Integrated Care Pathways Improve Older Schizophrenia Patient Care

Using an integrated care pathway to treat older patients with schizophrenia can produce higher monitoring rates and less psychotropic polypharmacy, according to a recent report.

Researchers from Toronto reviewed the medical records of 100 older patients with schizophrenia using an integrated care pathway and compared them to the medical records of 100 older patients with schizophrenia, using a treatment-as-usual approach in order to determine the use of recommended tools to monitor for adverse effects linked to antipsychotic use in older patients.

The investigators explained that integrated care pathways are designed to manage specific conditions using standardization assessments and measurement-based interventions. Because they were older (the majority were aged 65 years or more), these patients patients were more likely to experience adverse effects such as tardive dyskinesia, orthostasis, postural instability, falls, and cognitive impairment.

These conditions can have a direct impact on medication adherence, investigators noted, but integrated care pathways can improve the quality of care. Previous studies on integrated care pathways used in schizophrenia did not examine the effects on older patients, prompting this new analysis.

The following tools were employed to monitor the patients in the study: a metabolic tool tracking weight, height, waist circumference, fasting glucose, hemoglobin A, and lipid profiles; the Barnes Akathisia Rating Scale; the Abnormal Involuntary Movement Scale (AIMS); the Falls Risk Assessment; the Simpson-Angus Scale; and the Montreal Cognitive Assessment.

The integrated care pathway patients were diagnosed with schizophrenia or schizoaffective disorder, while 42 treatment-as-usual patients had 1 of these 2 diagnoses. The remaining treatment-as-usual patients had either major depressive disorder, bipolar disorder, neurocognitive disorder, and anxiety as their primary diagnoses.

Investigators found that monitoring rates were significantly higher in the integrated care pathways group than the treatment-as-usual patients across all measures. This included extrapyramidal symptoms (94% vs 5%), metabolic disturbances (91% vs 25%), fall risk (82% vs 35%) and cognitive impairment (72% vs 28%).

Despite the fact that it is not recommended—because it can increase the risk for adverse effects—investigators also examined antipsychotic polypharmacy among the 2 groups. The rates of antipsychotic pharmacy were 6 times greater in the treatment-as-usual group compared to the integrated care pathways cohort.

“Overall, this study augments the sparse literature on the use of integrated care pathways in patients with schizophrenia,” investigators wrote. “It is focused on older patients, but we believe integrated care pathways can increase the quality of care provided to all patients with schizophrenia.”

They added that although this analysis did not address whether this integrated care pathway intervention led to improved clinical outcomes, no published schizophrenia study looking at integrated care pathways have so far made that determination. Plus, as a retrospective review, consideration may not have been made for some of the treatment-as-usual monitoring being conducted informally.

“[The] results need to be confirmed and extended in a randomized controlled trial (with randomization at the clinician or practice level) that would assess not just quality of care but also clinical outcomes,” they concluded.

The paper, “Using an Integrated Care Pathway for Late-Life Schizophrenia Improves Monitoring of Adverse Effects of Antipsychotics and Reduces Antipsychotic Polypharmacy,” was published online in The American Journal of Geriatric Psychiatry.