Electronic health records analytics to identify cancer patients with metabolic syndrome

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Background: Metabolic syndrome, defined as the presence of at least 3 of 5 clinical factors including hypertension, elevated triglyceride levels, low high-density lipoprotein level, insulin resistance, and central obesity, increases the risk of heart disease, fatty liver, and multiple cancers. Metabolic syndrome in cancer patients has been associated with poor cancer-specific and overall survival. Lifestyle modification in patients with metabolic syndrome may reduce the risk of poor outcomes. In this quality improvement project, we aimed to determine the prevalence of metabolic syndrome among cancer patients and survivors seen in an outpatient general internal medicine (GIM) clinic and to determine the feasibility of using electronic health records (EHR) analytics to systematically identify such patients and refer them to lifestyle interventions and liver imaging. Methods: Study period was January-December 2021. During this period, an EHR algorithm was used to identify patients with metabolic syndrome based on the presence of ICD-10 diagnoses of metabolic conditions (diabetes, hypertension, lipid disease, and obesity). This algorithm was used to direct data from patient visits into an interactive dashboard to track metabolic syndrome prevalence and continuously monitor referrals to interventions. In September 2021, a best practice alert based on the EHR algorithm was created to identify patients with metabolic syndrome and prompt providers to refer them to nutrition counseling, liver ultrasound with elastography, and/or a community-based active-living support group for cancer survivors. GIM clinic nurses also reviewed medications and utilized an EPIC SmartPhrase that incorporated laboratory values (e.g., glucose, A1c, and lipids), blood pressure, and body mass index to confirm whether patients actually met the criteria for metabolic syndrome, and if so, they notified medical providers who then ordered the interventions. Patients confirmed to have metabolic syndrome received educational materials about lifestyle modifications. Data extracted from the dashboard were analyzed using Minitab 17 statistical software. Results: Among 1133 patients seen in the GIM clinic during 2021, 609 (54%) had metabolic syndrome. A total of 1045 patients (92%) had hypertension, 802 (71%) had hyperlipidemia, 571 (50%) had obesity, and 483 (43%) had diabetes. Among the 609 patients with metabolic syndrome, 148 (24%) were referred to liver ultrasound with elastography, 124 (20%) to nutrition counseling, and 21 (3%) to the support group. Beginning September 1, the best practice alert was triggered for 1131 clinical encounters meeting criteria for metabolic syndrome. Conclusions: The prevalence of metabolic syndrome among cancer patients seen in a GIM clinic was high. EHR analytics can lead to systematic identification and referral of patients with metabolic syndrome to lifestyle interventions and liver imaging.

The efficacy and safety of risperidone for the treatment of geriatric psychosis

Risperidone is an atypical antipsychotic drug which has been suggested to be beneficial for the treatment of elderly patients with psychotic symptoms. In this study, we assessed the short-term efficacy and the safety of risperidone in geropsychiatric inpatients with psychotic symptoms. The sample population included 110 elderly inpatients with psychotic disorders. Assessment for drug efficacy using the Brief Psychiatric Rating Scale, Sandoz Clinical Assessment-Geriatric scale, and Clinical Global Impression scale was conducted at baseline and also at 4 weeks subsequent to risperidone treatment commencement. Subsequent to commencing risperidone treatment, 80 patients completed a 4-week therapeutic evaluation. Seventy (87.5%) of the 80 patients experienced mild to substantial improvement using the Clinical Global Impression scale. Adverse effects were monitored in all 110 patients. The most commonly detected adverse effects were weakness of legs or walking problems (43/110; 39.1%) and dizziness (32/110; 29.1%). Peripheral edema was noted in 18 (16.4%) patients. Risperidone, in low doses, appeared to have been effective in this sample of patients older than 65 years with psychotic symptoms. The mean dose (2.1 +/- SD 1.4 mg/day) applied was lower then that suggested for young patients and was related to the each specific patient diagnosis. Peripheral edema and walking problems were commonly observed adverse effects for these elderly patients, such problems having not been seen to the same extent in previous studies of young patients.

Characteristics of Chinese suicide attempters admitted to a geropsychiatric unit

PURPOSE

To investigate the characteristics for elderly Chinese suicide attempters in Taiwan and make comparisons with Western reports.

METHODS

During a six-year period, patients admitted to a geropsychiatric unit as a result of a suicide attempt were investigated for factors related to the suicide attempt.

RESULTS

Of the 722 admissions during this period, 55 (7.6%) were patients who had been admitted due to suicide attempt. The sex and age distributions for the suicide attempters were similar to those for other patients. The most common diagnoses were depressive disorders (56.4%), followed by delusional disorders (20.0%). A total of 121 suicide motives were cited for the 55 attempters, an average of 2.2 per person, with depressive symptoms commonly found on admission. During the first week of hospitalization, 53 attempters (96.4%) still exhibited suicidal ideation and six patients made a further suicide attempt, however, only three patients retained suicidal ideation on discharge.

CONCLUSIONS

Our study confirms previous Western reports that depressive disorders are commonly manifested in elderly suicide attempters. There were differences in the motives and methods employed for the suicides, possibly due to cultural difference and/or sample source. Most of the suicide attempters exhibited a favourable response with hospitalization.

The clinical applications of Mini-Mental State Examination in geropsychiatric inpatients

OBJECTIVE

This study investigated the association between Mini-Mental State Examination (MMSE) scores and diagnosis, computerized tomographic scans or electroencephalogram findings in geropsychiatric inpatients (age > or = 65).

METHOD

We analyzed the MMSE records of patients sixty-five and older who had been hospitalized in our psychiatric ward during a nine-year period. Case data were collected by review of chart records.

RESULTS

In these patients, MMSE scores were significantly different among the seven diagnostic groups included. Demented patients had the lowest MMSE scores. Patients who had abnormal findings on computerized tomographic scans or electroencephalogram had lower MMSE than patients with normal findings.

CONCLUSION

Our findings suggest that the MMSE is a useful screening instrument for organicity in the geropsychiatric inpatients. However, because of the lower average MMSE score in geropsychiatric inpatients, the optimal cut-offpoint of MMSE for dementia should be lower than those used in other populations.

Repetitive phenomena in dementia

OBJECTIVE

Both repetitive talk and behaviors (repetitive phenomena) are common in demented patients and are bothersome to their caregivers and families. The purpose of this preliminary report was to explore these repetitive phenomena in demented patients admitted to a geropsychiatric ward.

METHOD

The sample population consisted of 141 demented patients. Patients' caregivers were asked if patients had presented a repetitive fixed pattern of physical action or talk since the onset of dementia.

RESULTS

Of the 141 demented patients included in the study, seventy-nine had repetitive phenomena. Patients with these phenomena had various presentations and developed them in the early stage of dementia.

CONCLUSIONS

Repetitive phenomena are widespread in dementia, especially for older patients, and may be an early sign of dementia. The characteristics of repetitive phenomena and some likely underlying mechanisms are discussed.

Characterization of soliton damping in the granular chain under gravity

A soliton created in the horizontal granular chain damps due to gravity in the vertical chain. We show that there are two types of propagating modes, quasisolitary and oscillatory, in the vertical chain, depending on the strength of impulse. We find that the type of damping is a power law in depth or time. We also find that the absolute value of the exponent of the power law decreases as the strength of the initial impulse increases in the quasisolitary regime. In the oscillatory regime, however, in which the initial impulse is weak, the power-law exponent is independent of the strength of the initial impulse. We show that the power-law damping is caused by the gravitation which results in the change of the force constant at each contact.

Persecutory delusions in dementia

BACKGROUND

Persecutory delusions are common in dementia. This study was undertaken to investigate the prevalence, associated factors, and characteristics of persecutory delusions in demented patients.

METHOD

The sample population included 167 demented patients (DSM-III-R criteria) admitted to a geropsychiatric ward. Patients were assessed for the occurrence of any persecutory delusions since the onset of dementia. The content of persecutory delusions, the patients' response to the delusions, and any concomitant psychiatric symptoms were also explored.

RESULTS

Of the 167 demented patients, 45 (26.9%) showed symptoms of persecutory delusions. Patients with persecutory delusions had a higher prevalence of other delusions, hallucinations, and physically aggressive behaviors. The deluded patients often thought that their caregivers were their persecutors and had a wide range of responses to their delusions. After they were hospitalized, many of these patients attacked medical staff and were uncooperative with treatment.

CONCLUSION

Persecutory delusions are common in dementia of various types. Deluded patients often have vigorous responses to their delusions including physically aggressive behaviors and suicide attempts. Careful evaluation is needed to assess the potential for violent and suicidal behaviors in these patients. Medical staff should be alert to clinical strategies for handling the treatment of such patients when they become violent or uncooperative.

Inappropriate sexual behaviors in dementia: a preliminary report

We investigated types of inappropriate sexual behavior (ISB) and patient characteristics in geriatric patients with dementia. The study group consisted of 133 consecutive geropsychiatric demented patients admitted to our ward. All patients underwent standardized diagnostic procedures for dementia, and ISB was assessed by a questionnaire completed by patients' caregivers and records during hospitalization. Patients were then subdivided on the basis of the presence or absence of ISB. Of the 133 demented patients, 20 (15.0%) were reported to demonstrate ISB at home or during hospitalization. Patients with ISB had various types of dementia. There were no significant differences in patients with and without ISB in regard to age, age of onset, gender, educational level, or Mini-Mental State Examination scores. ISB is not unusual in dementia patients and can be found in different types of dementia. Medical care providers need to be trained to discuss sexual issues with caregivers and offer ideas and training to help cope with patients with ISB.

Mortality in geriatric psychiatric inpatients

OBJECTIVE

This study investigated the deaths of patients sixty-five and older on a psychiatric ward to determine the mortality rate, the characteristics of illness, and the cause of death.

METHODS

We analyzed the case record of patients sixty-five and older who had died during hospitalization on a psychiatric ward during a seventeen-year period. Case data was collected by review of chart records.

RESULTS

The mortality rate in the patients sixty-five and older was 18/1208 (1.5%). Eight of these eighteen patients died of pneumonia. Mortality in the acutely ill geropsychiatric inpatients was difficult to predict. Age, sex, and diagnosis did not predict mortality.

CONCLUSIONS

To reduce mortality, especially in male veterans, management of geropsychiatric patients should include early recognition of pneumonia symptoms, especially for patients with history of pulmonary disease.

Hoarding behavior in dementia. A preliminary report

Hoarding behavior has been reported in several mental disorders and is occasionally reported by the caregivers of dementia patients. Such behavior may have adverse effects on the patients and increase the burden of the caregivers. This study was conducted to investigate the prevalence of hoarding behavior in patients with dementia and identify the characteristics and psychiatric symptoms associated with it. The sample was 133 dementia patients admitted to a geropsychiatric ward. Of the 133 dementia patients, 30 (22.6%) showed hoarding. Hoarding was found in various types of dementia. Patients with hoarding had a higher prevalence of repetitive behaviors, hyperphagia, and pilfering. Results suggested that hoarding behavior is a common symptom in dementia patients and a complex phenomenon. Better understanding of the underlying pathogenesis may highlight specific pharmacological or behavioral methods for treatment of the behavior.

Characteristics and outcome of delirium in psychiatric inpatients

Delirium, a transient organic psychiatric syndrome, is a common psychiatric diagnosis. It is associated with increased rates of morbidity and mortality in medical-surgical inpatients. There have been few reports describing the risk factors and prevalence of delirium among psychiatric inpatients. The purpose of the present study was to investigate the rate of delirium, the reasons for admission, the clinical features, the etiologies and the mortality during a 2 year follow-up in psychiatric inpatients admitted to a general hospital during a 3 year period. The results show that the rate of incidence of delirium in psychiatric and geriatric (age > or = 65 years) inpatients was 1.4 and 9.6% respectively. The most common cause of delirium was adverse effects of medication. The inpatient mortality (5.9%) was lower compared with reported mortality rates in medical-surgical inpatients. However, there was a high mortality rate during the 2 year follow-up period (39.4%), especially in older patients. The high mortality during follow-up stressed the importance of after-discharge care in these patients.

Delusional jealousy in dementia

BACKGROUND

Delusional jealousy is a major motive for violence and is sometimes found in demented patients. This study was undertaken to investigate the frequency and the characteristics of delusional jealousy in demented patients.

METHOD

The sample population consisted of 133 demented patients admitted to the geropsychiatric ward. Patients with and without delusional jealousy were compared in terms of general characteristics and psychotic symptoms.

RESULTS

Of the 133 demented patients, 21 (15.8%) showed delusional jealousy. Delusional jealousy was found in various types of dementia. There were no significant differences between the two groups in regard to age, age at onset, gender, educational level, and Mini-Mental State Examination score. All patients with delusional jealousy had at least one other psychotic symptom.

CONCLUSION

Delusional jealousy is a common problem in dementia. The psychobiological factors of delusional jealousy and cognitive function in demented patients may differ. There may be various underlying factors for the development of delusional jealousy in dementia.

Intramural coronary artery disease in swine with naturally occurring hypertrophic cardiomyopathy

Intramural coronary artery disease (ICAD) has been reported in myocardium affected with hypertrophic cardiomyopathy (HCM), but has never been studied in detail with respect to the cell type or lipid infiltration involved in the wall-thickening. The lack of heart samples may be one of the rationales to hamper the progress in investigating this disease. Recently, the discovery of naturally occurring HCM in swine has provided an excellent opportunity for the study of ICAD because of the high prevalence of ICAD in this animal. The present study provides a detailed structure feature in the thickened arterial wall of ICAD by both histologic and electron microscopic means. Morphologically, the feature of ICAD is due primarily to the neointimal thickening. Smooth muscle cells (SMC) and extracellular matrix (collagen and elastic fibers) are the major components responsible for the thickened neointima. Fragmentation of the internal elastic membrane is associated with the migration and proliferation of SMC from the media to the intima. Therefore, pigs with HCM may be a potential animal model not only for the study of the mechanism by which SMC migrate and proliferate into intima, but also for the future investigation of interventions in coronary artery occlusion.

Capgras' syndrome in a patient with vascular dementia: a case report

Capgras' syndrome is characterized by a subjective certainty that a familiar person has been replaced by an identical double. This syndrome has been observed in psychiatric and neurological diseases, and has been reported in several cases of dementia of the Alzheimer type. Here, we present a patient with vascular dementia in whom Capgras' syndrome developed in the early stages of dementia, and who exhibited violence. This case suggests that Capgras' syndrome can occur in vascular dementia. In older patients with this syndrome, dementia should also be considered in its differential diagnosis. In addition, patients with Capgras' syndrome should be evaluated for violent potential.

Behavioural disturbances in psychiatric inpatients with dementia of the Alzheimer's type in Taiwan

This report studied behavioural disturbances in psychiatric inpatients with dementia of the Alzheimer's type (DAT) in Taiwan. The sample consisted of 75 inpatients with DAT who were consecutively admitted to the geropsychiatric ward. Their behavioural disturbances were obtained from semistructured interviews with families and ward observation. There were eight main behavioural disturbances: getting lost, repetitive phenomena, sleep disturbance, aggression, wandering, hyperphagia, hoarding behaviour, and inappropriate sexual behaviour. Number of behavioural disturbances, wandering, hyperphagia and sleep disturbance were significantly associated with the severity of cognitive impairment.

Delusions of theft in dementia of the Alzheimer type: a preliminary report

Delusions of theft are commonly found in patients with dementia of the Alzheimer type (DAT). This report describes the frequency, onset, and characteristics of delusions of theft in DAT patients. The sample consisted of 54 geropsychiatric inpatients with DAT; delusions of theft were found in 30 (55.6%) patients. Two thirds of these patients had delusions of theft within 1 year after onset of illness. There were no significant differences in age, age of onset, duration of disease, years of education, or the Mini-Mental State Examination (MMSE) score between patients with and without delusions of theft. Delusions of theft frequently occur in the early stage of dementia, when the patients' cognitive impairments are relatively mild. The presence of this symptom may warrant a diagnosis of DAT.

Organic delusional disorder in psychiatric in-patients: comparison with delusional disorder

Organic delusional disorder (ODD) is rarely diagnosed in psychiatric in-patients, and may be misdiagnosed as delusional disorder (DD) from a similar clinical presentation. The aim of the present study was to investigate the characteristics of ODD and to make a comparison with those of DD patients. Patients who conformed to DSM-III-R criteria for ODD were recruited from an 8-year psychiatric in-patient database. Matching controls were DD patients admitted over the same time period. The prevalence of ODD according to DSM-III-R criteria was 0.4% of total admissions and 2.9% of organic mental disorders. Compared to DD patients, ODD patients less often had a family psychiatric history, and had an older age of onset of psychiatric disorder, longer hospital stays and lower treatment dosage of antipsychotic drugs. It is suggested that a detailed medical history and examination are needed in patients with delusion, especially in patients with a late onset of psychiatric symptoms and no family psychiatric history.

Psychotic symptoms in psychiatric inpatients with dementia of the Alzheimer and vascular types

BACKGROUND

Demented patients often manifest psychotic symptoms including delusion, hallucination and misidentification. This report attempts to describe the frequencies and characteristics of such symptoms in psychiatric inpatients with dementia, and to identify the characteristics of dementia with and without psychotic symptoms.

METHODS

The study included 78 demented patients who were consecutively admitted to the psychiatric ward. Their psychotic symptoms were obtained from semistructured interview and the assessment using BEHAVE AD. Delusion and hallucination were rated as "present" if the descriptions were consistent with the definition of Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). Misidentification was defined individually.

RESULTS

There were 54 patients with DAT and 24 patients with VD. The frequency of psychotic symptoms in DAT and VD was 71.8%. The frequency of delusion in DAT and VD was 59.0%, misidentification, 33.3% and hallucination, 25.6%. Demented patients with psychotic symptoms were older (p = 0.037) than those without psychotic symptoms.

CONCLUSIONS

Psychotic symptoms are common in psychiatric inpatients with DAT and VD, the most common being delusional. Delusion of theft is the most common one. Demented patients with psychotic symptoms were older than those without.

[Characteristics of dementia patients with hyperphagia]

Research into dementia has tended to concentrate on memory loss and other cognitive impairment, but attention has recently turned to the associated psychiatric symptoms and behavioral abnormalities. Among them, increases in the amount eaten or hyperphagia are not uncommon in dementia. This problem is of clinical importance since it not only jeopardizes patient's health, but also is a cause of caregiver burden. The aim of this study was to assess the prevalence of hyperphagia in dementia. Additionally, possible mechanisms underlying this problem were reviewed and related to the demographic data, cognitive function test, radiological findings and other psychiatric symptoms. Out of a sample of 91 demented inpatients, hyperphagia was present in 30.8%. Hyperphagia was significantly associated with delusion, misidentification, aggressive behavior, hoarding behavior and pica phenomena. But these patients did not show difference in cognitive function, radiological abnormalities, repetitive behavior and depressed mood when compared with other demented patients. The possible etiologies were discussed, including physiological and psychological factors. Hyperphagia is a complex phenomenon, better understanding of the underlying pathogenesis may highlight specific pharmacological or behavioral methods for the management this troublesome behavior.

Physical aggression and associated factors in probable Alzheimer disease

Aggressive behavior is thought to be pervasive among and devastating to demented patients and their caregivers. This study investigated the prevalence of physical aggression in demented inpatients with Alzheimer disease (AD). Additionally, the characteristics and psychiatric symptoms that may be associated with aggression were tested. Forty-seven patients with probable AD were included in this study. Physical aggression was reported in 27 (57.4%) of the patients. These patients were older, had a later onset of dementia, and had a higher prevalence of misidentification, activity disturbances, and day/night disturbance. The relationship between these factors and physical aggression needs further clarification, which may help provide effective predictors and treatment of the aggressive behavior.

[Characteristics of dementia patients with aggressive behaviors]

Aggressive behaviors are found in dementia patients and pose major problems for their caregivers and may be amenable to treatment. The present study aims to determine the frequency of aggressive behaviors in dementia patients and to test whether there is a relationship with the psychiatric symptoms. Ninety-one dementia patients from a geriatric psychiatry unit were surveyed for the aggressive behaviors and psychiatric symptoms by semi-structured interview with the patients and their caregivers. Major findings included that 53.8% of these patients had aggressive behaviors; these patients were older and had later onset of dementia; the presence of hallucination, misidentification and wandering were significant predictors of physical aggression; the association of aggressive behaviors with the cognitive test and delusion was not significant. These observations suggest that dementia patients have a high prevalence rate of aggressive behaviors that warrants the prevention and intervention. Hallucination, misidentification and wandering are risk factors for physical aggression and potentially trestable. Further research is needed to identify the cause and the management of aggressive behaviors in dementia patients.

[Characteristics of elderly patients admitted to the psychiatric ward of a general hospital]

The rapid growth of the over 65 population in Taiwan during recent decades has brought into focus the planning to provide health care for aged citizens. It is generally agreed that the incidence of mental disorders rises with age. With the stress on rapid treatment and early return to community, the concept of short-term hospitalization for the geropsychiatric patients has become more accepted. In this study we examined characteristics, diagnostic classification and treatment outcomes of 524 consecutive patients (age > or = 65) admitted to the geropsychiatric unit of a general hospital over a 5-year period. Results demonstrated that 45.9% of the patients had organic mental disorders. Among them, almost half of the patients were diagnosed as having dementia; delirium was the second most common diagnosis. The average length of stay was 26.7 days for all patients and it was not affected by diagnostic subtype. No significance was found in the length of stay between the geropsychiatric inpatients and the other psychiatric inpatients. Outcomes measure showed favorable response to hospitalization in most of these patients. These data suggested that there is a specific diagnostic distribution in the geropsychiatric inpatients. Rigorous organic work-up in these patients is necessary to rule out organic problems. The favorable response after short-term hospitalization indicated the restorative and rehabilitative functions of the general hospital geropsychiatric care. The hospital's fears of being burdened with a chronic population could be lessened with a suitable referral system. Further study is needed to explore whether early geropsychiatric intervention may obviate the need for admission or reduce the length of stay.