Innovations In Clinical Neuroscience

MAR-APR 2018

A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience

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26 ICNS INNOVATIONS IN CLINICAL NEUROSCIENCE March-April 2018 • Volume 15 • Number 3–4 R E T R O S P E C T I V E S T U D Y statin therapy and loss of behavioral control as evidenced by a CG (F=0.068; p=0.795) or use of RS (F=0.000; p=1.000). The mean total cholesterol levels were similar between the two groups (176.5mg/dL for those receiving statin therapy and 174.8mg/dL for those not receiving statin therapy), which facilitated the analysis of total serum cholesterol level versus CG and RS. Using ANOVA to assess the full range of cholesterol levels collected, a statistically significant relationship was found between total cholesterol level and requirement of a CG (F=1.435; p=0.029) and RS (F=2.891; p=0.000), indicating that increased psychiatric emergencies appear to be associated with total cholesterol level. Patients with lower total serum cholesterol levels in this inpatient sample were more likely to experience aggression and loss of behavioral control than those with normal or elevated serum cholesterol levels. DISCUSSION We found no statistical significance in the proposed relationship between receiving statin therapy and an increased incidence of CG or RS. Therefore, our results do not replicate the findings reported in the current literature supporting the hypothesis that the use of statin therapy results in an increased risk of patient aggression. The majority of our patients on statin therapy were either admitted to our psychiatric facility having already been prescribed statin therapy or had statin therapy initiated by an inpatient provider within 30 days of their admission. If the patient was initiated on statin therapy prior to hospital admission, the duration of his or her therapy prior to becoming an inpatient was unknown. Aggression, agitation, or loss of behavioral control could also have been measured by the number of psychiatric PRNs given; unfortunately, we were unable to effectively compare any differences in PRN medication use because all 114 patients were either admitted to the hospital receiving statin therapy or were initiated on statin therapy within 30 days of admission, which would not provide an adequate time period for comparison. Future analysis could be beneficial in examining this possible relationship, as PRN medications are often administered as a de-escalation intervention prior to the requirement of a CG/ RS. We were unable to analyze whether different statin medications could have contributed to increased aggression in the psychiatric inpatient population as many patients changed statin therapy throughout their hospitalization due to insurance formulary changes, and there was not a robust nor equal number of patients receiving each particular statin. Due to the small sample size, we were also unable to conduct a statistical analysis controlling for primary psychiatric diagnosis and severity, patient age, or patient sex and whether these variables contributed to instances of CG or RS. Our primary goal of exploring a potential link of statin use to aggression led to a secondary detection of significant unexplained deviations from current statin guideline recommendations involving calculated ASCVD risk and intensity of statin prescribed, thus warranting further independent evaluation. The number of CGs and RSs each patient required were only counted during the first year of admission for our control group as this is when patients are likely to be the most psychiatrically unstable. Total cholesterol levels used during this analysis were within one year of admission in order to match statin initiation date and CG/RS time period. This ensured the comparison between statin therapy, cholesterol level, and aggression was well matched and could be extrapolated to other psychiatric patients. Only total cholesterol levels were assessed during this analysis because not all patients had complete fasting lipid panels (FLPs); the majority of hospitalized patients only had total cholesterol and triglyceride levels available. Future analysis could assess whether LDL levels contribute to increased risk of aggression in psychiatric inpatients, considering statin therapy does primarily impact LDL level. Future analysis could be beneficial in examining at what total cholesterol level does the risk of aggression increase because this was not assessed during our analysis. The ANOVAs suggested that total cholesterol levels, and not statin therapy, were associated with increased CGs/use of RS. Our analysis demonstrates that increased aggression in psychiatric patients is very likely not a result of statin therapy, but instead a lower total cholesterol level, whether driven by statin therapy or by natural propensity. It appears that psychiatric patients with lower total cholesterol levels could be at an increased risk for loss of behavioral control aside from mitigation with both psychiatric medications and the inpatient milieu. CONCLUSION Recent trials and literature were specifically evaluated for behavioral changes associated with statin use. While cardiovascular benefits of statin medications have resulted in increased FIGURE 1. Percent of patients requiring behavioral control interventions, including "code green" and/or "restraint/ seclusion"

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