Overview - Legacy Hospice



PURPOSE:

To establish guidelines and clinical protocol for a visit with a patients with schizophrenia.

EQUIPEMENT:

None

OVERVIEW

Schizophrenia is a mixture of positive and negative symptoms that present for a significant portion during a 1 month period but persists for at least 6 months. Several subtypes exist. The clinical picture is complex and symptoms may differ in an individual from episode to episode. The natural progression of schizophrenia is deterioration over time with an eventual plateau in the symptoms. It is a chronic brain disease. The goals of treatment in the Behavioral Health Homecare Program are to reduce stress on the patient and provide support for the following:

1. Relapse prevention through symptom reduction.

2. Minimize likelihood of relapse (crisis re-hospitalization and emergency room visits).

3. Promote functional improvement and adherence to plan of care.

PROCEDURE:

Tools Used to Determine Medical Necessity

Based upon presenting signs and symptoms various tools will be administered to the patient at the evaluation visit, upon start of care to the program and at discharge. All patients will receive the Brief Psychiatric Rating Scale and when anti-psychotics are ordered, the Abnormal Involuntary Movement Scale.

1. Aggression Scale: Administered if the patient exhibits aggression. It measures the amount and type of aggression exhibited. The score corresponds to an acuity level. Interventions and a behavioral plan should be implemented to reduce the incidence and frequency of the behavior.

2. Abnormal involuntary movement scale (AIMS): Used for all patients who are on an anti-psychotic medication. The score corresponds to an acuity level. Interventions are implemented based on the acuity.

3. Brief psychiatric rating scale (BPRS): Rates psychiatric behaviors and symptoms for patients with major mental illness. The score corresponds to an acuity level. Interventions are implemented based on acuity.

4. SAD PERSONS suicide risk assessment: A scale used to assess the likelihood of a suicide attempt, based on risk factors.

5. Geriatric depression scale (GDS) or Patient health questionnaire (PHQ9) – See Depression Visit Guideline/Clinical Protocol.

a. Core Symptom Clusters:

1) Positive symptoms - Excess or distortion of normal function.

• Hallucinations.

• Delusions.

• Thought disorder.

• Disorganized speech.

• Bizarre behavior.

• Inappropriate affect.

(2) Negative symptoms - Lessening or loss of normal functions

• Affective flattening.

• Alogia.

• Avolition, apathy.

• Anhedonia, asociality.

• Attentional deficit.

(3) Neurocognitive impairment

• Memory.

• Attention, vigilance.

• Executive functions, abstraction, concept formation, problem solving, decision making.

(4) Mood symptoms

• Dysphoria.

• Suicidality.

• Hopelessness.

Phases of Schizophrenia Treatment and Associated Treatment Goals

1. Acute-1-3 days- Goal is to control agitation and behavior and provide safety. Most often, these patients are hospitalized.

2. Stabilization-7-14 days- Goal is to stabilize positive, negative and depressive symptoms, establish a medication regime and teach/educate (first 7 to 10 days usually is performed by inpatient staff then patient is discharged to the community). This is a vulnerable time; although positive symptoms have improved some positive symptoms remain.

a. During this time the person would benefit from a Behavioral health intervention.

b. The admission of a patient: 1) from an in-patient unit who will be at the end of the stabilization phase of treatment and the early portion of the stable phase or 2) medically ill patients with a concurrent diagnosis of schizophrenia and with an acute symptom exacerbation of the chronic mental illness.

3. Stable – 6 months or more-Goal is to improve symptoms particularly negative; enhance global functioning; psychotherapy; psycho education; promote reintegration; prevent relapse.

a. In this phase the behavioral interventions will provide services for a defined period of time. For example, 1-2 episodes followed by a referral to out patient psychiatric services for on-going monitoring and treatment.

Co-Morbid Medical Illness or Risks Associated with Schizophrenia:

This is pervasive in schizophrenia and leads to a significant decrease in the life span for schizophrenics.

1. Elevated rates of cardiovascular mortality due to multiple risk factors.

2. Weight gain during antipsychotic treatment leads to predictable disturbances in glucose and lipid metabolism and increase cardiovascular risk.

Emergent Care Issues/Risk Assessment Associated with Schizophrenia:

1. Suicidal Ideation-Suicide is the leading cause of premature death among patients with schizophrenia. Evaluate risk on a regular basis.

2. Aggressive behavior-A minority of patients have an increased risk. The risk increases with co-morbid alcohol (ETOH) abuse, substance abuse, antisocial personality or neurological impairment. Identify risk factors and evaluate behavior on a regular basis.

3. Water Intoxication-polydipsia and polyuria.

4. Neuroleptic Malignant Syndrome-medication emergency.

5. Acute Dystonic Reaction.

Commonly Used Medications: (not a complete list)

1. Anti psychotic medicationsAdjunctive medications:

a. Benzodiazepines-Clonazepam (Klonopin), Lorazepam (Ativan).

b. Anti-depressants- Sertraline (Zolft), Citalopram (Celexa), Amitriptyline, Duloxetine (Cymbalta), Venlafaxine (Effexor), Selegiline (Emsam).

c. Mood stabilizers- Divalproex (Depakote), Carbamazepine (Tegretol), Valproate (Depakene), Lamotrigine (Lamictal), Gabapentin (Neurontin), Topiramate (Topamax).

2. Beta-blockers

a. Specific and actual teaching/training interventions are defined below: These interventions are inclusive of categories that will ensure overall safe and quality care for the patient with schizophrenia and are defined by a recommended visit occurrence.

Visit recommendations are based upon the necessity and urgency of the information provided and the ability of the patient to learn and understand the information.

Management Transition from Stabilization to Stable Treatment Phase:

1. Clinician will make between 5-18 visits for a period of one (1) to two (2) episodes.

2. The visit frequency most likely will be once a week (QW) or twice a week (BIW) initially for more symptomatic patients.

Assessment/Interventions:

Every Visit:

1. Mental status evaluation.

2. Vital signs.

3. Weight.

4. Presence/severity of symptoms impairing functioning(e.g.-self care):

a. Positive symptoms.

b. Negative symptoms.

c. Neurocognitive impairment.

d. Mood symptoms.

e. Suicidal ideation/risk.

1) Identify target symptom(s)

a) Have patient score target symptoms on a scale of 0-10 each visit.

b) Observe for resurgence of symptoms.

2) Assess for treatment non-adherence behaviors.

3) Medication compliance with anti-psychotic and adjunctive medication.

4) Lab test results

a) CBC for patients treated with clozapine.

b) Consult with treating provider for appropriate lab monitoring.

f. Subjective distress due to side effects of the medication-this impacts on adherence to treatment (see below)

1) Extrapyramidal (EPS) side effects

2) Pseudoparkinsonism: masklike facies, stiff and stooped posture, shuffling, gait, drooling, tremor, “pill-rolling” phenomenon.

3) Acute Dystonic Reactions: Acute contractions of tongue, face, neck and back (tongue and jaw first).

4) Akathisia: Motor inner-driven restlessness (foot tapping incessantly, rocking forward and backward in chair, shifting weight from side to side).

5) Tardive Dyskinesia:

6) Facial: Protruding and rolling tongue, blowing, smacking, licking, spastic facial distortion, smacking movements.

7) Limbs:

a) Choreic: rapid, purposeless, and irregular movements.

b) Athetoid: Slow, complex, and serpentine movements.

c) Trunk: Neck and shoulder movements, dramatic hip jerks and rocking, twisting pelvic thrusts.

Teaching /Training Topics

1. Disease process:

a. Course and Outcome.

b. Causation-several accepted models.

1) Brain structure and functioning.

2) Genetics.

3) Psychological stress.

4) Environmental.

5) Vulnerability stress.

c. Psychopharmacologic agents-include drug action, dosage, frequency, possible adverse effects and importance of adherence. Link positive effects of medication with patients goals.

Self care activities:

1. Hygiene.

2. Prevent/reverse weight gain (anti psychotics, mood stabilizers and anti depressants can all cause weight gain). Be cognizant of hypertension, lipid abnormalities, clinical symptoms of diabetes, fasting glucose, hemoglobin A1c levels.

3. Assess need for nutritional services consult.

a. Patient self management strategies.

1) Self monitoring of symptoms.

2) positive, negative, cognitive impairments.

b. Teach behavioral strategies.

1) Nutrition (e.g., monitor calorie intake, portion control).

2) Activity and exercise (e.g., increase activity).

c. Identify and address occurrence of life stresses and events that.

1) Increase the risk of relapse.

2) Are obstacles to functional recovery

d. Family Education.

e. Decrease family/caregiver stress.

f. Family psycho education (as indicated).

Perform Skilled Cognitive Behavioral Therapy (CBT)/ Psychotherapy Techniques:

CBT is typically used as an adjunct to pharmacotherapy and involves identifying maladaptive cognitions and behaviors that may be barriers to a person’s recovery and symptom reduction. In treating schizophrenia CBT techniques are used to treat positive and negative symptoms, to treat co morbid depression and anxiety, for relapse prevention and to establish step by step plans to cope with symptoms and stress of daily life and any setbacks.

1. Establish a strong therapeutic alliance.

a. Acceptance support, collaboration.

2. Develop and prioritize problem list.

a. Target Symptoms (include negative and positive).

b. Treatment goal-management of symptoms.

3. Educate and normalize symptoms.

a. Disease process.

b. Medication acceptance/adherence.

c. Role of stress on symptoms.

d. Decrease mental illness stigma through education.

4. Educate about CBT.

a. Identify links between thoughts, feelings and behaviors.

b. Identify themes from the problem list.

c. Share formulation and cognitive focus with patient.

5. CBT for Positive and Negative Symptoms.

a. Test and re-frame beliefs.

b. Weigh the evidence.

c. Alternative explanations.

d. Behavioral experiments.

e. Elicit self-beliefs.

f. Investigate hierarchy of fears and suspicions.

g. Use images.

h. Use role playing.

i. Coping strategies.

6. CBT for Co-Morbid Depression and Anxiety.

a. Adapt standard strategies for anxiety and depression.

b. Test and reframe beliefs related to anxiety and depression.

c. Focus on misinterpretations.

d. Use relaxation exercises.

e. Use activity exercises.

7. Relapse Prevention.

a. Identify triggers/hi risk situations

b. Compliance with medication regimen. Teach patient:

1) to report side effects ASAP.

2) the benefit of medication to decrease symptoms.

3) to obtain family assistance in monitoring adherence.

4) to use environmental supports to cue and reinforce medication taking.

c. Responsiveness of supports (formal and informal).

d. Establish step-by-step action plan to deal with setbacks.

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