Inappropriate Use Of Benzodiazepines Research Articles

Seizure emergency code strategy: Improving treatment times and hospital outcomes for patients with urgent epileptic seizures.

Timely treatment is one of the most relevant prognostic factors in patients with urgent epileptic seizures. Despite the available evidence, treatment times remain suboptimal. The aim of this study was to demonstrate the impact of the "seizure code" in an emergency department, focusing on both treatment times and hospital outcomes of patients with urgent epileptic seizures. An ambispective cohort study was conducted in the emergency department of a public hospital in Bogotá, Colombia. Treatment times and hospital outcomes were evaluated both before and after the implementation of the seizure code. A total of 336 patients were included (94 in the pre-seizure code period and 242 in the post-seizure code period). Both cohorts were comparable in terms of clinical and demographic baseline characteristics. After the implementation of the seizure code, in-hospital treatment times improved among patients with status epilepticus and seizure cluster. For the group of patients with status epilepticus, the time from arrival to the first benzodiazepine decreased from a median of 100.5 min (IQR: 43-152.5) to a median of 20 min (IQR: 10-45) (p = .0063), and the time from arrival to the first non-benzodiazepine antiseizure medication decreased from a median of 155 min (IQR: 49-194) to a median of 39 min (IQR: 25-57) (p = .0071). For the group of patients with seizure cluster, the time from arrival to the first non-benzodiazepine antiseizure medication decreased from a median of 296 min (IQR: 112.5-409) to a median of 72 min (IQR: 46-111) (p < .001). The seizure code significantly decreased the risk of inappropriate benzodiazepine use (p = .0087), in-hospital seizure recurrence (p < .001), in-hospital mortality (p = .0074), and prolonged hospitalizations (more than 48 h) (p = .0475). The seizure code shortens the time to treatment, reduces the length of hospital stay, decreases the risk of inappropriate benzodiazepine use, and lowers both the in-hospital seizure recurrence and in-hospital mortality among patients with urgent epileptic seizures.

Psychotropic polypharmacy and inappropriate use of benzodiazepines in NHs in Croatia: results from the START/MED/093 project

Psychotropic polypharmacy and inappropriate use of benzodiazepines in NHs in Croatia: results from the START/MED/093 project

O uso inadequado de benzodiazepínicos e seus efeitos colaterais

Benzodiazepines (BZDs) are drugs that act on the central nervous system, generally used for their anxiolytic and sedative-hypnotic functionalities. The aim of the study is to demonstrate that the chronic and indiscriminate use of BZDs can bring many adverse events, which can lead to tolerance, dependence and withdrawal crises. This is a qualitative, descriptive research, carried out through an integrative literature review, in the SciELO, Google Scholar, Capes Journal Portal, and PubMed search bases. Ten studies were selected, which met the scope of the work. For the discussion, the following categories were listed: Benzodiazepines, The lack of guidance from a specialized doctor and its consequences in the use and Factors that influence the inappropriate use of benzodiazepines. Therefore, we sought to expand the offer of available studies on benzodiazepine drugs, alerting to the consequences arising from the prolonged use of drugs of this class.

The Safety of Benzodiazepines and Opioids in the Geriatric Population: An Analysis of Patient Safety Events Reported by Hospitals and Ambulatory Surgical Facilities

Benzodiazepines may increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in patients 65 years and older. The concomitant use of benzodiazepines and opioids may also be inappropriate for older adults due to the increased risk of overdose. We searched the Pennsylvania Patient Safety Reporting System (PA-PSRS) for reports of patient safety events related to the concomitant use of benzodiazepines and opioids in older adults in order to gain a better understanding of the potential risks of using these medications in combination. We identified 80 reports in which a patient may have experienced an adverse drug reaction (ADR) to the combined use of a benzodiazepine and an opioid pain medication. Reports were reviewed to determine the ADR(s) experienced by the patient. Changes in mental status were most common, occurring in more than two-thirds of reports (68.8%; 55 of 80), followed by respiratory reactions (51.3%; 41 of 80) and cardiovascular reactions (25.0%; 20 of 80). In over two-thirds of reports (70.0%; 56 of 80), the patient received a reversal agent, either flumazenil (10.7%; 6 of 56) or naloxone (35.7%; 20 of 56), or both (53.6%; 30 of 56). The inappropriate use of benzodiazepines and opioid pain medications in combination among patients 65 years and older is a growing problem, and an increased awareness may be the first step for providers to begin addressing it.

Estudio descriptivo del síndrome confusional agudo en Urgencias

ObjectiveTo better understand the clinical, functional and analytical variables associated with delirium in emergencies and their evolution in order to obtain an improvement in the therapeutic approach of the elderly patient, thus preventing morbidity and mortality in this type of patient. DesignThis is a prospective descriptive study of acute confusional syndrome in the emergency department. SiteGeneral University Hospital of Ciudad Real. ParticipantsAll patients from the emergency department with a diagnosis of delirium were included in the 24-h interval following admission to the geriatric service. Main measurementsAn analysis of the variables of the data set (sociodemographic and clinical variables) was performed, calculating frequency tables for qualitative variables and descriptive statistics for quantitative variables. Subsequently, statistical inference techniques have been used. ResultsThe most frequent medical antecedent were neurological pathology and hypertension, followed by rheumatologic diseases. The main reasons for consultation were deterioration in general condition, dyspnea, decreased level of consciousness, and fever. Highlight the incidence of polypharmacy, especially drugs such as diuretics, benzodiazepines or hypnotics. In relation to the main etiology, the role of urinary and respiratory infections is noteworthy. ConclusionsHighlight the fundamental role of neurological diseases (especially dementia), hypertension, polypharmacy (inappropriate use of benzodiazepines and hypnotics) and urinary and respiratory infections as treatable and/or preventable factors of delirium in Primary Care patients in our setting.

Economic and clinical burdens and associated health disparities in HIV/AIDS management using big data: potentially inappropriate use and deprescribing of benzodiazepines

ABSTRACT This study aimed to examine factors, healthcare utilization, and medical costs associated with potentially inappropriate use of benzodiazepines in persons living with HIV (PLWH). We used big data from Medicare claims in 2017. Potentially inappropriate use of benzodiazepines was defined as having any benzodiazepine claims in individuals 65+ years or having benzodiazepine claims for more than four weeks in individuals 18–64 years. Logistic regressions, zero-inflated negative binomial regressions, and generalized linear models were used. This study included 1,211 PLWH and 235 (19.41%) had potentially inappropriate use of benzodiazepines. PLWH who were 65+ years (OR: 0.56; 95% CI: 0.33, 0.96), non-Hispanic blacks (OR: 0.29; 95% CI: 0.20, 0.41), or Hispanics (OR: 0.55; 95% CI: 0.35, 0.88) were less likely to use benzodiazepines inappropriately. PLWH who had potentially inappropriate use of benzodiazepines had more inpatient (IRR: 1.46; 95% CI: 1.10, 1.94), outpatient (IRR: 1.14; 95% CI 1.02, 1.28), and emergency room (IRR: 1.32; 95% CI: 1.03, 1.68) visits. Potentially inappropriate use of benzodiazepines was associated with higher total (β: 0.16; 95% CI: 0.07, 0.25), Medicare (β: 0.18; 95% CI: 0.07, 0.28), and out-of-pocket (β: 0.21; 95% CI: 0.05, 0.36) costs. This study provides real-world evidence to support deprescribing benzodiazepines in PLWH.

Potentially inappropriate benzodiazepine use in Australian adults: A population-based study (2014-2017).

Inappropriate benzodiazepine use continues to cause substantial morbidity and mortality globally. We aimed to characterise the initiation of new benzodiazepine treatment episodes in Australia and identify correlates of potentially inappropriate benzodiazepine use. We conducted a population-based cohort study using dispensing claims from a 10% sample of Pharmaceutical Benefit Scheme eligible Australians (2014-2017). Our cohort comprised adults initiating a new benzodiazepine treatment; we defined potentially inappropriate use as ≥3 benzodiazepine dispensing over any continuous 90-day period in the year following initiation. We examined characteristics associated with potentially inappropriate benzodiazepine use using multivariable logistic regression. People initiating a new benzodiazepine treatment episode (n = 276 765) were more frequently female (59.1%) and <65 years of age (73.6%). In the 90 days prior to initiating benzodiazepine, people were commonly dispensed antidepressants (26.5%), opioid analgesics (17.6%) and antipsychotics (4.7%). In the first year after initiation, 20 938 (9.5%) people experienced 'potentially inappropriate use'. Having a greater initial quantity of benzodiazepine dispensed [odds ratio (OR), 1.10; 95% confidence interval (CI) 1.08-1.12 per 10 defined daily doses increase], dispensing of antipsychotics (OR 3.00, 95% CI 2.86-3.15) and >5 unique medicines (OR 2.54, 95% CI 2.44-2.64; vs. ≤5 unique medicines) in the 90 days prior to initiation were associated with potentially inappropriate benzodiazepine use. Approximately, 1 in 10 people who initiated benzodiazepines were using it beyond the guideline recommended period. We identified factors at the time of initiation associated with potentially inappropriate use; clinicians should consider these before prescribing benzodiazepines and initiate conversations about alternative therapy when necessary.

The effect of a multidisciplinary care bundle on the incidence of delirium after hip fracture surgery: a quality improvement study.

Delirium is a common complication following hip fracture surgery. We introduced a peri-operative care bundle that standardised management in the emergency department, operating theatre and ward. This incorporated: use of fascia iliaca blocks; rationalisation of analgesia; avoidance of drugs known to trigger delirium; a regular education program for staff; and continuous auditing of compliance. The study was conducted between June 2017 and December 2018. We recruited 150 patients before (control group) and 150 patients after (care bundle group) the introduction of the care bundle. In patients having surgery for a hip fracture, there was a lower incidence of delirium on the third postoperative day in the care bundle group compared with the control group (33 patients (22%) vs. 49 patients (33%)), respectively; p=0.04). Patients in the care bundle group had an adjusted OR of 2.2 (95%CI 1.1-4.4) (p=0.03) for the avoidance of delirium on the third postoperative day. There was no difference between groups for the secondary outcome measures (measured at 30days postoperatively) including: all-cause mortality; composite morbidity; institutionalisation; and walking status. During the study period, compliance with elements of the care bundle improved in the emergency department (49 patients (33%) compared with 85 patients (59%); p<0.001) and anaesthetic department (40 patients (27%) compared with 104 patients (69%); p<0.001), while orthogeriatrics maintained a high level of compliance (140 patients (93%) compared with 143 patients (95%); p=0.45). There was a clinically and statistically significant reduction in the incidence of delirium following hip fracture surgery in patients treated with a multidisciplinary care bundle.

97 Potentially Inappropriate Medications in Patients with Alzheimer’s Disease: Data from NILVAD

Abstract Background Prescription of Potentially Inappropriate Medications (PIMs) is common in older adults and is associated with adverse drug events, hospitalisation and mortality. Less well described are the patterns and predictors of PIM usage in patients with Alzheimer’s Disease (AD), a patient group who may be particularly vulnerable to polypharmacy and medication associated adverse events. Methods Secondary analysis of the NILVAD trial, an international phase three trial of Nilvadipine in mild/moderate AD. The v2 STOPP/START criteria were individually applied by a physician to each participant’s medication list and cross-reference with their medical history to identify PIM usage. Predictors of PIM usage were modelled using binary logistic regression. Results Five-hundred and ten patients with AD were included (mean age 72.8 +/-8.3 years; 62% female). The median number of prescribed medications was 5 (IQR 3-7). Over half (55.5%) were prescribed at least one PIM, whilst a minority of patients (14.8%) were prescribed three or more PIMs. The most frequent PIMs were benzodiazepines &gt;4 weeks without indication (n = 55), long-term Proton-Pump Inhibitor (PPI) use without appropriate indication (n = 49), use of non-steroidal analgesics without use of PPI (n=19) and antimuscarinic use in dementia (n= 18). On multivariate analysis, significant predictors of PIM use were higher total number of medications (p=0.001; OR 1.52; 1.36-1.59) in addition to greater AD severity, as rated using the Clinical Dementia Rating Scale Sum-of-Boxes (CDR-sb) (p=0.024; OR 1.18; 1.02-1.35). Conclusion The majority of older patients with AD were prescribed at least one PIM. Usage of PIMs was associated with greater number of medications and increased dementia severity. Particularly concerning is the potentially inappropriate use of benzodiazepines and anti-muscarinic agents in this population, given recent evidence for the adverse cognitive profile associated with these medications. De-prescribing and medication review interventions aimed particularly at patients with AD are warranted.

Inappropriate prescription of benzodiazepines in acutely hospitalized older patients

Benzodiazepines (BDZs) are widely prescribed in older people. The aims of the study are to assess the prevalence of inappropriate prescription of BZDs and the associated factors in acutely hospitalized older patients. Patients aged 65 years or more hospitalized from 2010 to 2017 in more than 100 Italian internal medicine and geriatric wards in the frame of the REPOSI register were included if prescribed with BDZs at hospital admission or discharge. Appropriateness of prescription was assessed according to the 2015 Beers criteria and their modified French and German versions. Among 4681 patients discharged from hospital, 15% (N = 710) were discharged with BDZs, and 62% of them (N = 441, 95% CI: 58.5%–65.6%) were inappropriately prescribed, being prescribed with BDZ to be always avoided in the elderly (45%), at higher doses than recommended (31%) or with no appropriate clinical conditions (19%). From admission to discharge the prevalence of inappropriate BDZ prescription decreased by 4%, but 62% of patients inappropriately prescribed at admission were still inappropriately prescribed at discharge. Among the 179 patients first prescribed at the time of discharge, half were inappropriately prescribed. Being female (OR 1.32, 95%CI 0.95–1.85), enrolled in REPOSI during the years 2016 and 2017 (OR 1.94, 95%CI 1.10–3.39; OR 1.57, 95%CI 0.95–2.58) and living in nursing homes (OR 2.04, 95%CI 0.95–4.37) were associated with an increased risk to be inappropriately prescribed. This study shows a high prevalence of inappropriate use of BDZ in acutely hospitalized older patients both at hospital admission and discharge.

Potentially inappropriate use of benzodiazepines and z-drugs in the older population-analysis of associations between long-term use and patient-related factors.

IntroductionThe long-term use of benzodiazepines (BZD) and z-drugs in older populations is associated with a variety of sociodemographic and health-related factors. Recent studies reported that long-term BZD and z-drugs use is associated with increased age, female sex, and severe negative psychological (e.g., depression) and somatic (e.g., chronic disease) factors. The current study explores the sociodemographic and health-related factors associated with long-term BZD and z-drugs use in the elderly.MethodsWe conducted a cross-sectional survey among randomly selected patients of one health insurance plan (“AOK North-West”) with BZD and z-drugs prescriptions in the past 12 months. The sample was stratified by appropriate German prescription guidelines (yes vs. no) and age (50–65 vs. >65 years). To examine the association of selected sociodemographic and psychological variables (e.g., sex, employment status, quality of life, depression) with long-term use, a binary logistic regression analysis was conducted.ResultsIn total, data from 340 patients were analyzed. The mean age was 72.1 (SD = 14.5) years, and the most commonly used substances were zopiclon (38.1%), oxazepam (18.1%), and lorazepam (13.8%). The mean defined daily dose (DDD) was 0.73 (SD = 0.47). Insomnia was the main reason for prescribing BZD and z-drugs. The long-term use of BZD and z-drugs was significantly associated with unemployment (OR = 2.9, 95% CI [1.2–7.1]) and generally problematic medication use (OR = 0.5, 95% CI [0.2–1.0]).DiscussionUnemployment status and problematic medication use had a significant association with the patient-reported, long-term use of BZD and z-drugs. Divergent prescription patterns might suggest problematic patterns of BZD and z-drugs use. The causal connection between the identified factors and problematic BZD and z-drugs prescription is not discussed in this paper. Nevertheless, employment status and possible evidence of general problematic drug use may be a warning signal to the prescribers of BZD and z-drugs.

\u2018Worried to death\u2019: the assessment and management of anxiety in patients with advanced life-limiting disease, a national survey of palliative medicine physicians

BackgroundAnxiety adversely affects quality of life and is common in adults with advanced life-limiting disease. There are no UK-wide guidelines on the assessment and management of anxiety in this specific population and there is little evidence regarding drug treatments. This study aimed to explore how palliative care physicians assess and manage anxiety in their patients, and to identify barriers encountered.MethodsA cross-sectional survey was undertaken of all physicians working in specialist palliative care in the UK who were members of the Association for Palliative Medicine. This was conducted in February 2014 using an online questionnaire.ResultsThe response rate was 23% (230/980) and 61% of respondents were consultants. Most did not use tools to screen for anxiety (87%) and almost all used the clinical interview to diagnose anxiety (99%). Only 8% used psychiatric criteria. Most physicians reported difficulties managing anxiety (93%). Only 33% thought they had adequate training in this area. Most had difficulty accessing psychological and/or psychiatric services (71%, 64% respectively). The majority used a combination of pharmacological and non-pharmacological treatments for anxiety. The most frequently prescribed first-line medications for patients with a prognosis of days to weeks were benzodiazepines (93%), usually lorazepam. The use of benzodiazepines over antidepressants was statistically significant (p < 0.001). For patients with a prognosis of months, antidepressants were most frequently prescribed first-line (60%), significantly more than benzodiazepines (p < 0.001). However, benzodiazepine use was still common in this prognostic group with 47% prescribing it first-line, sometimes in combination with an antidepressant.ConclusionThis is the first national survey on the assessment and management of anxiety in palliative care. Findings demonstrate the infrequent use of screening tools, variation in prescribing practice, potentially inappropriate use of benzodiazepines for patients with a prognosis of months, training gaps and poor access to psychological and psychiatric services in the UK. This highlights the need for formal training, further research into the pharmacological management of anxiety in this population and evidence-based national guidance to support clinical decision-making and service development.

“You Don’t Feel”: The Experience of Youth Benzodiazepine Misuse in Ireland

ABSTRACTThere are negative effects to inappropriate use of benzodiazepines, yet the percentage of young people in Ireland experimenting with benzodiazepines has increased. There is a paucity of research about why Irish young people misuse benzodiazepines. In this study, people between 18 and 25 years attending substance misuse services in the south of Ireland (N = 13) were interviewed in a semi-structured style between June 2012 and April 2013. Content analysis was performed. The main motivations for benzodiazepine misuse were to self-regulate negative emotions and to induce dissociation from their environment. Interviewees also described the consequences of benzodiazepine misuse, such as disengagement from family relationships and other protective environments such as school and sports clubs. The consequences of chronic misuse were discussed, such as the compulsion to take more benzodiazepines despite experiencing severe side-effects. The incidence of paradoxical aggression on benzodiazepines is also explored. Education about benzodiazepines and their risks to young people, families, and the public may reduce benzodiazepine misuse. Future research on the role of trauma and mental health in young people’s substance misuse is needed.

Prevalence and correlates of inappropriate use of benzodiazepines in Kosovo

In post-war Kosovo, the magnitude of inappropriate use of benzodiazepines is unknown to date. The aim of this study was to assess the prevalence and correlates of continuation of intake of benzodiazepines beyond prescription (referred to as "inappropriate use") in the adult population of Gjilan region in Kosovo. A cross-sectional study was conducted in Gjilan region in 2015 including a representative sample of 780 individuals attending different pharmacies and reporting use of benzodiazepines (385 men and 395 women; age range 18-87years; response rate: 90%). A structured questionnaire was administered to all participants inquiring about the use of benzodiazepines and socio-demographic characteristics. Overall, the prevalence of inappropriate use of benzodiazepines was 58%. In multivariable-adjusted models, inappropriate use of benzodiazepines was significantly associated with older age (OR 1.7, 95% CI 1.1-2.7), middle education (OR 1.8, 95% CI 1.2-2.7), daily use (OR 1.4, 95% CI 1.1-2.0) and addiction awareness (OR 2.7, 95% CI 2.0-3.8). Furthermore, there was evidence of a borderline relationship with rural residence (OR 1.2, 95% CI 0.9-1.7). Our study provides novel evidence about the prevalence and selected correlates of inappropriate use of benzodiazepines in Gjilan region of Kosovo. Health professionals and policymakers in Kosovo should be aware of the magnitude and determinants of drug misuse in this transitional society.

Assessment of dependence and anxiety among benzodiazepine users in a provincial municipality in Rio Grande do Sul, Brazil

Benzodiazepines are among the most prescribed drugs for anxiety and one of the most used drug classes in the world and have a high potential for addiction. The objective of this study was to assess levels of dependence and anxiety among users of these drugs in the public health system. This was a cross-sectional, descriptive and quantitative study. Benzodiazepine users treated on the public health system were selected. Anxiety levels were assessed with the Hamilton Anxiety Scale and dependency with the Benzodiazepine Dependence Self-Report Questionnaire. Benzodiazepine use was higher among women and in older age groups. Duration of benzodiazepine use was greater than 1 year for all respondents. The dependence assessment indicated that more than half of users were dependent on taking benzodiazepines and most had a severe degree of anxiety. This study found evidence of prolonged and inappropriate use of benzodiazepines. It is necessary to educate users about the risks of these drugs and to develop strategies to rationalize use of these drugs by working with prescribers and dispensers.

Benzodiazepine Use, Misuse, and Harm at the Population Level in Canada: A Comprehensive Narrative Review of Data and Developments Since 1995.

Benzodiazepines are commonly prescribed psycho-pharmaceuticals (e.g., for anxiety, tension, and insomnia); they are generally considered safe but have potential adverse effects. Benzodiazepine use in Canada versus internationally is comparably high, yet no recent comprehensive review of use, misuse, or related (e.g., morbidity, mortality) harm at the population level exists; the present review aimed to fill this gap. We searched four key scientific literature databases (Medline, CINAHL, EBM Reviews, and Web of Science) with relevant search terms, and collected relevant "gray literature" (e.g., survey, monitoring, government reports) data published in 1995-2015. Two reviewers conducted data screening and extraction; results were categorized and narratively summarized by key sub-topics. Levels of benzodiazepine use in the general population have been relatively stable in recent years; medical use is generally highest among older adults. Rates of non-medical use are fairly low in general but higher in marginalized (e.g., street drug use) populations; high and/or inappropriate prescribing appears common in older adults. Benzodiazepines are associated with various morbidity outcomes (e.g., accidents/injuries, cognitive decline, sleep disturbances, or psychiatric issues), again commonly observed in older adults; moreover, benzodiazepines are identified as a contributing factor in suicides and poisoning deaths. Overall there is a substantial benzodiazepine-related health problem burden-although lower than that for other psycho-medications (e.g., opioids)-in Canada, mainly as a result of overuse and/or morbidity. National benzodiazepine prescription guidelines are lacking, and few evaluated interventions to reduce benzodiazepine-related problems exist. There is a clear need for reducing inappropriate benzodiazepine use and related harm in Canada through improved evidence-based practice as well as monitoring and control.

A consumer-targeted, pharmacist-led, educational intervention to reduce inappropriate medication use in community older adults (D-PRESCRIBE trial): study protocol for a cluster randomized controlled trial.

BackgroundMedication safety for older persons represents an ongoing challenge. Inappropriate prescriptions – those with a high risk of evidence-based harm – persist in up to 25 % of seniors, and account for a significant proportion of avoidable emergency department visits. This project is the sequel to the EMPOWER study, in which a novel consumer-targeted written knowledge transfer tool aimed at empowering older adults to act as drivers of benzodiazepine de-prescription resulted in a 27 % reduction of inappropriate benzodiazepine use at 6-month follow-up (number needed to treat (NNT) = 4). Failure to discontinue in the EMPOWER study was attributable to re-emerging symptoms among participants, prescribing inertia, and lack of knowledge and skills for substituting alternate therapy among physicians and pharmacists. To maximize de-prescription of inappropriate therapy, educational medication-risk reduction initiatives should be tested that simultaneously include patients, physicians and pharmacists. The objective of this trial is to: 1) test the beneficial effect of a new de-prescribing paradigm enlisting pharmacists to transfer knowledge to both patients and prescribers in a 2-pronged approach to reduce inappropriate prescriptions, compared to usual care and 2) evaluate the transferability of the EMPOWER study concept to other classes of inappropriate prescriptions.MethodsWe intend to conduct a 3-year pragmatic cluster randomized parallel-group controlled trial to test the effect of the new de-prescribing intervention compared to usual care for reducing 4 classes of inappropriate prescriptions from the 2012 Beers criteria among 450 community-dwelling older adults with polypharmacy. Inappropriate prescriptions will include benzodiazepines, sulfonylurea hypoglycemic agents, first generation antihistamines and non-steroidal anti-inflammatory drugs. The study population is community-dwelling older adults recruited from community pharmacies in Quebec, Canada. The intervention was developed based on a systematic review of the evidence for each medication. Participants in the experimental group will receive the written educational program following randomization and have their pharmacist send their physicians an evidence-based pharmaceutical opinion to recommend de-prescription and be followed for a year. The control group will be wait-listed for 6 months.DiscussionSystem change to effectively reduce medication risk among community-dwelling seniors requires a coordinated approach targeting physicians, pharmacists and patients. This trial will test the feasibility and effectiveness of a tripartite approach to de-prescribing.Trial registrationRegistered via ClinicalTrials.gov on 31 January 2014, identifier: NCT02053194.

Addressing the Issue of Chronic, Inappropriate Benzodiazepine Use: How Can Pharmacists Play a Role?

Prescribing guidelines do not recommend the long-term use of benzodiazepines since their effectiveness with chronic use is out-weighed by risks including dependence, memory and cognitive impairment, hip fractures and traffic accidents. Despite these guidelines, historical data points to an increasing proportion of inappropriate, repeat prescribing of benzodiazepines in Ireland and elsewhere, with up to 33% of patients who use these drugs doing so long-term. The typical long-term benzodiazepine user is an older, socio-economically disadvantaged patient who has been prescribed these medicines by their general practitioner (GP) and dispensed them by their community pharmacist. Misuse of benzodiazepines in nursing homes and psychiatric institutions is also of concern, with one Irish study indicating that almost half of all admissions to a psychiatric hospital were prescribed these drugs, usually despite a lack of clear clinical need. Discontinuation of benzodiazepines has proven to be of benefit, as it is followed by improvements in cognitive and psychomotor function, particularly in elderly patients. It is obvious that an inter-professional effort, focusing on the primary care setting, is required to address benzodiazepine misuse and to ensure appropriate pharmaceutical care. Pharmacists must be an integral part of this inter-professional effort, not least because they are uniquely positioned as the health professional with most frequent patient contact. There is already some supporting evidence that pharmacists’ involvement in interventions to reduce benzodiazepine use can have positive effects on patient outcomes. Here, this evidence is reviewed and the potential for pharmacists to play an expanded role in ensuring the appropriate use of benzodiazepines is discussed.

Évaluation de l’usage à risque des benzodiazépines chez les personnes âgées : facteurs de risque et impacts

Inappropriate benzodiazepine use among the elderly is a common and frequently underestimated problem. The present literature revie explores benzodiazepine abuse in this population from a biological, psychological, and environmental perspective. A further objective is the identification of intervention strategies for addressing this problem. The scientific literature reveals a lack of consensus and validity concerning the description of BZD abuse. The prescription practices and somewhat lax attitudes of doctors working with the elderly contribute substantially to the lack of acknowledgement of the magnitude of this problem. Complications specific to the elderly, such as attitudes toward mental illness and differential manifestation of distress, are discussed. Difficulties related to the evaluation of anxiety and depression in elderly patients, have also been identified to contribute too many cases of BZD abuse. In conclusion, it is proposed that research in this area investigate integrative methods for evaluating BZD abuse in the elderly.

Correlates of (inappropriate) benzodiazepine use: the Netherlands Study of Depression and Anxiety (NESDA)

Results on determinants of benzodiazepine (BZD) use in general and inappropriate use were inconsistent and mostly univariate. The relative importance of sociodemographic, psychological and physical determinants has never been investigated in a comprehensive, multivariate model. We included 429 BZD users and 2423 non-users from the Netherlands Study of Depression and Anxiety (NESDA) in order to investigate sociodemographic, psychological and physical determinants of BZD use and inappropriate use by logistic and linear regression analyses. BZDs were used by a considerable proportion of the 2852 NESDA participants (15.0%). BZD use was independently associated with older age, singleness, unemployment, treatment in secondary care, higher medical consumption (more severe) anxiety, depression (OR [95% CI]=1.95 [1.29, 2.93]), comorbidity, insomnia, SSRI (OR [95% CI]=2.05 [1.55, 2.70]), TCA and other antidepressant (OR [95% CI]=2.44 [1.64, 3.62]) use. Overall, BZD use was rarely in accordance with all guidelines, mainly because most users (82.5%) exceeded the recommended duration of safe use. Inappropriate use was independently associated with older age (β=0.130) and chronic illnesses (β=0.120). Higher scores on agreeableness were associated with less inappropriate use. Mentally or physically vulnerable subjects were most likely to use BZDs. The most vulnerable (i.e. the old and physically ill) BZD users were at highest risk of inappropriate BZD use. Without further evidence of the effectiveness of BZDs in long-term use, caution in initiating BZD prescriptions is recommended, particularly when patients are chronically ill and old, as those are most likely to display inappropriate use.