to make fully-informed prescribing decisions for their patients." Patients and their families know the cognitive baseline of individuals being prescribed medications, and therefore, should always monitor for any neuropsych impact seen if CV drugs are used, on an individual basis for what is safe per person. Any and all side effects should be know, along with contradictions to other drugs, for all medication being taken. * Dr Huffman is a professor of psychiatry at Harvard Medical School and the director of the Cardiac Psychiatry Research Program in the Massachusetts General Hospital (MGH) Division of Psychiatry and Medicine. He also serves as the associate chief for clinical services in the Department of Psychiatry at MGH. 
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by Rose Rohloff  The 2009 HITECH Act and the Center for Medicare Medicaid Services’ (CMS) Meaningful Use regulations caused a massive spend for electronic medical records (EMRs), the push for interoperability, as the solution to healthcare quality. However, EMRs are not solutions - along with massive IT overhead spend with decreasing quality - because in a high percent of instances, nurses and doctors don’t even read them. A 40-year old mother went to the doctor after treating herself holistically for some laryngitis, stuffy nose, congested sinus, with continued symptoms after five days. After an exam, the doctor stated, “I am not going to give you antibiotics. You do not have a fever; your lungs sound clear. It looks like a little virus with severe allergies. I recommend an antihistamine.” The patient told him, “Thank you for not putting me on antibiotics when they are not needed, that makes me happy.” He responded, “I am glad you are glad.” He then said something and the patient responded, “I have MS.” He responded, “Oh wait, you have Multiple Sclerosis?” This story is sadly too often the new normal, numerous instances of patients and their caregivers stating issues of diagnosing with medication prescription, or misdiagnosis; the doctor or nurse having no idea of pre-existing conditions or a full list of medications currently being taken, a lack of care coordination or care planning because the time was not taken to simply read the chart (whether written or electronic), and ensuring a comprehensive history followed by the necessary physical assessment. No physician or nurse should walk in to care for a patient without first having read the patient’s record, knowing all current information, the last visit/healthcare encounter, chronic conditions/comorbidities, and all medications; then, asking for updates of changes. Unfortunately, even without having to decipher poor handwriting, being able to read clean typed text, clinicians are not simply reading the basics of information they should before doing any diagnosing, planning and delivering of care - especially prescribing of medications.  by Rose Rohloff The June 29, 2018 BECKER'S Hospital Review article shares the viewpoint "Froedtert CEO Cathy Jacobson: Not every patient needs a primary care physician" (PCP). The article is the perspective from the viewpoint of a health system CEO. The following is a perspective, counterview from patients, the individuals in the population.  In speaking with individuals across the country, spanning several major health systems and states, 100% of the comments and feelings are that health systems are large, top-heavy and more inefficiently run because of their size. Many people have expressed utter frustration from lack of a good Primary Care Doctor, warranting unnecessary ER visits because a doctor will not call back; the lack of one doctor in charge who would simply LISTEN to them, who knows them - not as personal friends, but with an in-depth professional relationship. I have been asked several times in various states, "Do you know of any good Primary Care Doctors? I cannot find one." Universally, I am hearing: a gross lack of comprehensive assessments from doctors; clinicians not taking the time to get to know and listen to what is going on, causing the passing through of patients to specialists versus a primary care doctor creating a plan of care and focused tests for getting an actual diagnosis; lack of avoidance for hospital visits with increasing costs that could and should be avoided because conditions allowed to worsen; and doctors simply writing prescriptions for symptoms. Health systems are relying on data analysis, defining as population health, as Froedtert is quoted, "As we start stratifying our patients into distinct populations based on their health needs." The issue with this premise is that the data is not always clean, and it will never tell the story, the whole story, of the realities going on with the patients. (See I Wish I Had Known stories.) Her quote continues, "... insight further into consumer driven wants, we are finding that a substantial sector of the population does not want or need a primary care physician relationship. People need primary care but not necessarily a physician relationship." The issue is the primary care physician practices have been acquired by the hospital-health systems, with the biggest complaint from people in the population not being able to find a PCP; and those now under health systems, the doctor only giving 10-15 minutes of time, before passing off to specialists with no plan of care, and/or simply writing another prescription. Many in the public just find it faster, or are being told to just go to the ER. From the perspective of health system CEOs, it would appear primary care is not wanted or needed, which drives up the hospital ER and inpatient business. When actually speaking with individuals across the country, it is the opposite, people complain lack of care coordination, and "the doctor doesn't know me and is not taking the time to listen to me - I want them to actually figure out a diagnosis of what is wrong."   by Rose Rohloff A middle aged male was recently experiencing severe abdominal pain, subsequently prescribed three (3) medications in two (2) weeks from three (3) different sources (an Emergency Room, a primary care doctor, a Gastroenterologist). There was no diagnosis, no care coordination within an established plan of care, no thorough instruction in the medications, with the last prescription based on a guessed misdiagnosis which worsened his pain. One prescription was a steroid with the patient being instructed to take as he needed it; the second was an offering by the office secretary blindly asking if he wanted an Epipen when he called to actually speak with the physician for worsening abdominal pain, swelling and to discuss his lab work. The common standard operating procedure (SOP) in medicine has become symptom and write a prescription, another symptom and write another prescription, etc. This SOP has lent to the opioid crisis, antibiotic resistance, as well as many other drugs being dispensed routinely with side effects causing secondary prescriptions for the side effects of the existing medications being taken. Several variables cause the use of this SOP beginning with the lack to get a full, detailed history - taking time to speak with patients - to establish a diagnosis and then plan of care, determining if simple steps are first needed such as icing and therapy for pain before opioids, or to remove foods and medications isolating side effects or allergies. Last week, I attended the HIMSS conference, the largest healthcare conference in the country, with attendees from around the world. One executive stated, "I just returned from Finland where they have an effective health system, because people live healthy, and the doctors appropriately tell their patients NO when seeking a simple, quick fix of a drug that is not needed." Reasons for the mainstream SOP? I think there are always multiple reasons for issues within healthcare. The symptom=prescription issue can be: Doctors are processing patients through with 'factory-care', Physicians receiving kickbacks from pharmaceutical companies; The lack of proper clinical training; Protocols blindly being followed without individual evaluation (e.g. Vanderbilt University study on Plavix standard for all Cardiac Cath Patients); as well as the alliance of public policy and pharma, direct consumer marketing without proper education. A healthcare executive summarized the situation well last week when stating to me, "I ultimately make the decision for my own care, with the advice of the physician. It is the doctor's role to diagnosis, and then we discuss all options, along with a plan of care, coordinated with speaking with all other involved physicians." It is important for consumers to understand the need to champion their own care working with physicians, determining what options should be used before medications (diet and some of the old fashioned home remedies still hold true), addressing underlying issues versus only symptoms, and removing or changing medications to eliminate side effects when there are alternatives. Questions to have answered: An example of direct consumer marketing lacking in education: In 2016, there was broad publication when the company Mylan raised the prices of the Epipen after State Law was passed to stock it in every school. Many individuals and groups were upset because there is not a generic offering. With proper information, the public would be educated that Epipen is the patented delivery system, not the drug epinephrine. The generic already existed in the form of a $15-$18 sterile needle. It is also necessary to establish where and when is it appropriate to stock epinephrine, not specifically the Epipen. Why are you prescribing this medication, what is it specifically doing in my system? What are non-medication alternatives, what are other medication alternatives? How long should I take this, what is the outcome? How does it interact with my other medications? What should be monitored for an outcome, side effects?  by Rose Rohloff
As a 35-year healthcare veteran, I am a firm believer of cross-pollinating successful processes from other industries into the healthcare industry, for positive transformation. Delivering quality care will continue to be complex and challenging, with the need to leverage solutions that work. And SEAL teams are a proven efficient and effective success in the military. By rebranding PC teams and the team process, expanding with additional SEAL successful methods and approaches, we can create the Healthcare version of SEALs (sea, air, land), as APAC Teams (acute, post-acute, and community) - expanding the process to operate in every environment versus only in facilities, for enhancing the quality of care of high risk patients versus limiting to end-of-life cases. The following chart displays characteristics of SEALs, obtained from several former SEAL, special operation personnel, and military officers; with several of the attributes emulating characteristics regarding the successful palliative care (PC) team process.
* https://www.navy.com/dam/Navy/Navy-IMG/Downloads/pdf/enlisted/seal-brochure.pdf ** http://www.nsonswmentor.com/Navy-SEAL.html Within the industry, PC is still aligned or mistaken with hospice, as demonstrated in the following two scenarios. Recently, a viral video was circulated and applauded, Australian paramedics fulfill dying woman’s wish to go to the beach, telling the story of a Hervey Bay crew transporting a patient to the palliative care unit, but she wished she could, “Just be at the beach” instead, and so the crew drove to the beach to provide her peace, based on her wishes of quality of life. This story is lovely regarding true care of a patient. Additionally, in April of this year I attended the Becker’s Hospital Conference in Chicago with the top leaders in healthcare, with a wonderful presentation about business analytics regarding palliative care, end-of-life. Both stories demonstrate clearly that palliative care is still being confused with hospice, or limited to a specific unit definition, instead of the effective use of the team process use with complex and/or chronic conditions.
However, what is it continuing to do to their brains having more medications and anesthesia, while it may not be improving their actual quality of life?” With APAC team coverage, a non-end-of-life case can be reviewed with a sound plan of care based on the desired quality of life for the patient and family. The PC coverage in the community has been focused on cancer patients, with a high focus on children. With the demonstrated cost savings and positive outcomes with The value of palliative care teams (HFMA, March 2013), the community coverage can be successful for individuals with multiple comorbidities, such as diabetes with congestion heart failure and hypertension; as well as elderly who are being targeted when ‘sundowning’ with fraud scams, or confused with medication regime, and those with family living in other states who are their primary support system/durable power of attorney. It is daunting, emotionally and financially, for the families of high-risk consumers to search out the various interdisciplinary resources such as dieticians, social workers, case managers, pharmacists, nurse practitioners, and spiritual counselors. APAC teams would also address the necessary information gathering for determining the real issues of consumers, for example, who needs dietary changes or removal of drugs with side effects before being prescribed new medications by physicians, causing even more side effects or noncompliance, and self medicating or opiate abuse. PC teams can be expanded to APAC teams utilizing the successful palliative care process across the care and health continuum, eliminating the end-of-life association, and differentiating from the terminally ill care of hospice. Just as SEALs operate in every environment (air, sea and land), APAC teams can be an extension of PC teams to be the quick, nimble action teams in all settings, especially the community, for patients with complex and chronic conditions.  by Rose Rohloff
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