Central Nervous System Medications Research Articles

313 Potentially Inappropriate Medications Do Not Clinically Impact Trauma Recidivism in the Elderly

The study evaluated the association between potentially inappropriate medications (PIM) as defined by Beers’ Criteria and the risk of trauma recidivism in the elderly. The American Geriatric Society (AGS) modified the list of PIMs in 2012 to include 19 categories of medications with limited effectiveness in the elderly but with a positive association with complications such as delirium, bleeding, fracture and falls, a major cause of elderly trauma. We hypothesized that the presence of PIM increases the risk of trauma recidivism. This case-control study reviewed patients over age 65 evaluated at a single Level 1 Trauma center from February 1, 2013 through August 1, 2018. We performed a 1:1 propensity score matched analysis using age and sex between injured patients with one trauma evaluation at any level of trauma activation and those with more than one trauma evaluation during the study period. We used a receiver operating characteristic (ROC) curve to determine the number of PIM with a maximum predictive value for recidivism. Area under the curve (AUC) with 95% confidence intervals (CI) were calculated. We also evaluated if there were specific categories of PIM that were associated with recidivism using Chi square analysis. A p value of <0.05 was deemed significant. During the study period, there were 11,089 trauma evaluations meeting study criteria. 8252 patients had one trauma evaluation only and 2837 patients had more than one trauma evaluation for a 26.2% recidivism rate. Propensity matching resulted in 2324 patients in each group. Patients with one trauma evaluation and recidivists had similar mean number of total medications (12.34, standard deviation (SD) 6.71 vs 12.67, SD 6.83, p = 0.09) but those with one trauma evaluation had a lower mean number of PIM (11.09, SD 6.74 vs 11.88, SD 6.99, p =0.001). ROC curve analysis showed that the maximum predictive threshold was 11 PIM (AUC = 0.545, 95% CI=0.529-0.560). In addition, analgesics, antidepressants, antiplatelets, antipsychotics, anxiolytics, central nervous system medication and stimulants were each significantly associated with recidivism (p <0.001 for all categories). Recidivists were on a greater mean number of medications in these seven categories than non-recidivists (6.45, SD 3.034 vs 6.15, SD 3.038, p = 0.001) PIM are statistically associated with trauma recidivism in the elderly. However, of the 19 categories of PIM identified by the AGS, only seven were associated with recidivism. Moreover, as the mean number of PIMs differed by less than one between the two groups, the clinical significance of our findings is doubtful. We conclude that PIMs do not clinically influence trauma recidivism in the elderly.

Polypharmacy patterns in the last year of life in patients with dementia

PurposeTo describe prescribing of medicines in primary care in the last year of life in patients with dementia.MethodA retrospective cohort analysis in UK primary care using routinely collected data from the Clinical Practice Research Datalink. Number of medications and potentially inappropriate medication prescribed one year prior to, and including death, was ascertained.ResultsDementia patients (n = 6923) aged 86.6 ± 7.3 years (mean ± SD) were prescribed 4.8 ± 4.0 drugs 1 year prior to death, increasing to 5.6 ± 4.0 2 months prior, before falling to 4.9 ± 4.1 at death. One year prior to death, 50% of patients were prescribed a potentially inappropriate medication, falling to 41% at death. Cardiovascular medications were the most common, with decreases in drug count only occurring in the last month prior to death. Prescriptions for gastrointestinal and central nervous system medication increased throughout the year, particularly laxatives/analgaesics, antidepressants and hypnotic/antipsychotics. Women (vs. men) and patients with Alzheimer’s (vs. vascular dementia) were prescribed 4.7% (95% CI 2.3%–7%) and 14.6% (11.7–17.3%) fewer medications, respectively. Prescribing decreased with age and increased with additional comorbidities.ConclusionsDementia patients are prescribed high levels of medication, many potentially inappropriate, during their last year of life, with reductions occurring relatively late. Improvements to medication optimisation guidelines are needed to inform decision-making around deprescribing of long-term medications in patients with limited life-expectancy.

The Therapeutic Potential of Resveratrol in Gliomas

Resveratrol (RSV) is found in most human foods especially fruits such as grapes, peanuts, strawberry, blueberry, cranberry, mulberry, lingberry, sparkleberry, bilberry and in flowers as well as leaves like butterfly orchid tree, eucalyptus, spruce, lily, gnetum and so many others. Functionally, RSV has the propensity to safeguard DNA as well as the induction of DNA repair. RSV is precipitously metabolized in the liver via phase-II detoxification enzymes leading to its principal urine excretion. RSV steered growth inhibition, induction of apoptosis and G0/G1-phase cell cycle arrest in an experiment involving glioma cells. RVS can block the triggering of signal transducer and activator of transcription (STAT3) signaling of glioma cells. RSV subdues STAT3 signaling via the inhibition of SRC or Janus kinase (JAK2) induction, thereby inducing growth inhibitory and apoptotic properties. RSV explicitly blocks both COX-1 and COX-2 in-vitro. In the cancer inflammatory milieu, the blockade effects of RSV on NF-κB could also lead to the blockade of TNF-α resulting in inhibition of cancer advancement as well as metastasis. Individually, RSV has proven to very potent in glioma cells. It is able to down-regulate glioma angiogenesis as well as metastasis. In combination with other agents, RVS augment its potency in glioma. RVS is able to cross the blood brain barrier (BBB) via gap junctions making it very efficient central nervous system medication. RVS after oral administration peaks in the blood stream after one hour meaning it acts very fast. This review focuses on the neuropharmacological role of RVS in glioma.

Normal brain metabolism on FDG PET/MRI during childhood and adolescence.

The aim was to investigate normal patterns of brain metabolism determined by F-fluorodeoxyglucose positron emission tomography (FDG PET)/MRI during childhood and adolescence. A retrospective analysis was carried out on all paediatric patients who underwent FDG PET/MRI at our institution between March 2016 and August 2017. Exclusion criteria were neurological disease, central nervous system metastases, previous chemotherapy/radiotherapy, general anaesthesia/sedation and medications suspected to affect cerebral metabolism. Standardized uptake value (SUV)mean and SUVmax were calculated for 12 brain grey matter regions. Subgroup analysis of childhood (≤10 years old) and adolescence (≥11 years old) was also carried out. From 492 PET/MRI scans, 28 patients (11 children, 17 adolescents) were deemed representative of normal brain metabolism. SUVmean and SUVmax increased with age in all regions. The highest rates of increasing SUVmean were in the thalamus, basal ganglia, frontal lobes, insula and occipital lobes. Higher SUVmean was found in the right frontal, right lateral temporal, right temporal pole, right cingulate/paracingulate, right thalamus, left occipital, left basal ganglia, left insula and left cerebellum compared with the contralateral side. This SUVmean asymmetry was present in both childhood and adolescence in the majority of regions. The highest rates of increasing SUVmax with age were in the occipital lobes, frontal lobes, thalamus and central region. There was no asymmetry in SUVmax in the majority of regions. This FDG PET/MRI study shows that normal brain metabolism measured by SUVmean and SUVmax increases with age in all regions, proceeding at different rates between distinct anatomical sites. Our results suggest that there is mild asymmetry in SUVmean, but mostly symmetric SUVmax during normal development.

Central Nervous System Medication Burden and Risk of Recurrent Serious Falls and Hip Fractures in Veterans Affairs Nursing Home Residents.

To examine the association between central nervous system (CNS) medication dosage burden and risk of serious falls, including hip fractures, in individuals with a history of a recent fall. Nested case-control study. Veterans Health Administration (VHA) Community Living Centers (CLCs). CLC residents aged 65 and older with a history of a fall or hip fracture in the year before a CLC admission between July 1, 2005, and June 30, 2009. Each case (n = 316) was matched to four controls (n = 1264) on age, sex, and length of stay. Outcomes were serious falls identified using International Classification of Diseases, Ninth Revision (ACD-9) or Current Procedural Terminology (CPT) E codes, diagnosis codes, or procedure codes associated with a VHA emergency department visit or hospitalization during the CLC stay. Bar code medication administration data were used to calculate CNS standardized daily doses (SDDs) for opioid and benzodiazepine receptor agonists, some antidepressants, antiepileptics, and antipsychotics received in the 6 days before the outcome date by dividing residents' actual CNS daily doses by the minimum effective geriatric daily doses and adding the results. Multivariable conditional logistic regression models were used to evaluate the association between total CNS medication dosage burden, categorized as 0, 1 to 2, and 3 or more SDDs, and the outcome of recurrent serious falls. More cases (44.3%) than controls (35.8%) received 3.0 or more CNS SDDs (p = .02). Risk of serious falls was greater in residents with 3.0 or more SDDs than in those with 0 (adjusted odds ratio (aOR)=1.49, 95% confidence interval (CI)=1.03-2.14). Those with 1.0 to 2.9 SDDs had a risk similar to that of those with 0 SDDs (aOR=1.03, 95%CI=0.72-1.48). Nursing home residents with a history of a fall or hip fracture receiving 3.0 or more CNS SDDs were more likely to have a recurrent serious fall than those taking no CNS medications. Interventions targeting this vulnerable population may help reduce serious falls. J Am Geriatr Soc 67:74-80, 2019.

PCP30 - COMPARISON REGARDING THE TRANSPARENCY OF REIMBURSEMENT DECISIONS FOR PHARMACEUTICALS USED TO TREAT DEPRESSION IN HUNGARY, ROMANIA, TURKEY AND CIS

Increased transparency with regard to how Central Nervous System (CNS) medication - with a particular emphasis on Depression - is assessed throughout the reimbursement process has several benefits: justifies for previous decisions, may influence reflection on patients needs and gives clear market access criteria for manufacturers. Our objective was to highlight the level of transparency of Drugs used to treat Depression in some European countries: Hungary, Romania as well as neighboring areas such as Turkey and CIS. We evaluated HTA process for Drugs used to treat Depression (or in general CNS drugs) against a pre-defined scorecard of transparency. Information was obtained from public sources: websites of governmental institutions and official legislations. Evaluation was made on the following six elements: requirements for reimbursement, availability of submitted documents by manufacturers, process of the submissions evaluation or appraisal, recommendations by those who conducted evaluation, final reimbursement decision, follow-up on decisions. In Hungary an HTA guideline and a critical appraisal checklist are available to draw up the basic requirements for reimbursement submissions. However, apart from the final decision no other transparency element is available. In Romania, he current general legislation provides clear timelines and evaluation criteria, in reality, the deadlines are not met. Criteria for evaluation are clearly mentioned in the legislation, but a more clear guidance is still required. In Turkey and CIS, the overall legislation provides clear information for the P&R process. Even if important steps in providing a clear and transparent HTA process for CNS drugs had been established in the legislative framework of the different countries, many areas require improvement. This could be done through clear published submission timeline, closing the gap between evaluation process and actual reimbursement, functional appealing committee and objective criteria are still missing in key points of the evaluation process.

Longitudinal study of falls among HIV-infected and uninfected women: the role of cognition.

Although fracture rates are higher in HIV+ than HIV- women, whether HIV infection increases risk of falls is unclear. We determined the longitudinal occurrence and risk factors for falls in the Women's Interagency HIV Study (WIHS), and explored associations with cognitive complaints. Recent (prior 6 months) self-reported falls were collected in 1,816 (1,250 HIV+; 566 HIV-) women over 24 months. Generalized estimating equation models using stepwise selection determined odds of any fall (versus none). HIV+ women were older than HIV- women (median 49 versus 47 years; P=0.0004), more likely to report neuropathy (20% versus 16%; P=0.023), and had greater central nervous system (CNS) medication use. At least one fall was reported in 41% HIV+ versus 42% HIV- women, including ≥2 falls in 25% HIV+ and 24% HIV- (overall P=0.30). Cognitive complaints were associated with falls among HIV+ (odds ratio [OR] 2.38; 95% CI 1.83, 3.09) and HIV- women (OR 3.43; 95% CI 2.37, 4.97); in adjusted models, cognitive complaints remained significant only in HIV- women (adjusted [aOR] 2.26; 95% CI 1.46, 3.48). Factors associated with any fall in adjusted analyses included: depressive symptoms and neuropathy (both HIV+ and HIV-); age, marijuana use, multiple CNS medications, and HCV infection (HIV+ only); and cognitive complaints, quality of life, hypertension and obesity (HIV- only). Middle-aged HIV+ and HIV- women had similar fall rates. Among HIV+ women, factors affecting cognition such as age, depressive symptoms, marijuana use and multiple CNS medications were important predictors of falls, however, cognitive complaints were not.

A PROSPECTIVE STUDY ON GERIATRIC PRESCRIBING PATTERN AND MEDICATION ADHERENCE IN A TERTIARY CARE HOSPITAL

Objectives: To identify potentially inappropriate medications (PIMs) using Beers criteria 2015 and to recommend safer alternative medication for the above. To assess the medication adherence in geriatric patients and to categorize according to their adherence.Methods: This is prospective, interventional study. A total of 90 patients aged 65 years and above were involved in the study. Data were collected and recorded. The prescriptions were analyzed for appropriateness using updated Beers criteria 2015 and assess medication adherence using 8-item Morisky questionnaire.Results: Majority of the patients were in the age group of 65-74 years. Males (53%) showed predominance than females. The highest rate of (53%) polypharmacy was found in general medicine department than other departments. Out of 147 disease conditions observed, chronic renal failure (21.1%) was the most common condition. A total of 66 patients had comorbid conditions. Most frequently prescribed medications belonged to cardiovascular drugs (56; 14.62%). A total of 46 patients received PIMs; majority belonged to Category 1 - amitriptyline. Commonly prescribed medication in PIMs belonged to central nervous system medications (20%). Majority of patients were low adherent (51.11%) in which female patients showed preponderance in low adherence.Conclusion: Study showed prevalence of disease pattern, medication use, polypharmacy, PIMs, and medication adherence. It is important for pharmacists to stay updated and prescribers need to be educated and encouraged about Beers criteria for rational prescription for better pharmaceutical care and increased medication adherence.

An Evaluation of the Central Nervous System Medication Use and Frailty among Residents of Aged Care Homes in Malaysia

Background/Aims: Old age and institutionalization in care homes are associated with increased use of risk medications affecting the central nervous system (CNS). This study evaluated medication utilization and appropriateness; and assessed frailty among residents of Malaysian aged care homes. Methods: The subjects of this study included 202 elderly (≥65 years) residents of 17 aged care homes in suburban peninsular Malaysia. Frailty was measured using the Groningen Frailty Indicator (GFI) score and independence in daily living was measured as KATZ activity of daily living score. Medication appropriateness was assessed using the Medication Appropriateness Index (MAI) and 2015 Beers' criteria for Potentially Inappropriate Medication (PIM). Results: CNS medications constituted about 16% of the total, with an average of 0.8 ± 1.1 medications per resident, which reduced to 0.5 ± 0.8 medications after 3 months. Frailty (154/202) and polypharmacy (90/202) were highly prevalent in study subjects. Subjects on CNS medications had significantly higher GFI score (7.1 vs. 5.9; p = 0.031), polypharmacy (57.8 vs. 35.3%; p = 0.002), number of PIMs (0.9 vs. 0.2; p = 0.001), and mean summed MAI score (3.6 vs. 2.6; p = 0.015) than subjects not on CNS medications. Medication number was also significantly correlated with GFI (r = 0.194; p = 0.006) and KATZ (r = 0.141; p = 0.046) scores. Conclusion: Frailty and polypharmacy were highly prevalent among aged care home subjects taking CNS medications. These findings support the notion that periodic regular medication review should improve the overall use of medications in elderly patients.

Deprescribing in Older Nursing Home Patients: Focus on Innovative Composite Measures for Dosage Deintensification.

Deprescribing, which includes stopping or reducing the dosage of medications, is designed to improve safety and prevent adverse drug reactions in older patients. To date, there has been limited work on measuring decreases in dosage intensity, or deintensification, across therapeutic classes of medications. Given the ongoing focus on central nervous system (CNS) medications and the frequency with which providers encounter hypertension and diabetes in older nursing home patients, the objective of this expert review is to describe and critique innovative composite dosage intensity measures that have been, or could be, applied to quantify deintensification within three therapeutic medication targets commonly encountered in nursing home patients: CNS agents, antihypertensive therapy, and antidiabetic therapy and the extent to which they are associated with health outcomes. Composite measures for CNS medication intensity considered dividing a patient's daily dose by defined daily dosage (DDD), or the minimum effective adult or geriatric daily dosage. In contrast, composite measures for antihypertensives used either DDD or maximum recommended daily dosage in the denominator. We were not able to identify any composite measure of intensity for antidiabetic classes. There was a paucity of interventional studies that showed reducing the dosage intensity resulted in improved health outcomes. In conclusion, we identified several innovative composite measures of dosage intensity for CNS and antihypertensive medications, and discussed possible approaches for developing an antidiabetic regimen composite measure. It is critical for future research to compare and contrast various measures and to determine their impact on important clinical outcomes.

The Ultimate Outlier: Transitional Care for Persons with Dementia and BPSD.

Transitional care units aim to assist caregivers who cannot manage the care for persons with dementia who manifest behavioral and psychological symptoms of dementia (BPSD). However, there is a dearth of research on such care units. The current study reviewed one specialized transitional unit to better understand the characteristics of the persons with dementia and behavioral symptoms entering such unit. The study also looked at the change in terms of (a) BPSD, (b) use of psychotropic medications and (c) function of the patients in this unit. A retrospective chart review of 73 residents of a transitional care unit was conducted. Background and outcome information were collected on electronic data entry sheets. Patients had an average age of 75.0 years, 74.0% were men. Mean Cognitive Performance Scale score was 4.7. Comparing admission to discharge, there was a significant decrease in BPSD, and a significant increase in number of central nervous system medications. There were no significant changes in cognition or ability to perform activities of daily living. Patient characteristics differed from those of other long term care settings. This unique population requires further study to optimize the outcomes.

Pharmacotherapy of Persons with Dementia in Long-Term Care in Australia: A Descriptive Audit of Central Nervous System Medications.

Background: Neuropsychiatric symptoms of dementia are often treated through the prescription of one or more psychotropic medications. However, limited efficacy and potential harmful side-effects has resulted in efforts to reduce the use of psychotropic medication in this population, particularly for those living in long-term care.Objectives: This study sought to describe the pattern of central nervous system medication usage in older adults with dementia living in long-term care; assess the appropriateness of prescribing against Beers criteria; and detect potential drug interactions from co-administered medications.Methods: A retrospective descriptive audit of the medical records of n=415 residents, aged >60 years with a diagnosis of dementia, from 28 long-term care facilities in Queensland, Australia. Information extracted included the types and usage of regular and Pro Re Nata central nervous system medications.Results: Of those taking medication (n=317), 68% were prescribed at least one potentially inappropriate medication, and there was a significant positive correlation between the number of medications prescribed and the number of potentially inappropriate medications. Two-hundred potential interactions with variable severity were identified from 130 residents on ≥1 medication – 38% were potentially severe interactions, 46% were moderate.Conclusion: This medication audit raises concerns that prescription of medications may still be the first resort to treat behavioural and psychological symptoms of dementia. There is a need for effective and sustainable person-centred interventions that address barriers for appropriate prescribing practice, and involve the collaboration of all healthcare professionals to optimise prescribing and improve the quality of medicines in older people with dementia.

A Review of Adjunctive CNS Medications Used for the Treatment of Post-Surgical Pain.

Inadequate post-operative pain management can have significant impacts on patients' quality of life. Effective management of acute pain after surgery is important for early mobilization and discharge from hospital, patient satisfaction, and overall well-being. Utilizing multimodal analgesic strategies has become the mainstay of acute post-operative pain management. A comprehensive search was performed, assessing the published or otherwise publically available literature on different central nervous system (CNS) drugs [excluding opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and acetaminophen] and their uses to treat acute post-surgical pain. Included among the drugs evaluated in this review are anticonvulsants, N-methyl-D-aspartic acid (NMDA) agonists, local anesthetics, α2-agonists, cannabinoids, serotonin-noradrenaline reuptake inhibitors (SNRIs), and serotonin-noradrenaline-dopamine reuptake inhibitors (SNDRIs). Timing, dosing, routes of administration, as well as mechanisms of action are discussed for these CNS drugs.

Guterman Award Winner: CMS Medication Burden Linked to Serious Falls

PHOENIX — Research defining the central nervous system (CNS) medication burden that is associated with an increased risk of serious falls in nursing home residents won the Howard Guterman Best Poster Award at the AMDA – the Society for Post-Acute and Long-Term Care Annual Conference. Alan Abrams, MD, MPH, chair of the Society’s poster judging committee, presented the award to the research team led by Joseph Hanlon, PharmD, MS, of the Department of Medicine (Geriatrics) at the University of Pittsburgh. David A. Nace, MD, MPH, CMD, a member of the University of Pittsburgh research team, accepted the award. “We know that falls are linked to medication use, particularly medications that act upon the central nervous system,” Dr. Nace said in a presentation on the research. However, studies examining this association and the dose–response relationships have been limited. The team’s nested case-control study identified a threshold, showing that a CNS medication burden of approximately three or more standardized daily doses is associated with a nearly twofold increased risk of serious falls in nursing home residents compared with those not taking any CNS medications. A serious fall was defined as one resulting in a hip fracture and an emergency department visit or hospitalization. There was no significant difference in serious fall risk for residents taking up to three standardized daily doses compared with those taking no CNS medications. The CNS medications studied were specific antidepressants, antiepileptics, antipsychotics, benzodiazepine receptor agonist hypnotics, and opioid receptor agonists. The standardized daily dose (SDD) for each CNS drug was calculated by dividing the resident’s actual daily dose by the “minimum effective geriatric daily dose” as reported in the geriatric pharmacotherapy literature. The SDDs were then added together for a summary CNS medication burden, or combined SDD. Knowing that there’s a “pretty clear demarcation” in fall risk at a total SDD of three or greater, “the question becomes, can we tweak the dosing? Can we reduce [medications] to a minimum when they cannot be eliminated?” said Dr. Nace. “You may not be able to get rid of all the medications, but you may be able to reduce the overall burden and therefore reduce the risks of falls,” he said. The study used Minimum Data Set (MDS) information merged with 2009–2010 Medicare claims and Prescription Drug Event data from the Centers for Medicare and Medicaid Services for a random 10% sample of traditional fee-for-service beneficiaries with a recent fall history who were admitted to the nursing home between Jan. 1, 2010, and Sept. 30, 2010. The residents were evaluated from the first day of the non-skilled nursing stay episode until discharge, death, or the end of 2010. (The study did not include short-stay, private pay, or Medicare Advantage residents.) Of a sample of 5,556 nursing home residents with a fall history, 367 were identified through ICD-9 diagnosis codes and ICD-9/CPT procedure codes as experiencing a serious fall while in the nursing home. Each case was matched with four controls on the basis of age, gender, and time of events. Investigators then looked at CNS medication use within 6 days before the fall or the index date. The study, which was recently published in the Journal of the American Geriatrics Society [Feb. 2, 2017; doi:10.1111/jgs.14759], did not include as-needed (PRN) medications, and it did not fully include information on benzodiazepine use, as these drugs were not covered by Medicare Part D at the time. The investigators adjusted for other risk factors for serious falls, including other medications, vision impairment, wandering, urinary incontinence, and cognitive impairment. Dr. Hanlon told Caring that “we tried to tease out everything we know about risk factors for falls.” For guidance on calculating the CNS medication burden with a summated standardized daily dose score, see the University of Pittsburgh’s educational brochure “How to Prevent Falls in Older Nursing Home Residents by Reducing CNS Medication Burden,” at www.pepper.pitt.edu/factsfindings.html. Christine Kilgore is a freelance writer in Falls Church, VA.

Opioids and Other Central Nervous System-Active Polypharmacy in Older Adults in the United States.

To determine patterns of and trends in contributions to central nervous system (CNS) polypharmacy, defined by the Beers Criteria as three or more CNS-active medications of each medication class, of adults aged 65 and older seen in U.S. outpatient medical practices. National Ambulatory Medical Care Survey (2004-2013). U.S. outpatient medical care. Visits by older adults to outpatient physicians (N = 97,910). Visits including three or more CNS medications including antipsychotics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics (NBRAs), tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and opioids. The proportion of CNS polypharmacy that each medication class contributed during 2011 to 2013 was determined, and then logistic regression was used to determine trends from 2004 to 2013 in the contribution of individual medication classes to such polypharmacy. Of recent CNS polypharmacy visits, 76.2% included an opioid, and 61.8% included a benzodiazepine; 66.0% of the polypharmacy visits with benzodiazepines included opioids, and 53.3% of the polypharmacy visits with opioids included benzodiazepines. Between 2011 and 2013, opioid and benzodiazepine co-prescribing occurred at approximately 1.50 million visits (95% confidence interval (CI) = 1.23-1.78 million) annually. From 2004 (reference) to 2013, the proportion of polypharmacy visits with opioids rose from 69.6% to 76.2% (adjusted odds ratio = 2.15, 95% CI = 1.19-3.91, P = .01), and the corresponding proportion that included benzodiazepines fell. Of the polypharmacy visits, the odds of SSRI, NBRA, and antipsychotic use were unchanged, and that of TCAs decreased. In older adults, opioid use appears to be largely driving the recent national increase in CNS polypharmacy. Although concomitant use of opioids and benzodiazepines is associated with greater mortality, they are the most common contributors to CNS polypharmacy in older adults.

Central Nervous System (CNS) Medication Burden & Risk of Serious Falls in Older Nursing Home Residents

Central Nervous System (CNS) Medication Burden & Risk of Serious Falls in Older Nursing Home Residents

Central Nervous System Medication Burden and Serious Falls in Older Nursing Home Residents.

To examine the association between CNS medication burden and serious falls in those with a recent fall history. Nested-case control study; cases matched to four controls by age, gender, and date. US nursing homes. 5,556 residents age ≥65 with a recent fall history admitted to a nursing home between 1/1-9/30/2010 and followed until discharge, death, or December 31, 2010. Outcome was serious falls as per Medicare Part A and B ICD/CPT codes. CNS burden, from Medicare Part D data, was calculated by dividing the daily dose of each CNS agent (i.e., specific antidepressants, antiepileptic, antipsychotic, benzodiazepine and opioid receptor agonists) received during the 6 days prior to the index (outcome) date by the minimum effective geriatric daily dose and summing the results across medications. There were 367 cases and 1,468 matched controls. Those taking 3 + CNS standardized daily doses were more likely to have a serious fall than those not taking any CNS medications (Adjusted Odds Ratio 1.83; 95% confidence interval 1.35-2.48). There was no significant difference in fall risk for residents taking >0 to <3 CNS standardized daily doses compared to residents taking no CNS medications (Adjusted Odds Ratio 0.85; 95% CI 0.63-1.15). CNS medication burden, approximately 3 + standardized daily doses, was associated with an increased risk of serious falls in nursing home residents with recent fall. Clinicians should be vigilant for opportunities to discontinue or decrease the doses of individual CNS medications and/or consider non-pharmacological alternatives. Such interventions that reduce use of CNS medications in nursing homes could reduce fall rates but further research is needed to confirm this.

Specific Central Nervous System Medications Are Associated with Temporomandibular Joint Symptoms.

Aims There is evidence of association between bruxism and the increasingly common central nervous system stimulants prescribed for attention deficit hyperactivity disorder (ADHD), as well as the selective serotonin reuptake inhibitors (SSRIs) often prescribed for depression or anxiety. However, the evidence is not clear on whether these medications inducing bruxism are directly associated with temporomandibular joint disorder (TMD). The aim of this work is to evaluate whether these medications are associated with TMD symptoms. Methods Medical history and participant data were obtained for 469 patients from the University of Pittsburgh School of Dental Medicine, Dental Registry and DNA Repository, dating back to 2006. The chi-square test was used to determine any statistically significant associations. Results There were no statistically significant associations between ADHD stimulant medications or SSRIs and reported TMD symptoms. However, there were significant differences seen between specific brands of medications and reported TMD symptoms. Individuals prescribed methylphenidate (Concerta) were less likely to report temporomandibular joint discomfort (p = 0.01). Conversely, individuals prescribed citalopram (Celexa) were more likely to report temporomandibular joint discomfort (p = 0.04). Conclusion Signs and symptoms of temporomandibular joint dysfunction may be influenced by the use of certain medications prescribed for depression or attention deficit hyperactive disorder.

Balance and Mobility in Community-Dwelling Older Adults: Effect of Daytime Sleepiness.

To examine the effect of self-reported daytime sleepiness on performance-based balance measures and self-reported balance confidence in community-dwelling older adults. Cross-sectional secondary analysis of an observational cohort study designed to develop and refine measures of balance and mobility in community-dwelling older adults. Community. Older adults (aged 78.2 ± 5.9) (n = 120). The performance-based gait and balance measures included gait speed, double support time, and step width. Narrow walk, obstacle walk, and timed standing balance were also assessed. The Activities-Specific Balance Confidence Scale was included as a self-reported measure. Daytime sleepiness was defined as an Epworth Sleepiness Scale score of 9 or greater. Body mass index, fall-related comorbidities, and use of central nervous system (CNS) medications were considered as covariates. Forty-five percent of participants reported daytime sleepiness. Participants reporting daytime sleepiness differed significantly from those without in gait speed (adjusted difference (standard error (SE)) -0.09 (0.04) m/s, P = .03), step width (adjusted difference (SE) 0.02 (0.01), P = .03), and self-reported balance confidence (adjusted difference (SE) -1.02 (0.38), P = .01) even after adjusting for covariates. Two-way analysis of variance of CNS medication use and daytime sleepiness showed no significant interaction effects. Self-reported daytime sleepiness is associated with slower gait speed and poor balance confidence in community-dwelling older adults. Subjective sleep assessment should be considered when assessing balance and implementing interventions for improving balance in older adults. Further study is needed to examine the role of CNS medication use.

A Prospective Study of Back Pain and Risk of Falls Among Older Community-dwelling Men.

Musculoskeletal pain is associated with increased fall risk among older men. However, the association of back pain, the most prevalent type of pain in this population, and fall risk is unknown. We conducted a prospective investigation among 5,568 community-dwelling U.S. men at least 65 years of age from the Osteoporotic Fractures in Men Study (MrOS). Baseline questionnaires inquired about back pain and its location (such as low back), severity, and frequency in the past year. During 1 year of follow-up, falls were summed from self-reports obtained every 4 months. Outcomes were recurrent falls (≥2 falls) and any fall (≥1 fall). Associations of back pain and fall risk were estimated with risk ratios (RRs) and 95% confidence intervals (CIs) from multivariable log-binomial regression models adjusted for age, dizziness, arthritis, knee pain, urinary symptoms, self-rated health, central nervous system medication use, and instrumental activities of daily living. Most (67%) reported any back pain in the past year. During follow-up, 11% had recurrent falls and 25% fell at least once. Compared with no back pain, any back pain was associated with elevated recurrent fall risk (multivariable RR = 1.3, 95% CI: 1.1, 1.5). Multivariable RRs for 1, 2, and 3+ back pain locations were, respectively, 1.2 (95% CI: 1.0, 1.5), 1.4 (1.1, 1.8), and 1.7 (95% CI: 1.3, 2.2). RRs were also elevated for back pain severity and frequency. Back pain was also associated with risk of any fall. Among older men, back pain is independently associated with increased fall risk.