Use Of Long-acting Benzodiazepines Research Articles

Another Option for Aggression and Self-Injury, Alternative Benzodiazepines for Catatonia in Profound Autism.

Introduction: Individuals with profound autism often present for inpatient care due to aggression. Diagnostic and treatment options are limited. Agitated catatonia is a treatable comorbidity in autism, which should be considered in cases of aggression. Preliminary data report high clinical response rates of catatonia in autism when treated with electroconvulsive therapy (ECT), with poor response to lorazepam. However, access to ECT is often limited, especially in pediatric populations. Methods: We conducted a retrospective chart review to identify cases of hyperactive catatonia with partial response to lorazepam in profoundly autistic children presenting to the pediatric medical hospital. Five cases were identified, all of whom were followed by the child and adolescent psychiatry consult-liaison service during admission and treated without the use of ECT. Data from the medical record were obtained after institutional review board (IRB) approval including the following: (1) treatment course, (2) Bush-Francis Catatonia Rating Scale (BFCRS) scores, and (3) Kanner Catatonia Rating Scale (KCRS) severity scores. The Clinical Global Impressions-Improvement (CGI-I) Scale was applied retrospectively to each case. Results: All five patients demonstrated clinically significant improvements. The average CGI-I score was 1.2. The average percentage reduction in the BFCRS and KCRS severity scores was 63% and 59%, respectively. Two of five patients were first stabilized with infusions midazolam and dexmedetomidine due to the symptom severity and then transitioned to long-acting oral benzodiazepines. Overall, four of five patients were stabilized with oral clonazepam and one of five with oral diazepam. Notably, four of five patients experienced an acute worsening of aggression, self-injury, and other catatonic symptoms with escalating dosages of antipsychotic treatment, which occurred before inpatient admission. All patients experienced resolution of physical aggression toward self and/or others, experienced improvement in their communicative abilities, and were able to return home or enter residential level of care upon discharge. Conclusions: Given the limited availability of ECT and the unclear utility of lorazepam for hyperactive catatonia in autism, the use of long-acting benzodiazepines and/or midazolam infusion may offer a safe and readily available treatment alternative.

Trends and variation in benzodiazepine use in nursing homes in the USA.

Because of toxicities, benzodiazepines are not usually recommended in older adults. We therefore sought to describe the trends in benzodiazepine use in long-term care and examine the variation in benzodiazepine use among nursing homes. In this retrospective repeated cross-sectional analysis of Medicare Parts A, B, and D claims data linked to the Minimum Data Set from 2013 to 2018, we included long-term residents who stayed in a nursing home for at least one entire quarter of a calendar year in 2013-2018. The outcome was whether residents were prescribed a benzodiazepine drug for at least 30days during each quarter stay. We use mixed effects logistic regression models to assess the variation in benzodiazepine use among nursing homes, adjusting for patient and nursing home characteristics. The cohort for the time trend analysis included 270,566 unique residents and 1,843,580 quarter stays for 2013-2018. Prescribing rates for short-acting benzodiazepines were stable over 2013-2016, then declined from 12.1% in 2016 to 10.6% in 2018. The rate of long-acting benzodiazepine use remained relatively steady at around 4% over 2013-2018. During 2017-2018, the variation among nursing homes in benzodiazepine use was 7.2% for short-acting vs. 9.3% for long-acting benzodiazepines, after controlling for resident characteristics. Prescribing for short-acting benzodiazepines in long-term care declined after 2016, while long-acting benzodiazepine use did not change. The variation in benzodiazepine use among nursing homes is substantial. Identifying factors that explain this variation may help in developing strategies for deprescribing benzodiazepines in nursing home residents.

The quality of primary care provided to the elderly in Israel

BackgroundIn view of increasing global and local trends in population ageing and the high healthcare utilization rates among the elderly, this study assesses the quality of primary care provided to the elderly population in Israel. It examines changes in quality over time, how quality varies across sub-groups of the elderly, and how quality in Israel compares with other countries. Data originate from the National Program for Quality Indicators in Community Healthcare (QICH), which operates in full collaboration with Israel’s four HMOs.MethodsThe study population included all elderly Israeli residents aged 65 years or older during 2002–2015 (N = 879,671 residents in 2015). Seven elderly-specific quality indicators from within the QICH framework were included: influenza and pneumococcal vaccinations, benzodiazepine overuse, long-acting benzodiazepine use, body weight documentation, weight loss and underweight. In addition, two non-age specific quality indicators relating to diabetes mellitus were included: the rate of HbA1C documentation and uncontrolled diabetes. Data were collected from patient electronic medical records (EMR) in accordance with each HMO, and aggregated by three variables: gender, age, and socio-economic position (SEP).ResultsDuring the measurement period, vaccination rates significantly increased (Influenza: from 42.0% in 2002 to 63.2% in 2015; and pneumococcal vaccination: from 25.8% in 2005 to 77.0% in 2015). Body weight documentation (in 65–74 year old persons) increased from only 16.3% in 2003 to 80.9% in 2015. The rate of underweight (BMI < 23 kg/m2) and significant weight-loss (10% or more of their body weight) was only measured in 2015. The overall rate of benzodiazepine overuse remained steady from 2011 to 2015 at around 5%, while the rate of long-acting benzodiazepine use decreased from 3.8% in 2011 to 2.4% in 2015.The rate of HbA1c documentation for elderly diabetics was higher than for non-elderly diabetics in 2015 (92.2% vs 87.9%). The rate of uncontrolled diabetes was lower for the elderly than the non-elderly population in 2015 (6.9% vs. 15.7%).Gender disparities were observed across all measures, after age stratification, with worse indicator rates among females compared to males. SEP-disparities were not consistent across measures.In all indicators except benzodiazepine overuse, Israel showed a higher quality of care for the elderly in comparison with the international healthcare community.ConclusionsOverall, the quality of care received by elderly Israelis has improved substantially since measurements first began; yet, females receive lower quality care than males. Monitoring results of primary care quality indicators can contribute to population’s successful aging; both chronic conditions at earlier ages (e.g. diabetes), and short-term hazardous conditions such as the use of potentially harmful medications and weight loss should be evaluated.

Can clinical practice indicator relating to long-acting benzodiazepine use in the elderly be easily generated in a hospital setting?

To improve the appropriate use of long-acting benzodiazepine (la.bzd) prescriptions in the elderly, the Haute Autorité de Santé (HAS) has developed clinical practice indicators (CPI). The alert indicator (AI) evaluates the prevalence of la.bzd prescription among older people. The mastering indicator (MI) corresponds to the prevalence of elderly with a justified, i.e., appropriate, la.bzd prescription among all the elderly with la.bzd prescriptions. The objective of this study was to test the feasibility of routine generation of CPI regarding la.bzd prescriptions among the elderly in the hospital setting. This was a retrospective study. The study was conducted in two university hospitals located in Paris. Eligible cases were patients aged 65years and older who were hospitalized in acute care units from January to June 2014. The AI calculation was based on information extracted from medical databases from these hospitals. The appropriateness of la.bzd prescription was assessed by a physician and a pharmacist and was based on review of computerized patient records and prescriptions, using an ad hoc algorithm. The MI was then calculated. Variation in the level of indicators was explored according to the characteristics of patients and of their hospitalization using chi2 test. Factors associated with a potentially inappropriate prescription (PIP) of la.bzd were studied using univariate and multivariate logistic regression. Among the 4167 patients included in the study, 362 had la.bzd prescriptions, i.e., the AI was 9%. Prescriptions were found to be appropriate for 83 patients, i.e., the MI was 23% and PIP was 77%. The MI varied between 13 and 31% according to characteristics of patients and of hospitalization. In multivariate analysis, factors associated with PIP were age, number of comorbidities, type of care unit, and concurrent prescription of a neuroleptic or hypnotic. Generation of the AI was routinely possible but only for acute care units with computerized prescriptions, corresponding to 78% of patients. Production of the MI has required medical record review for all patients with a la.bzd prescription and cannot be automated. However, difficulties in generating the MI have identified areas for significant improvement. Moreover, strategies to improve the care of older people with a la.bzd prescription could be targeted using characteristics of patients and of hospitalization associated with PIP. The future deployment of a single electronic medical record in all care departments would make it easier to mine the data and make possible automated production of CPI.

Real-world prescribing patterns of long-acting benzodiazepines for elderly Koreans in 2013 .

We aimed to estimate the prevalence of prescriptions to long-acting benzodiazepines (BZDs) among elderly outpatients in Korea in 2013 and analyze the factors that led to inappropriate prescription practices. Using the Korea Health Insurance Review and Assessment Service-National Patients Sample database in 2013, we estimated the pattern of BZD prescription among elderly outpatients. BZDs were categorized as long-acting (half-life (T_1/2) ≥20hours) or short-acting (T_1/2 <20hours). In addition, we investigated the pattern of BZD prescription for populations defined according to patient, healthcare provider, and geographic characteristics. Multivariate logistic regression analysis was performed to estimate odds ratios and 95% confidence intervals and identify predictors of long-acting BZD use. Overall, 58,056 elderly patients (38,910 females, 67%) received at least 1 BZD prescription. The total number of BZD prescriptions was 78,843, of which long-acting BZD prescriptions accounted for 44.7%. Diazepam was the most frequently prescribed BZD (39.7%). Long-acting BZDs were most frequently prescribed in the primary-care setting and were relatively frequently prescribed in rural areas. Of the patients prescribed long-acting BZDs, 435 (3.5%) had chronic obstructive pulmonary disease. Long-acting BZD use varied across different medical institutions (p < 0.05). A decrease in long-acting BZD use was identified relative to data from previous studies. However, BZDs continued to be used, and their use should be further limited in the primary-care setting and in rural areas. The results of this study may provide fundamental data for further review of BZD utilization. .

Health risk appraisal in older people 7: long-acting benzodiazepine use in community-dwelling older adults in London: is it related to physical or psychological factors?

Long-acting benzodiazepine consumption among older people has implications for mortality, morbidity and cost-effective prescribing. Two models explain benzodiazepine use in this age group, one linked to physical illness and disability and one to psychological factors. Secondary analysis of baseline data from a study of 1059 community-dwelling non-disabled people aged 65 years and over recruited from three general practices in London. For this analysis, use of long-acting benzodiazepines was defined as any self-reported use of diazepam or nitrazepam in the last four weeks. Associations between demographic factors, health service use, and physical and psychological characteristics and benzodiazepine use were investigated. Findings The prevalence of benzodiazepine use in this sample was 3.3% (35/1059). In univariate analyses, benzodiazepine use was associated with female gender, low income, high consultation rates, physical factors (medication for arthritis or joint pain, polypharmacy, difficulties in instrumental activities of daily living, recent pain) and psychological factors (poor self-perceived health, social isolation, and symptoms of anxiety or agitation). In a multivariate logistic regression analysis only two factors retained statistically significant independent associations with benzodiazepine use: receiving only the state pension (OR=4.0, 95% CI: 1.70, 9.80) and pain in the past four weeks (OR=3.79, 95% CI: 1.36, 10.54).

Association between use of short-acting benzodiazepines and migraine occurrence: a nationwide population-based case–control study

Aim: To evaluate the association between using benzodiazepines (BZDs) with short- or long-acting durations and migraine occurrence.Methods: The migraine group comprised 9616 subjects older than 20 years and newly diagnosed with migraine between 2005 and 2011, and the comparison group comprised 38,464 subjects without migraine. The BZDs used in the subjects were dichotomously defined as short-acting (half-life ≤24 h) and long-acting substances. A logistic regression model was used to calculate the odds ratio (OR) of migraine associated with BZD exposure and other diseases.Results: The adjusted OR of migraine associated with BZD exposure was 1.73 (95% confidence interval [CI] = 1.63–1.84). Either exposure to a short-acting BZD alone or using it combining with a long-acting BZD had significant higher risks of migraine (adjusted OR = 1.69, 95% CI = 1.59–1.80; adjusted OR = 2.06, 95% CI = 1.91–2.24, respectively), whereas only long-acting BZD use was not associated with an increase of migraine. Meanwhile, sleep disorders, anxiety, and stroke were strongly associated with migraine (adjusted OR = 2.00, 1.91, and 1.57, respectively).Conclusions: We observed a significant increase of migraine occurrence in subjects using short-acting BZDs, either alone or in combination with long-acting ones.

Beers versus STOPP criteria in polyharmacy community-dwelling older patients

Objective:To assess potentially inappropriate prescribing (PIP) using Beers (2012 version) and STOPP (2008 version) criteria in polypharmacy, community-dwelling, older patients. Methods:From the information collected in the invoicing data of the prescriptions and the electronic medical records, a sample was selected of 223 > 65-year-old patients who were taking simultaneously 10 or more drugs per day. Beers and STOPP criteria were separately applied, and the results obtained with the two methods were compared. Results:A total of 141 (63.2%) patients presented at least one Beers criterion. The two most frequently observed Beers criteria independent of diagnosis were the use of benzodiazepines and the use of non-COX-2-selective non-steroidal anti-inflammatory drugs. With regard to Beers criteria considering diagnosis, the most frequent were the use of anticholinergic drugs in patients with lower urinary tract symptoms or benign prostatic hyperplasia, and the use of benzodiazepines, antipsychotics, Zolpidem or H2-antihistamines, in patients with dementia or cognitive impairment. A total of 165 (73.9%) patients had at least one PIP according to the STOPP criteria. Duplicate drug classes and long-term use of long-acting benzodiazepines were the two most frequent STOPP criteria. Discussion:Our study identified a high frequency of PIP in poly-medicated community-dwelling older patients. Simultaneous application of Beers and STOPP criteria represents a useful tool to improve prescribing in this population group.

Effects of a geriatric intervention aiming to improve quality care in nursing homes on benzodiazepine use and discontinuation.

Benzodiazepines and "Z drugs" are often prescribed in residents of nursing homes (NH) despite their well-known deleterious effects. We aimed to investigate if a general intervention on quality of care led to discontinuation of benzodiazepine, and to examine which NH-related factors were associated in change of benzodiazepines use. IQUARE is a quasi-experimental study, investigating the impact of an intervention based on a geriatric education with NH staff on several quality indicators of care (including appropriate prescriptions). All participating NH received an initial and 18-month audit regarding drug prescriptions and other quality of care variables. The analysis included 3973 residents, 2151 subjects (mean age: 84.6 ± 8.5 years; 74.3% women) in the control group and 1822 (mean age: 85.5 ± 8.1 years; 77.4% women) in the intervention group. Outcomes at 18 months were benzodiazepines use, long-acting benzodiazepines use, new-use of benzodiazepines, and discontinuation. The effect of the intervention was investigated using mixed-effect logistic regression models, including NH variables and residents' health status as confounders. Higher reductions in benzodiazepine use (-2.8% vs. -1.5%) and long-acting benzodiazepine (-3.7% vs. -3.5%) were observed in intervention group, but not statistically significant. None of the structural and organisational NH-related variables predicted either discontinuation or new-use of benzodiazepines; hospitalisations and initial use of meprobamate increased the likelihood of becoming a new-user of benzodiazepines. Multivariate analysis suggested that living in a particular NH could affect benzodiazepines discontinuation. A general intervention designed to improve overall NH quality indicators did not succeed in reducing benzodiazepines use. External factors interfered with the intervention. Further studies are needed to examine which NH-related aspects could impact benzodiazepines discontinuation.

Prescripción potencialmente inadecuada en pacientes mayores grandes polimedicados según criterios «STOPP»

IntroductionAppropriate prescribing is especially relevant in elderly people. The objective of this study is to analyse the potentially inappropriate prescription (PIP) in heavily polymedicated elderly patients according to the criteria Screening Tool of Older Person's Prescriptions. Patients and methodsA descriptive cross-sectional study was conducted in Primary Care on patients assigned to the Siero-Sariego (Asturias) Health Centre, who were over 64 years old and heavily polymedicated (consumption >10 drugs for six months).The 65 Screening Tool of Older Person's Prescriptions criteria were reviewed in the electronic Primary Care patient records, collecting sociodemographic variables, prescribed medications, and chronic diseases. Frequency distributions were made for each criterion, and causes related to PIP were explored using contingency tables, the Spearman correlation coefficient, and logistic regression. ResultsA total of 349 polymedicated elderly patients were analysed with a prevalence of 6.4 (95% CI:5.76-7.08), a mean age of 79.2 years (SD:3.7), 62.2% were female, 14% institutionalised, a Charlson index of 2.9. The mean of number of drugs was 11.5 (SD:1.7), and the most frequent pathologies were high blood pressure (64%), diabetes (46%), and osteoarticular diseases (41%).There was at least one PIP in 72.9% of heavily polymedicated elderly patients [(Mean: 1.32 (SD:1.2)]. The Screening Tool of Older Person's Prescriptions criteria least complied with were: therapeutic duplication (25.2%), use of long-acting benzodiazepines (15.8%), and inappropriate use of aspirin (10.9%).An association was found between having any inappropriate prescription and the number of medications prescribed (OR=1.22 [95% CI:1.04-1.43]) and inversely to the Charlson index (OR=0.76 [95% CI:0.65-0.89]). ConclusionsPIP is common in heavily polymedicated elderly patients. Special attention must be paid to the use of psychotropic drugs, which are implicated in a high volume of PIP.

Alprazolam withdrawal delirium and brief reversible psychosis: a case report.

To the Editor: Documented cases of sedative, hypnotic, or anxiolytic withdrawal delirium are highlighted by autonomic instability, as well as particular physical examination findings that characterize the suspected diagnosis. We present a patient with alprazolam withdrawal delirium, who lacks measurable signs of withdrawal, including but not limited to, significant examination findings of tremor, psychomotor agitation, or grand mal seizures. Case report: Mr A, a 33-year-old Middle Eastern man, was brought to the emergency department in 2014 for the investigation of altered mental status following alprazolam withdrawal 2 days prior. Previously, he had been prescribed alprazolam 4 mg daily. Subsequent to completion of his prescription, Mr A exhibited expansive behavior and hypervigilance, with periods of collapsing to appear dead. He also had recurrent delusions involving harm to both family and self. Mr A reportedly admitted to abusing alprazolam, consuming 6–7 pills (total 14 mg) daily. Based on the recommendation of Mr A’s primary care physician, the family administered an extra dose of risperidone 2 mg, trazadone 100 mg, and buspirone 15 mg to help calm him, which was unsuccessful. He received alprazolam 2 mg in route to the hospital. After presenting to the emergency department, Mr A displayed altered consciousness; disorientation to person, time, and purpose; flight of ideas; poor judgment and insight; and bizarre, agitated, and delusional behavior but no suicidal ideation. He received regularly scheduled doses of medications in the emergency department. Mr A’s vital signs were within normal limits; his physical examination was unremarkable. Results of extensive laboratory work, including electrolytes, renal and liver function tests, and complete blood counts, were within normal limits. The urine toxicology screen was negative for amphetamines, cannabis, hallucinogens, benzodiazepines, cocaine, opiates, and 3,4-methylenedioxymethamphetamine. His blood alcohol result was < 0.01%. Workup for sudden onset of altered mental status revealed no abnormal results. Initial psychiatric evaluation obtained in the emergency department revealed disorientation to person, time, and purpose; poor judgment and insight; poor concentration; poor recent and remote memory; and no suicidal or homicidal ideation. Mr A was placed on involuntary commitment and transferred to a psychiatric hospital for further management. A diagnosis of alprazolam withdrawal delirium and brief reversible psychosis (DSM-5 criteria for sedative, hypnotic, or anxiolytic withdrawal) was made. Mr A denied any psychiatric history and was physically healthy. Family expressed that he had a history of suicidal ideation, homicidal ideation, and violence toward others. Other pertinent details relayed by family included a history of anxiety, depression, and previous inpatient psychiatric admissions. Prior to admission to the emergency department, Mr A’s father, the primary caregiver, stated that he noticed the alprazolam pill counts were inaccurate. Soon after, his son’s behavior became bizarre; specifically, Mr A demonstrated prolonged periods of wakefulness and verbalized threats to harm himself and his family. Diagnostic features of sedative, hypnotic, or anxiolytic withdrawal are highlighted by 2 or more symptoms including “autonomic hyperactivity (eg, increases in heart rate, respiratory rate, blood pressure, or body temperature, along with sweating); a tremor of the hands; insomnia; nausea, sometimes accompanied by vomiting; anxiety; and psychomotor agitation. 1(p558) We present a case of reversible brief delirium and psychotic episode following withdrawal of alprazolam in an otherwise healthy young man. Our case shows that sedative, hypnotic, or anxiolytic withdrawal delirium can occur in the absence of cardinal withdrawal symptoms. Alprazolam withdrawal delirium and brief psychosis is reversible and can be treated with use of long-acting benzodiazepines. In our case, we used clonazepam to control symptoms of alprazolam withdrawal delirium and psychosis. According to PubMed, there are 3 published cases of alprazolam withdrawal delirium4–6; all 3 patients experienced autonomic instability in the presence of delirium and brief reversible psychosis. In conclusion, physicians should be aware of the possibility of alprazolam withdrawal delirium and brief reversible psychosis in the absence of cardinal withdrawal symptoms as outlined in the DSM-5. Alprazolam withdrawal should be included in the differential diagnosis of conditions with sudden onset of delirium and brief psychotic symptoms in younger individuals experimenting with illicit substances despite a negative toxicology screen. An increased incidence of reversible brief psychotic episodes might be induced by the short-acting benzodiazepine alprazolam, which is undetected in routine urine or blood drug screen after only 24 hours of discontinuation.

Potentially inappropriate prescribing in older primary care patients.

ObjectivesThe aim of the study was to determine the rate of Potentially Inappropriate Medicines (PIM) and Potential Prescription Omissions (PPO) according to Screening Tool of Older Person's potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right Treatment (STOPP/START) criteria.Study DesignA cross-sectional survey in community pharmacy.MethodA prospective cross-sectional study was performed, during March-May 2012, in five community pharmacies. Patients aged ≥65 years, who collected one or more prescribed medications, were asked to participate in the study, and an interview was scheduled. Patients were asked to provide their complete medical and biochemical record from their general practitioner.Results509 patients, mean age 74.8±6.5 years, 57.4% female, participated in the study. 164 PIM were identified in 139 patients (27.3%). The most common were: long-term use of long-acting benzodiazepines (20.7%), use of non-steroidal antiinflammatory drugs (NSAID) in patients with moderate-severe hypertension (20.1%), use of theophylline as monotherapy for chronic obstructive pulmonary disease (COPD, 15.9%) and use of aspirin without appropriate indication (15.2%). Patients with more than four prescpritions had a higher risk for PIM (OR 2.85, 95% CI 1.97–4.14, p<0.001). There were 439 PPO, identified in 257, (50.5%) patients. Predictors for PPO were older age, presence of diabetes, myocardial infarction, osteoporosis, stroke, COPD and/or angina pectoris.ConclusionSTOPP/START criteria may be useful in identifying inappropriate prescribing and improving the current prescribing practices. Pharmacists should focus more on patients with more than four medications and/or patients with gout or pain accompanied with arterial hypertension because those patient may be at higher risk of PIM. Additionlly, patients older than 74 years with diabetes, osteoporosis, myocardial infarction, stroke, angina pectoris and/or COPD may have an increased risk of PPO.

Prescripción potencialmente inapropiada en mayores de 65 años en un centro de salud de atención primaria

ObjectiveTo identify potentially inappropriate prescriptions (PPI) and prescribing omissions (OP) by means of the STOPP/START criteria, as well as associated factors in ≥65year old patients in a Primary Care setting in Spain. Study designA cross-sectional, descriptive study. SettingCentro de Salud Monóvar, Primary Health Care. Study period: 6months. Patients Random sample247patients. Eligibility criteria: ≥65years patients who attended an urban Primary Care clinic 2 or more times were studied. Terminally ill and nursing home residents were excluded. MethodsData were collected from electronic clinical records. STOPP and START criteria were evaluated in each clinical record, including age, sex, co-morbidity, number of chronic prescriptions. Main outcomes: PPI and OP identified by STOPP and START criteria, respectively. ResultsA total of 81 patients (32.8%) had PPI, with the most common being the long-term use of long-acting benzodiazepines in 17 (6.9%). OP was found in 73 (29.6%) patients, with the most common being the omission of statins in patients diagnosed with diabetes mellitus and/or one or more major cardiovascular risk factors in 21 (8.5%). After adjustment by gender and age, correlations were found between PPI and multiple medication (OR: 2.02; 95%CI: 1.15-3.53; P=.014), and OP and polypharmacy (OR: 2.37; 95%CI: 1.32-4.24; P=0.004). ConclusionsInappropriate prescribing in older people is frequent, and is mainly associated with long-acting benzodiazepines. There are diabetic patients who do not have statins prescribed. Multiple medication is associated with PPI and OP.

Potentially inappropriate prescribing in hospitalized patients with comparative study between prescription by internist and geriatricians

To analyze potentially inappropriate prescribing in hospitalized patients and compare the prescription by internists and geriatricians. Cross-sectional study in hospitalized patients older than 65 years. We recorded prevalence of potentially inappropriate prescriptions according to the criteria of "Screening Tool of Older Person's Prescriptions". We included 95 hospitalized patients over 65 years with a median age of 79 years (interquartile range: 73-82 years) and 50.5% female. One hundred eighty-three potentially inappropriate prescriptions were detected in 81 patients (85.2% of patients). The most frequent potentially inappropriate prescription were the prolonged use of inhibitors of proton pump high dose (32.6% of patients), the use of benzodiazepines in patients prone to falling (23.2% of patients), the prolonged use of long-acting benzodiazepines (21.1% of patients) and prolonged use of neuroleptic as hypnotics (21.1% of patients). In comparative study between medical specialties, significant differences were found in mean number of drugs (P = 0.0001) and in prolonged use of neuroleptics as hypnotics (P = 0.015). A high percentage of hospitalized patients older than 65 years receive potentially inappropriate prescribing. Prolonged use of inhibitors of the proton pump at high doses was the most frequent potentially inappropriate prescribing criterion.

Association between use of benzodiazepines and risk of fractures: a meta-analysis

Benzodiazepines (BZDs) are some of the most commonly prescribed drugs in the world. It has been shown that BZD use could be associated with increased fracture risk. However, studies on the use of BZDs and fracture risk have yielded inconsistent results. Results from the present meta-analysis show that BZD use is associated with a moderate and clinically significant increase in the risk of fractures. The relationship between the use of BZDs and fracture risk has been neither well identified nor summarized. This meta-analysis reports on the use of BZDs, especially short-acting BZDs, and their correlation with a moderate and clinically significant increase in fracture risk. This analysis will provide evidence for clinicians to consider fracture risk when prescribing BZDs among the elderly population. This study was conducted to determine whether people who take BZDs are at an increased fracture risk. A systematic search of studies published through January 2013 was conducted using MEDLINE, EMBASE, OVID, and ScienceDirect. Case-control and cohort studies that assessed the relationship between BZD use and the risk of fractures were identified. Literature searches, study selections, methodological assessments, and data mining were independently conducted by two reviewers. Disagreements were resolved by consensus. STATA 12.0 software was used for the meta-analysis. Random effects models were used for pooled analysis due to heterogeneity among the studies. There were 25 studies, including 19 case-control studies and 6 cohort studies, that met the inclusion criteria. Overall, the results of the meta-analysis indicated that BZD use was associated with a significantly increased fracture risk (relative risk (RR) = 1.25; 95% confidence intervals (CI), 1.17-1.34; p < 0.001). Increased fracture risk associated with BZD use was observed in participants aged ≥65 years old (RR = 1.26; 95% CI, 1.15-1.38; p < 0.001). When only hip fractures were included as the outcome measure, the RR increased to 1.35. However, subgroup meta-analyses showed that there was no significant association between BZD use and fracture risk in Eastern countries (RR = 1.27; 95% CI, 0.76-2.14; p = 0.362) as well as between long-acting BZD use and risk of fractures (RR = 1.21; 95% CI, 0.95-1.54; p = 0.12). After accounting for publication bias, we observed that the overall association between BZD use and fracture risk to be slightly weaker (RR = 1.21; 95% CI, 1.13-1.30) but still significant. The results of this meta-analysis demonstrate that the use of BZD, especially short-acting BZD, is associated with a moderate and clinically significant increase in fracture risk. However, large prospective studies that minimize selection bias are necessary to determine a more accurate fracture risk associated with BZD use.

The elimination half-life of benzodiazepines and fall risk: two prospective observational studies

the STOPP criteria advise against the use of long-acting benzodiazepines (LBs). to study whether LBs are associated with a higher fall risk than short-acting benzodiazepines (SBs) (elimination half-life ≤ 10 h). we used base-line data and prospective fall follow-up from the Longitudinal Aging Study Amsterdam, a longitudinal cohort study including 1,509 community-dwelling older persons (Study 1) and from a separate fall prevention study with 564 older persons after a fall (Study 2). Time to the first fall after inclusion and number of falls in the first year after inclusion were the primary endpoints. both in Study 1 and Study 2 the use of SBs was associated with time to the first fall, hazard ratio (HR) 1.62 (95% CI: 1.03-2.56) and HR 1.64 (95% CI: 1.19-2.26),respectively. LBs were not significantly associated with time to first fall, HR 1.40 (0.85-2.31) and HR 1.08 (0.72-1.62). In both studies, the use of SBs was also associated with number of falls, odds ratio (OR) 1.28 (95% CI: 1.01-1.61) and OR 1.37 (95% CI: 1.10-1.70). LBs were not significantly associated with number of falls, OR 1.23 (0.96-1.57) and 1.10 (0.82-1.48). the use of SBs is not associated with a lower fall risk compared with LBs. The use of both SBs and LBs by old persons should be strongly discouraged.

Indicators of Benzodiazepine Use in Nursing Home Residents in France: A Cross-Sectional Study

Little information is available about associations between nursing home (NH) structural and organizational aspects and benzodiazepine prescriptions, particularly for long-acting drugs. This study addressed this knowledge gap. Cross-sectional study. One hundred seventy-five NHs from France. A total of 6275 NH residents, aged 86 years (± 8.2), and mostly women (73.7%). Outcome measures were: (1) benzodiazepine and (2) long-acting benzodiazepine use. NH staff sent to research team all drug prescriptions in the week participants were included in the study; staff also recorded information on residents' characteristics, and NHs structure and internal organization. Binary logistic regressions were performed separately on total and long-acting benzodiazepine. A total of 3350 persons took benzodiazepine; 577 took long-acting benzodiazepine. Subject-related characteristics were the main correlates of benzodiazepine use. NH characteristics were also related to this outcome: number of beds ≥ 91 (Odds Ratio (OR) 0.820, 95% Confidence Interval (CI) 0.682-0.986), special care unit (OR 1.131, 95% CI 1.000-1.279), pharmacy for internal usage (OR 1.341, 95%CI 1.128-1.594), and date records of the first prescription of psychotropics (OR 1.394, 95% CI 1.209-1.607). Pharmacy for internal usage was also associated with long-acting benzodiazepine (OR 1.374, 95% CI 1.076-1.754). NH structure- and organization-related indicators impact benzodiazepine use among NH residents. This finding is of particular importance because these indicators are more easily modifiable than subject-related characteristics. Therefore, NH directors and medical staff should be aware about this to implement feasible modifications for reducing inappropriate and chronic benzodiazepine use.

Adequacy of medication in patients 65 years or older in teaching health centers in Cáceres, Spain

The appropriateness of drug prescription is objective of the National Health System for the sanitary and economic repercussions linked. The main objective of this paper is to analyze the appropriateness of drug prescription on patients 65 years or older and identify the most prevalent prescribing errors. Observational, descriptive, transversal, multicenter study in Health Centers doctors in training in Cáceres. 471 patients 65 years or older were included by convenience samplin.The sample size was calculated to an accuracy 3.5%-5% and a confidence level 95%. The measured variable was the criteria STOPP/START. We calculated mean and standard deviation for quantitative variables and relative frequencies for qualitative variables. The most frequent STOPP criteria were: duplication of drugs (9.76% CI 95% 7.40 to 12.78), prolonged use of long-acting benzodiazepines (7.22%, 95% CI 5.21 to 9, 92) and the use of aspirin in patients without cardiovascular secondary prevention (7% 95% CI 5.03 to 9.68). The most frequent START criteria were: omission of antiplatelet agents and statins in diabetes coexisting one or more cardiovascular risk factors (9.34 and 7.03 to 12.31% 95% 95% 4.46% 2.93 to 6, 72), calcium and vitamin D in osteoporosis (5.31%, 95% CI 3.61 to 7.72) and metformin in type 2 diabetes metabolic syndrome ± (4.46%, 95% CI 2.93 - 6.72). The main inappropriate prescribing concerns treatments that should be suspended or modify. The duplications were the most common cause of inappropriate prescribing, being more frequently involved drugs like benzodiazepines, NSAIDs and drugs in drugs associations. The second cause of inadequacy most prevalent was the prescription of benzodiazepines with long half life. The third most common cause was acetylsalicylic acid, both through overuse or omission.

Inappropriate Medication in Home Health Care.

The Authors Reply: —We are pleased to respond to Dr. Lau and Ms. Dwyer’s letter. Dr. Lau and Ms. Dwyer point out that the validity of using the Beers list to evaluate prescribing quality among patients receiving end-of-life (EOL) care is questionable. They raise concerns about our examination of potentially inappropriate medication (PIM) without distinguishing between patients receiving and not receiving EOL care in the home health setting. We agree with Dr. Lau and Ms. Dwyer that, given the different needs and treatment goals between the two patient populations, medication appropriateness should be examined by EOL status. In response, we conducted the same analysis as reported in our article, but stratified by EOL status. To define EOL status, we used a variable in the survey indicating that the patient had a life expectancy of 6 months or less or was receiving palliative/EOL care. Consistent with Lau and Dwyer, we estimated that a weighted 15.7% of our original study population were EOL patients. Estimated rate of PIM use was similar between EOL patients (36.6%, 95% CI: 29.2–44.8%) and non-EOL patients (39.0%, 95% CI: 36.0–42.1%). Lau and Dwyer mentioned several classes of medications on the Beers list that may be clinically appropriate for EOL patients. Our estimates indicate that prevalence of medication use in these classes were also comparable by EOL status. For example, 6.5% (CI: 3.6–11.4%) of EOL patients vs. 6.5% (CI: 5.1–8.2%) of non-EOL patients used antihistamines included in the Beers list. The rate of long-acting benzodiazepines use was 2.9% (CI: 1.5–5.4%) among the EOL patients vs. 2.2% (CI: 1.5–3.2%) among the non-EOL patients. Use of anticholinergic agents (including gastrointestinal antispasmodics and other anticholinergics on the Beers list) was low (1–2%) for both populations, with confidence intervals overlapping. These results indicate that our original estimate of close to 40% PIM use among older home health care patients was not driven by the potentially greater (and appropriate) use of these medications by patients with limited life expectancy or receiving EOL care. Lau and Dwyer make a legitimate point of the need to take into account EOL status when examining medication appropriateness. The policy and practice implications of our original findings, however, remain highly relevant to the vast majority of home health patients who receive active treatment.

Inappropriate medication use and risk of falls – A prospective study in a large community-dwelling elderly cohort

BackgroundExplicit criteria for determining potentially inappropriate medication consumption in elderly were elaborated by Beers et al. These lists have been used worldwide to evaluate medical prescriptions but there is little epidemiologic evidence demonstrating negative consequences of inappropriate medication use. It has been reported that some drugs could increase the risk of falls, which are a frequent and serious problem in elderly population. We aimed to evaluate the association between the use of potentially inappropriate medications and the risk of falls.MethodsThe 3C Study is a multicentre prospective cohort study conducted in France with 4 years of follow-up. Non-institutionalized men and women aged 65 years or over (N = 6343) were randomly selected from electoral rolls. Data on socio-demographic, medical characteristics and medication use (based on self-reports and data from the national healthcare insurance) were collected. Use of inappropriate medication for elderly was defined from established criteria. Data about falls were collected at the two follow-up examinations (2 years and 4 years after baseline). The association between the exposure to inappropriate medications and the risk of falls was evaluated using multivariate models (Cox model and logistic regression).Results32% of subjects reported inappropriate medication use at baseline and 29% at least two of the three examinations; 22% had fallen 2 times or more during follow-up. Overall, inappropriate medication users had an increased risk of falling. This increase was mainly due to the use of long-acting benzodiazepines (adjusted odds ratio (OR) = 1.4, 95% confidence interval: [1.1–1.8], in both occasional and regular users), other inappropriate psychotropics (adjusted OR = 1.7 [1.7–2.7] in regular users), or medication with anticholinergic properties (adjusted OR = 1.6 [1.2–2.1] in regular users). Neither occasional, nor regular use of short- or intermediate-acting benzodiazepines was associated with an increased risk of falling. Further analysis in long-acting benzodiazepines users did not show any dose-effect relation between the number of prescriptions filled over a 3-year period and the risk of falling.ConclusionOur study showed that use of inappropriate medications was associated with an increased risk of falling in elderly persons. This increase was mainly due to long-acting benzodiazepines and other inappropriate psychotropics, and to medications with anticholinergic properties.