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Mansour W, Knauert MP. Adding Insult to Injury: Sleep Deficiency in Hospitalized Patients. Sleep Med Clin 2024; 19:607-623. [PMID: 39455181 DOI: 10.1016/j.jsmc.2024.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2024]
Abstract
Sleep deficiency is a common problem in the hospital setting. Contributing factors include preexisting medical conditions, illness severity, the hospital environment, and treatment-related effects. Hospitalized patients are particularly vulnerable to the negative health effects of sleep deficiency that impact multiple organ systems. Objective sleep measurement is difficult to achieve in the hospital setting, posing a barrier to linking improvements in hospital outcomes with sleep promotion protocols. Key next steps in hospital sleep promotion include improvement in sleep measurement techniques and harmonization of study protocols and outcomes to strengthen existing evidence and facilitate data interpretation across studies.
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Affiliation(s)
- Wissam Mansour
- Department of Internal Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Duke University School of Medicine, 1821 Hillandale Road, Suite 25A, Durham, NC 27705, USA
| | - Melissa P Knauert
- Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, 300 Cedar Street, PO Box 208057, New Haven, CT 06520-8057, USA.
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Koopmans I, Geerse D, de Ridder L, Roerdink M, Juachon MJ, Muehlan C, Dingemanse J, van Gerven J, Groeneveld GJ, Zuiker R. The interactive walkway provides fit-for-purpose fall-risk biomarkers in the elderly: Comparison of zolpidem and suvorexant. Clin Transl Sci 2024; 17:e13875. [PMID: 38978326 PMCID: PMC11231031 DOI: 10.1111/cts.13875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 06/04/2024] [Accepted: 06/11/2024] [Indexed: 07/10/2024] Open
Abstract
Dynamic balance assessments such as walking adaptability may yield a more realistic prediction of drug-induced falls compared with postural stability measurements, as falls often result from limited gait adjustments when walking. The Interactive Walkway (IWW) measures walking adaptability but sensitivity to medication effects is unknown. If proven sensitive and specific, IWW could serve as a biomarker for targeted fall-risk assessments in early clinical drug development. In this three-way crossover study, 18 healthy elderly (age: 65-80 years) subjects received 5 mg zolpidem, 10 mg suvorexant, or placebo in the morning. Assessments were performed pre-dose and approximately hourly until 9 h post-dose. IWW assessments included an 8-meter walking test, goal-directed stepping, obstacle-avoidance, and tandem-walking. Other pharmacodynamic measurements were the Timed-Up-and-Go (TUG) test at a comfortable and fast pace, adaptive tracking, and body sway. A decline in performance was observed for zolpidem compared with placebo for 3 h post-dose in IWW walking adaptability outcome measures, TUG, adaptive tracking, and body sway. For the IWW tasks, a decrease in walking speed (among others) was observed. IWW parameters were not affected by suvorexant compared with placebo at any timepoint. However, an increase of 9.8% (95%CI: 1.8%, 18.5%) in body sway was observed for suvorexant compared with placebo up to 3 h post-dose. The IWW successfully quantified drug effects of two hypnotic drugs and distinguished between zolpidem and suvorexant regarding their effects on walking. As a biomarker, the IWW demonstrated sensitivity in assessing dynamic balance and potential fall risk in early phase clinical drug development.
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Affiliation(s)
- Ingrid Koopmans
- Centre for Human Drug Research, Leiden, The Netherlands
- Leiden University Medical Center, Leiden, The Netherlands
| | - Daphne Geerse
- Leiden University Medical Center, Leiden, The Netherlands
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, Netherlands
| | | | - Melvyn Roerdink
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, Netherlands
| | | | - Clemens Muehlan
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
| | - Jasper Dingemanse
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
| | - Joop van Gerven
- Centre for Human Drug Research, Leiden, The Netherlands
- Leiden University Medical Center, Leiden, The Netherlands
| | - Geert Jan Groeneveld
- Centre for Human Drug Research, Leiden, The Netherlands
- Leiden University Medical Center, Leiden, The Netherlands
| | - Rob Zuiker
- Centre for Human Drug Research, Leiden, The Netherlands
- Leiden University Medical Center, Leiden, The Netherlands
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Handa N, Ishizaki T, Mitsutake S, Ono K, Akishita M. Safety profile of hypnotics or sedatives on community-dwelling older adults aged 75 or older in Japan: A retrospective propensity-matched cohort study. Int J Geriatr Psychiatry 2024; 39:e6085. [PMID: 38622754 DOI: 10.1002/gps.6085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 04/01/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVE The purpose of the study is to assess if daily use of hypnotics increases mortality, aspiration pneumonia and hip fracture among relatively healthy individuals aged 75 years or older who lead independent lives in the community. METHOD AND PATIENTS Of the adults aged 75 years or older residing in Hokkaido prefecture of Japan (n = 705,538), those who did not meet several exclusion criteria were eligible for generating propensity score-matched cohorts (n = 214,723). Exclusion criteria included co-prescribed medications acting on the central nervous system, diagnoses of malignant neoplasm, dementia, depression, etc. We compared 33,095 participants who were prescribed hypnotics for daily use (hypnotic group) with a propensity score-matched cohort without a prescription (control group). Participants were followed for more than 42 months. RESULTS During the 42-month follow-up period, the incidence of the three outcome measures in the hypnotics group was significantly higher than that in the control group (aspiration pneumonia p < 0.001, hip fracture p = 0.007, and all-cause mortality p < 0.001). Sensitivity analyses utilizing inverse probability weighting demonstrated hazard ratios of 1.083 [1.023-1.146] for mortality, 1.117 [1.014-1.230] for aspiration pneumonia, and 1.720 [1.559-1.897] for hip fracture. Meanwhile, the attribute risk differences were 2.7, 1.5, and 1.0 per 1000 patient-years, respectively. CONCLUSIONS Although daily use of hypnotics increased the risk of three events, their attribute risk differences were fewer than 3.0 per 1000 patient-years. The results will help provide guidance on whether it is reasonable to prescribe hypnotics to geriatric population aged 75 or older leading independent lives in the community. CLINICAL TRIAL REGISTRATION UMIN-CTR UMIN000048398.
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Affiliation(s)
- Nobuhiro Handa
- Department of Digital Therapeutics, Juntendo University, Graduate School of Medicine, Tokyo, Japan
- Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
- Kino-Medic Clinic, Ichigao, Yokohama, Japan
- Medical Technology Innovation Center, Juntendo University, Graduate School of Medicine, Tokyo, Japan
| | | | | | - Koki Ono
- Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
- Department of Social Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masahiro Akishita
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Mekkawy KL, Rodriguez HC, Gosthe RG, Corces A, Roche MW. Immediate Postoperative Zolpidem Use Increases Risk of Falls and Implant Complication Rates Following Total Hip Arthroplasty: A Retrospective Case-Control Analysis. J Arthroplasty 2024; 39:169-173.e1. [PMID: 37562745 DOI: 10.1016/j.arth.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Zolpidem is the most widely used hypnotic in the United States and has known side effects. However, the morbidity of zolpidem use following total hip arthroplasty (THA) is not well-defined. Thus, the aim of this study was to assess the effects that zolpidem use has on medical and implant complications, falls, lengths of stay, and medical utilizations following THA. METHODS A retrospective query of a nationwide insurance claims database was conducted from 2010 to 2020. All cases of THA and hypnotic use were identified using procedural and national drug codes. Patients who were prescribed zolpidem within 90 days of surgery were matched to hypnotic naive patients 1:5 based on demographic and comorbidity profiles. The 90-day medical complications, falls, fragility fractures, costs, and readmission rates, as well as 2-year implant complications were compared between cohorts. A total of 50,328 zolpidem patients were matched to 251,286 hypnotic naive patients. RESULTS The zolpidem group had significantly higher rates of medical complications, falls, and fragility fractures when compared to the hypnotic-naive group. The zolpidem group had significantly higher rates of dislocation, mechanical loosening, and periprosthetic fracture. Likewise, healthcare utilization was significantly greater in the zolpidem group. CONCLUSION Zolpidem use following THA is associated with significant risk of medical and implant complications, as well as fall risks, increased costs, lengths of stay, and readmissions. The findings of this study may affect discussions between orthopaedic surgeons and their patients on the benefits of sleep quality in their recovery versus the incurred risks of zolpidem use. LEVEL OF EVIDENCE III, retrospective case-control study.
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Affiliation(s)
- Kevin L Mekkawy
- Holy Cross Orthopedic Research Institute, Holy Cross Health, Fort Lauderdale, Florida; Hospital for Special Surgery, West Palm Beach, Florida; Department of Surgery, South Shore Universtiy Hospital, Bay Shore, New York
| | - Hugo C Rodriguez
- Hospital for Special Surgery, West Palm Beach, Florida; Larkin Community Hospital, Department of Orthopaedic Surgery, South Miami, Florida
| | - Raul G Gosthe
- Holy Cross Orthopedic Research Institute, Holy Cross Health, Fort Lauderdale, Florida
| | - Arturo Corces
- Larkin Community Hospital, Department of Orthopaedic Surgery, South Miami, Florida
| | - Martin W Roche
- Holy Cross Orthopedic Research Institute, Holy Cross Health, Fort Lauderdale, Florida; Hospital for Special Surgery, West Palm Beach, Florida
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Sawatari H, Yoshikawa T, Ando SI. Impact of zolpidem and lemborexant on sleep and morning symptoms when used as a single dose for polysomnography. Sleep Biol Rhythms 2024; 22:155-158. [PMID: 38476849 PMCID: PMC10900022 DOI: 10.1007/s41105-023-00485-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 08/15/2023] [Indexed: 03/14/2024]
Abstract
This study evaluated the effect of zolpidem and lemborexant on sleep and morning symptoms in patients undergoing type-1 polysomnography for suspected sleep-disordered breathing based on questionnaires and polysomnography results. We enrolled 127 patients (lemborexant: N = 57, zolpidem: N = 25, without hypnotics: N = 45). Rapid eye movement sleep in patients on lemborexant was higher than that in patients without hypnotics (P = 0.02). Frequency of unsteadiness in the morning was higher in patients on zolpidem than that in patients without hypnotics (P = 0.04), which remained after adjustment for potential confounders (P = 0.03). Low-dose lemborexant might be suitable when administered as a single dose during polysomnography.
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Affiliation(s)
- Hiroyuki Sawatari
- Department of Perioperative and Critical Care Management, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Tomoko Yoshikawa
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shin-ichi Ando
- Sleep Medicine Center, Saiseikai Futsukaichi Hospital, 3-13-1 Yumachi, Chikushino, Fukuoka 818-8516 Japan
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Alcohol and aging - An area of increasing concern. Alcohol 2023; 107:19-27. [PMID: 35940508 DOI: 10.1016/j.alcohol.2022.07.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/21/2022] [Accepted: 07/22/2022] [Indexed: 12/18/2022]
Abstract
Alcohol use is increasing among adults 65 and older and the size of this population is expanding rapidly. Aging is associated with systemic inflammation, sleep disturbances, cancers, cognitive decline, and increased risk of injury and death from falls and other accidents. Alcohol misuse exacerbates and accelerates these age-related changes. Older drinkers are more sensitive to acute alcohol-induced impairments in memory, coordination, reaction time, and driving performance. Oxidative stress and DNA damage resulting from chronic heavy alcohol consumption contribute to an increased risk of cancer, liver disease, and cardiovascular disease. Medication use increases with age and many medications prescribed to older adults can interact negatively with alcohol. The rapid expansion of the population aged 65 and older, combined with higher levels of alcohol use and AUD in the Baby Boomer cohort than the preceding generation, could significantly increase the burden of alcohol on the healthcare system resulting from AUD and alcohol-related injuries and diseases. Screening and brief intervention for hazardous alcohol use among older patients along with education regarding potential interactions between alcohol and medications could substantially reduce the risk of harms from alcohol but currently is underutilized.
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Valencia Morales DJ, Laporta ML, Johnson RL, Schroeder DR, Sprung J, Weingarten TN. A Case-Control Study of Accidental Falls During Surgical Hospitalizations. Am Surg 2023; 89:61-68. [PMID: 33870764 DOI: 10.1177/00031348211011114] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Postoperative falls are preventable complications. The study aims were to describe the rate and circumstances surrounding postoperative falls and explore potential associations with patient and procedural characteristics with emphasis on the use of sedative medications. METHODS Medical records of hospitalized patients undergoing non-lower extremity surgery under general anesthesia from January 1, 2010, through April 30, 2018 were reviewed for falls within 72 postoperative hours. Perioperative use of sedatives, sleep aids, gabapentinoids, and opioids were abstracted. Each fall case was matched with two controls on age, sex, and procedure type. Descriptive statistics and multivariable analysis accounting for the matched design were performed. RESULTS There were 343 falls among 200 186 hospitalized surgical patients (incidence of 17.1 [95% CI: 15.4, 19.0] falls per 10 000 procedures) with largest proportion of falls occurring on postoperative day 2 (n = 134, 39.1%). Most falls occurred in the general hospital wards (n = 304, 88.6%) and were unwitnessed (n = 186, 55.9%). The incidence of major injuries was 1.0 (95% CI: .1 - 3.6) per 100 000 procedures. Home use of non-benzodiazepine hypnotics (odds ratio 2.68, 95% CI: 1.47, 4.88, P=.001) and blood transfusions were associated with increased fall risk. Hospital stay was longer in patients who fall (7 [4, 15] vs. 5 [3, 9] days, P < .001). CONCLUSIONS The rate of postoperative falls in our institution was low and frequently unwitnessed. The use of non-benzodiazepine hypnotics is a modifiable risk factor associated with postoperative falls. Serious complications after falls were rare.
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Affiliation(s)
- Diana J Valencia Morales
- Departments of Anesthesiology and Perioperative Medicine, and Health Sciences Research, Rochester, MN, USA6915
| | - Mariana L Laporta
- Departments of Anesthesiology and Perioperative Medicine, and Health Sciences Research, Rochester, MN, USA6915
| | - Rebecca L Johnson
- Departments of Anesthesiology and Perioperative Medicine, and Health Sciences Research, Rochester, MN, USA6915
| | - Darrell R Schroeder
- Division of Biomedical Statistics and Informatics, 6915Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Juraj Sprung
- Departments of Anesthesiology and Perioperative Medicine, and Health Sciences Research, Rochester, MN, USA6915
| | - Toby N Weingarten
- Departments of Anesthesiology and Perioperative Medicine, and Health Sciences Research, Rochester, MN, USA6915
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Melatonin for Insomnia in Medical Inpatients: A Narrative Review. J Clin Med 2022; 12:jcm12010256. [PMID: 36615056 PMCID: PMC9821578 DOI: 10.3390/jcm12010256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/07/2022] [Accepted: 12/15/2022] [Indexed: 12/31/2022] Open
Abstract
In this narrative review, we describe what is known about non-pharmacological and pharmacological treatments for insomnia in medical inpatients, with a focus on melatonin. Hospital-acquired insomnia is common, resulting in shortened total sleep time and more nighttime awakenings. Sleep disturbance has been shown to increase systemic inflammation, pain, and the likelihood of developing delirium in hospital. Treatment for insomnia includes both non-pharmacological and pharmacological interventions, the latter of which requires careful consideration of risks and benefits given the known adverse effects. Though benzodiazepines and non-benzodiazepine benzodiazepine receptor agonists are commonly prescribed (i.e., sedative-hypnotics), they are relatively contraindicated for patients over the age of 65 due to the risk of increased falls, cognitive decline, and potential for withdrawal symptoms after long-term use. Exogenous melatonin has a comparatively low likelihood of adverse effects and drug-drug interactions and is at least as effective as other sedative-hypnotics. Though more research is needed on both its effectiveness and relative safety for inpatients, small doses of melatonin before bedtime may be an appropriate choice for inpatients when insomnia persists despite non-pharmacological interventions.
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Wickwire EM, Amari DT, Juday TR, Frech FH, Gor D, Malhotra M. Cardiac events and economic burden among patients with hypertension and treated insomnia in the USA. Future Cardiol 2022; 18:731-741. [PMID: 35787013 DOI: 10.2217/fca-2022-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Cardiovascular (CV) event risk, healthcare resource utilization (HCRU) and costs have not been elucidated among hypertension patients with treated insomnia (H + TI). Materials & methods: Adult patients with H + TI were identified in IBM MarketScan databases. H + TI patients were matched 1:1 on age and sex to controls with hypertension but without sleep disorders. Multivariable models were used to estimate associations between treated insomnia and CV event risk, HCRU and costs. Results: In total, 81,502 H + TI patients (mean age = 62 years, 53% female) were matched. Relative to controls, H + TI patients were 2.4 times as likely to have CV events. H + TI patients incurred higher costs per patient per month (US$2343 vs US$1013). Conclusion: Treated insomnia was associated with higher costs and HRCU in hypertension patients.
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Affiliation(s)
- Emerson M Wickwire
- Department of Psychiatry, University of Maryland, Baltimore, MD 21201, USA.,Sleep Disorders Center, Division of Pulmonary & Critical Care Medicine, Department of Medicine, University of Maryland, Baltimore, MD 21201, USA
| | | | | | | | - Deval Gor
- Genesis Research, Hoboken, NJ 07030, USA
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Amari DT, Juday T, Frech FH, Wang W, Wu Z, Atkins N, Wickwire EM. Falls, healthcare resources and costs in older adults with insomnia treated with zolpidem, trazodone, or benzodiazepines. BMC Geriatr 2022; 22:484. [PMID: 35658904 PMCID: PMC9166444 DOI: 10.1186/s12877-022-03165-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 05/23/2022] [Indexed: 11/24/2022] Open
Abstract
Background Falls are the leading cause of injury-related death among older Americans. While some research has found that insomnia heightens falls, health care resource utilization (HCRU) and costs, the impact of insomnia treatments on fall risk, mortality, HCRU and costs in the elderly population, which could be of substantial interest to payers, has not been fully elucidated. This study evaluated the risk of falls and related consequences among adults ≥ 65 years of age treated with common prescription medications for insomnia compared with non-sleep disordered controls. Methods This was a retrospective cohort analysis of deidentified Medicare claims from January 2011 through December 2017. Medicare beneficiaries treated for insomnia receiving zolpidem extended-release, zolpidem immediate-release, trazodone, or benzodiazepines were matched with non-sleep disordered controls. The main outcomes were falls, mortality, healthcare resource utilization (HCRU), and medical costs during the 12 months following the earliest fill date for the insomnia medication of interest. Generalized linear models controlled for several key covariates, including age, race, sex, geographic region and Charlson Comorbidity Index score. Results The study included 1,699,913 Medicare beneficiaries (59.9% female, mean age 75 years). Relative to controls, adjusted analyses showed that beneficiaries receiving insomnia medication experienced over twice as many falls (odds ratio [OR] = 2.34, 95% CI: 2.31–2.36). In adjusted analyses, patients receiving benzodiazepines or trazodone had the greatest risk. Crude all-cause mortality rates were 15-times as high for the insomnia-treated as controls. Compared with controls, beneficiaries receiving insomnia treatment demonstrated higher estimated adjusted mean number of inpatient, outpatient, and emergency department visits and longer length of inpatient stay. All-cause total adjusted mean costs were higher among insomnia treated patients ($967 vs $454). Conclusions Individuals receiving insomnia treatment had an increased risk of falls and mortality and higher HCRU and costs compared with matched beneficiaries without sleep disorders. Trazodone and benzodiazepines were associated with the greatest risk of falls. This analysis suggests that significant risks are associated with common, older generation insomnia medication treatments in the elderly. Nonetheless, these results should be interpreted with caution as the use of these medications may be indicative of underlying morbidity with potential for residual confounding. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03165-6.
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Mansour W, Knauert M. Adding Insult to Injury: Sleep Deficiency in Hospitalized Patients. Clin Chest Med 2022; 43:287-303. [PMID: 35659026 PMCID: PMC9177053 DOI: 10.1016/j.ccm.2022.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Sleep deficiency is a common problem in the hospital setting. Contributing factors include preexisting medical conditions, illness severity, the hospital environment, and treatment-related effects. Hospitalized patients are particularly vulnerable to the negative health effects of sleep deficiency that impact multiple organ systems. Objective sleep measurement is difficult to achieve in the hospital setting, posing a barrier to linking improvements in hospital outcomes with sleep promotion protocols. Key next steps in hospital sleep promotion include improvement in sleep measurement techniques and harmonization of study protocols and outcomes to strengthen existing evidence and facilitate data interpretation across studies.
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Affiliation(s)
- Wissam Mansour
- Department of Internal Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Duke University School of Medicine, 1821 Hillandale Road, Suite 25A, Durham, NC 27705, USA
| | - Melissa Knauert
- Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, 300 Cedar Street, PO Box 208057, New Haven, CT 06520-8057, USA.
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Mainero Rocca L, L'Episcopo N, Gordiani A, Staderini A. Direct multiclass desorption electrospray ionization-tandem mass spectrometry method for the analysis of sleep inducers and ototoxic drugs in dried blood spots. RAPID COMMUNICATIONS IN MASS SPECTROMETRY : RCM 2022; 36:e9265. [PMID: 35128730 DOI: 10.1002/rcm.9265] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 02/01/2022] [Accepted: 02/01/2022] [Indexed: 06/14/2023]
Abstract
RATIONALE An unconventional and innovative approach for the quantitative determination of 11 ototoxic and narcoleptic drugs in whole blood is described. The multiclass method allows the inclusion of the most widespread drugs on the market (antihistamines, antidepressants, antihypertensives, anxiolytics, opioids, Z-drugs) responsible for 10% of occupational accidents. METHODS The developed procedure involved the use of the desorption electrospray ionization (DESI) interface for the direct analysis of dried blood spots (DBS). All the issues strictly connected to the chemical-physical characteristics of DBS and DESI (sample inhomogeneity, DBS support, DESI geometry and solvent) were carefully evaluated and innovative strategies were applied. Haematocrit was managed using a small and measured volume of blood (2 μL) with analysis of the entire DBS. RESULTS The proposed method was fully validated in terms of limits of detection, limits of quantitation (LOQs; between 60 pg/mm2 and 1.6 ng/mm2 ), linearity (one order of magnitude starting from LOQs) and inter- and intra-day precision (on three levels, with relative standard deviation values not exceeding 17%). Accuracy was calculated by comparison with an ultrahigh-performance liquid chromatography-tandem mass spectrometry method (suitable also as a confirmatory method). CONCLUSIONS Results showed a surprising sensitivity, demonstrating that this procedure could be suitable for applications in various fields, e.g. forensic analysis. Moreover, as a collateral benefit, it was discovered that the method is able to analyse very light traces left on plastic and glass surfaces by detached dried blood.
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Affiliation(s)
- Lucia Mainero Rocca
- Chemical Agents Laboratory, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Italian Workers' Compensation Authority (INAIL), Monte Porzio Catone, Rome, Italy
| | - Nunziata L'Episcopo
- Chemical Agents Laboratory, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Italian Workers' Compensation Authority (INAIL), Monte Porzio Catone, Rome, Italy
| | - Andrea Gordiani
- Chemical Agents Laboratory, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Italian Workers' Compensation Authority (INAIL), Monte Porzio Catone, Rome, Italy
| | - Alessandro Staderini
- Chemical Agents Laboratory, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Italian Workers' Compensation Authority (INAIL), Monte Porzio Catone, Rome, Italy
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Amari DT, Juday TR, Frech FH, Wang W, Gor D, Atkins N, Wickwire EM. Fall Risk, Healthcare Resource Use, and Costs Among Adult Patients in the United States Treated for Insomnia with Zolpidem, Trazodone, or Benzodiazepines: A Retrospective Cohort Study. Adv Ther 2022; 39:1324-1340. [PMID: 35072889 DOI: 10.1007/s12325-022-02041-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/07/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Falls are a common cause for morbidity and mortality among patients taking prescription insomnia medication. The objective of this study is to compare the risk of falls, all-cause healthcare resource utilization (HCRU), and costs among patients treated with commonly used, older generation insomnia medications and non-sleep-disordered controls. METHODS This retrospective cohort study used the IBM® MarketScan® Commercial and Medicare Supplemental Databases to identify patients aged at least 18 years treated with commonly prescribed medications for insomnia (zolpidem, trazodone, benzodiazepines) between 1 January 2012 and 30 September 2017. The insomnia-treated cohort were age- and sex-matched (1:1) to non-sleep-disordered controls. Odds ratios (ORs) compared risk of falls in each cohort, adjusting for covariates. Costs were adjusted to 2018 dollars, the most recent year for the study data. RESULTS Relative to matched controls (n = 313,086), the insomnia-treated cohort had a higher rate of falls (3.34% vs. 1.33%), and higher risk of falls [OR = 2.36 (95% confidence interval 2.27-2.44)]. Relative to other index treatments, patients treated with trazodone had the greatest risk of falls. Compared with matched controls, the estimated mean number of inpatient visits, emergency department visits, outpatient visits, and mean length of inpatient stay were all significantly higher among patients treated for insomnia. Such patients incurred greater total costs per patient per month than matched controls ($2100 versus $888; estimated mean ratio, 2.36; 95% CI 2.35-2.38; p < 0.0001). CONCLUSIONS Relative to matched controls, the insomnia-treated cohort showed higher risk of falls with greater HCRU and costs. Each outcome measured was highest among patients treated with trazodone, relative to other index treatments. Findings suggest the need for new treatment options to optimize quality of care for patients with insomnia.
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Affiliation(s)
- Diana T Amari
- Genesis Research, 111 River Street, Ste 1120, Hoboken, NJ, 07030, USA
| | | | - Feride H Frech
- Eisai Inc., 100 Tice Blvd, Woodcliff Lake, NJ, 07677, USA
| | - Weiying Wang
- Genesis Research, 111 River Street, Ste 1120, Hoboken, NJ, 07030, USA
| | - Deval Gor
- Genesis Research, 111 River Street, Ste 1120, Hoboken, NJ, 07030, USA
| | - Norman Atkins
- Eisai Inc., 100 Tice Blvd, Woodcliff Lake, NJ, 07677, USA
| | - Emerson M Wickwire
- Department of Psychiatry, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD, 21201, USA
- Division of Pulmonary and Critical Care Medicine, Sleep Disorders Center, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD, 21201, USA
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14
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Campbell R, Chabot I, Rousseau B, Bridge D, Nicol G, Meier G. Understanding the unmet needs in insomnia treatment: a systematic literature review of real-world evidence. Int J Neurosci 2021:1-15. [PMID: 34668828 DOI: 10.1080/00207454.2021.1995383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE The objective of this study was to define and characterize the unmet needs in the pharmacological management of insomnia. METHODS A systematic literature review was conducted to identify relevant literature reporting real-world evidence in insomnia, published from January 2009 to April 2020. Pharmacological treatments - both prescription (benzodiazepines, 'Z-drugs' and suvorexant) and off-label (antidepressants, antipsychotics, and antihistamines) - were considered. RESULTS Overall, 108 publications describing the humanistic (n = 59) and economic burden (n = 20) of insomnia, off-label treatment patterns (n = 28) and factors influencing treatment adherence or persistence (n = 8) were identified. A high prevalence of comorbid conditions was reported in patients with insomnia resulting in significantly lower health-related QoL compared to those with insomnia or a comorbidity alone. Current treatment options were associated with adverse events, including reduced sleep quality and next-day somnolence. An increased risk of accidents/injuries was also associated with insomnia and its treatment. Furthermore, safety concerns and perceived lack of efficacy for approved treatments have led to frequent off-label prescribing, despite a lack of clinical evidence of risk/benefit ratios. Safety concerns associated with benzodiazepines include risk of dependence, leading to prolonged treatment persistence and exacerbated adverse events, making them unsuitable for use in patients with chronic insomnia. Finally, the substantial economic burden of insomnia was evident, with reduced work productivity demonstrated in patients with insomnia compared to the general population. CONCLUSIONS This review highlights a clear unmet need for insomnia therapies that improve sleep quality without resulting in next-day impairment and/or dependence.
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Affiliation(s)
- Renee Campbell
- Formerly at Global Value and Access, Eisai, New York, USA
| | - Isabelle Chabot
- Faculty of Pharmacy, University of Montreal, Montreal, Canada
| | - Ben Rousseau
- Adelphi Values PROVE, Adelphi Mill, Bollington, UK
| | - Daisy Bridge
- Adelphi Values PROVE, Adelphi Mill, Bollington, UK
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15
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Milani SA, Raji MA, Chen L, Kuo YF. Trends in the Use of Benzodiazepines, Z-Hypnotics, and Serotonergic Drugs Among US Women and Men Before and During the COVID-19 Pandemic. JAMA Netw Open 2021; 4:e2131012. [PMID: 34694388 PMCID: PMC8546497 DOI: 10.1001/jamanetworkopen.2021.31012] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/21/2021] [Indexed: 01/06/2023] Open
Abstract
Importance The ongoing COVID-19 pandemic and associated mitigation measures have disrupted access to psychiatric medications, particularly for women. Objective To assess the sex differences in trends in the prescribing of benzodiazepines, Z-hypnotics and serotonergic (selective serotonin reuptake inhibitors [SSRIs] and serotonin and norepinephrine reuptake inhibitors [SNRIs]), which are commonly prescribed for anxiety, insomnia, and depression. Design, Setting, and Participants This cohort study used data from Clinformatics Data Mart, one of the largest commercial health insurance databases in the US. Enrollees 18 years or older were required to have complete enrollment in a given month during our study period, January 1, 2018, to March 31, 2021, to be included for that month. Main Outcomes and Measures Prescription of a benzodiazepine, Z-hypnotic, or SSRI or SNRI. For each month, the percentage of patients with benzodiazepine, Z-hypnotic, or SSRI or SNRI prescriptions by sex was calculated. Results The records of 17 255 033 adults (mean [SD] age, 51.7 [19.5] years; 51.3% female) were examined in 2018, 17 340 731 adults (mean [SD] age, 52.5 [19.7] years; 51.6% female) in 2019, 16 916 910 adults (mean [SD] age, 53.7 [19.8] years; 51.9% female) in 2020, and 15 135 998 adults (mean [SD] age, 56.2 [19.8] years; 52.5% female) in 2021. Compared with men, women had a higher rate of prescriptions for all 3 drugs classes and had larger changes in prescription rates over time. Benzodiazepine prescribing decreased from January 2018 (women: 5.61%; 95% CI, 5.60%-5.63%; men: 3.03%; 95% CI, 3.02%-3.04%) to March 2021 (women: 4.91%; 95% CI, 4.90%-4.93%; men: 2.66%; 95% CI, 2.65%-2.67%), except for a slight increase in April 2020 among women. Z-hypnotic prescribing increased from January 2020 for women (1.39%; 95% CI, 1.38%-1.40%) and February 2020 for men (0.97%; 95% CI, 0.96%-0.98%) to October 2020 (women: 1.46%; 95% CI, 1.46%-1.47%; men: 1.00%; 95% CI, 0.99%-1.01%). Prescribing of SSRIs and SNRIs increased from January 2018 (women: 12.77%; 95% CI; 12.75%-12.80%; men: 5.56%; 95% CI, 5.44%-5.58%) to April 2020 for men (6.73%; 95% CI, 6.71%-6.75%) and October 2020 for women (15.18%; 95% CI, 15.16%-15.21%). Conclusions and Relevance In this cohort study, coinciding with the COVID-19 pandemic onset was an increase in Z-hypnotic as well as SSRI and SNRI prescriptions in both men and women along with an increase in benzodiazepine prescriptions in women, findings that suggest a substantial mental health impact of COVID-19-associated mitigation measures.
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Affiliation(s)
- Sadaf Arefi Milani
- Department of Internal Medicine–Geriatrics and Palliative Medicine, University of Texas Medical Branch, Galveston
- Sealy Center on Aging, University of Texas Medical Branch, Galveston
- Center for Interdisciplinary Research in Women’s Health, University of Texas Medical Branch, Galveston
| | - Mukaila A. Raji
- Department of Internal Medicine–Geriatrics and Palliative Medicine, University of Texas Medical Branch, Galveston
- Sealy Center on Aging, University of Texas Medical Branch, Galveston
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston
| | - Lu Chen
- Office of Biostatistics, University of Texas Medical Branch, Galveston
| | - Yong-Fang Kuo
- Department of Internal Medicine–Geriatrics and Palliative Medicine, University of Texas Medical Branch, Galveston
- Sealy Center on Aging, University of Texas Medical Branch, Galveston
- Center for Interdisciplinary Research in Women’s Health, University of Texas Medical Branch, Galveston
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston
- Office of Biostatistics, University of Texas Medical Branch, Galveston
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16
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Burry L, Turner J, Morgenthaler T, Tannenbaum C, Cho HJ, Gathecha E, Kisuule F, Vijenthira A, Soong C. Addressing Barriers to Reducing Prescribing and Implementing Deprescribing of Sedative-Hypnotics in Primary Care. Ann Pharmacother 2021; 56:463-474. [PMID: 34301151 PMCID: PMC8899816 DOI: 10.1177/10600280211033022] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To describe interventions that target patient, provider, and system barriers
to sedative-hypnotic (SH) deprescribing in the community and suggest
strategies for healthcare teams. Data Sources: Ovid MEDLINE ALL and EMBASE Classic + EMBASE (March 10, 2021). Study Selection and Data Extraction: English-language studies in primary care settings. Data Synthesis: 20 studies were themed as patient-related and prescriber inertia, physician
skills and awareness, and health system constraints. Patient education
strategies reduced SH dose for 10% to 62% of participants, leading to
discontinuation in 13% to 80% of participants. Policy interventions reduced
targeted medication use by 10% to 50%. Relevance to Patient Care and Clinical Practice: Patient engagement and empowerment successfully convince patients to
deprescribe chronic SHs. Quality improvement strategies should also consider
interventions directed at prescribers, including education and training,
drug utilization reviews, or computer alerts indicating a potentially
inappropriate prescription by medication, age, dose, or disease. Educational
interventions were effective when they facilitated patient engagement and
provided information on the harms and limited evidence supporting chronic
use as well as the effectiveness of alternatives. Decision support tools
were less effective than prescriber education with patient engagement,
although they can be readily incorporated in the workflow through
prescribing software. Conclusions: Several strategies with demonstrated efficacy in reducing SH use in community
practice were identified. Education regarding SH risks, how to taper, and
potential alternatives are essential details to provide to clinicians,
patients, and families. The strategies presented can guide community
healthcare teams toward reducing the community burden of SH use.
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Affiliation(s)
- Lisa Burry
- Sinai Health System, Toronto, Ontario, Canada.,University of Toronto, Ontario, Canada
| | - Justin Turner
- Université de Montréal, Montréal, Québec, Canada.,Institut universitaire de gériatrie de Montréal, Québec, Canada
| | | | | | - Hyung J Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Lown Institute, Brookline, Massachusetts, MA, USA
| | | | - Flora Kisuule
- Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | | | - Christine Soong
- Sinai Health System, Toronto, Ontario, Canada.,University of Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, Toronto, Ontario, Canada
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17
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Neville HL, Granter C, Adibi P, Belliveau J, Isenor JE, Bowles SK. Interventions to reduce benzodiazepine and sedative-hypnotic drug use in acute care hospitals: A scoping review. Res Social Adm Pharm 2021; 18:2874-2886. [PMID: 34253470 DOI: 10.1016/j.sapharm.2021.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 05/17/2021] [Accepted: 07/04/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Benzodiazepines and sedative-hypnotic drugs (BZD/SHD) are commonly utilized in the acute care setting for insomnia and anxiety and are associated with cognitive impairment, falls, and fractures. Interventions to reduce use of BZD/SHD in hospitals are not well characterized. OBJECTIVE The objective was to conduct a scoping review to identify and characterize interventions to reduce the use of BZD/SHD by adults in the acute care setting. METHODS English language studies and abstracts that described an intervention to reduce BZD/SHD in adult hospital patients were included. Six databases (PubMed, EMBASE, CINAHL, PsycINFO, Scopus, and Web of Science) were searched up to July 2018 and updated to February 3, 2021. The grey literature (Opengrey, Grey Matters, Google Advanced) was searched up to July 2018. Titles and abstracts were screened and full-text articles were reviewed and charted by three independent reviewers. Stakeholders were consulted to inform the scoping review and collect perspectives on the findings. RESULTS There were 13,046 records identified and 43 studies included. The most common study designs were uncontrolled before and after (23/43, 53.5%) and randomized controlled trials (7/43, 16.3%). The majority of studies tested a single intervention (32/43, 74.4%) such as education, deprescribing, relaxation training and sleep protocols. Patients were frequently the target of relaxation training and behavior change interventions; while sleep protocols, multifaceted interventions, education and deprescribing were usually directed at healthcare providers, either alone or in combination with patients. Most studies reported positive results in decreasing BZD/SHD use (27/43, 62.8%). CONCLUSIONS The scoping review found a variety of interventions to decrease the utilization of BZD/SHD in hospitals. Multifaceted interventions aimed at patients and healthcare providers that include a combination of education, sleep protocols, and deprescribing may support reductions in BZD/SHD use. Stakeholders also recommended policy and system changes such as computer alerts due to feasibility and workload.
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Affiliation(s)
- Heather L Neville
- Nova Scotia Health, 1276 South Park Street, Halifax, Nova Scotia, B3H 2Y9, Canada.
| | - Courtney Granter
- Nova Scotia Health, 1276 South Park Street, Halifax, Nova Scotia, B3H 2Y9, Canada; IWK Health Centre, 5980 University Ave, Halifax, Nova Scotia, B3H 1V7, Canada.
| | - Pegah Adibi
- Nova Scotia Health, 1276 South Park Street, Halifax, Nova Scotia, B3H 2Y9, Canada.
| | - Julia Belliveau
- Nova Scotia Health, 1276 South Park Street, Halifax, Nova Scotia, B3H 2Y9, Canada.
| | - Jennifer E Isenor
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Susan K Bowles
- Nova Scotia Health, 1276 South Park Street, Halifax, Nova Scotia, B3H 2Y9, Canada; College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada.
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18
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MacGregor AJ, Markwald RR, Dougherty AL, Seda G. The relationship between military occupation and diagnosed insomnia following combat deployment. J Clin Sleep Med 2021; 16:1125-1132. [PMID: 32248897 DOI: 10.5664/jcsm.8444] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Our objective was to investigate the relationship between military occupation and diagnosed insomnia following combat deployment. METHODS This retrospective cohort study was conducted using existing electronic military databases. Eligible participants were military personnel with a deployment to Iraq, Afghanistan, or Kuwait between 2005 and 2009. A total of 66,869 U.S. Navy and U.S. Marine Corps service members constituted the study sample and were categorized by military occupation. Military medical databases were used to abstract information on insomnia diagnoses and prescription medications. RESULTS The overall prevalence of diagnosed insomnia was 3.4%. In multivariable logistic regression, personnel in law enforcement (odds ratio = 1.62; 95% confidence interval, 1.28-2.04), motor transport (odds ratio = 1.38; 95% confidence interval, 1.14-1.66), and health care occupations (odds ratio = 2.24; 95% confidence interval, 1.85-2.71) had significantly higher odds of an insomnia diagnosis following deployment than did those in infantry occupations. These results remained unchanged after excluding those who reported posttraumatic stress disorder symptoms. Nonbenzodiazepine sedative/hypnotics were prescribed for 44.2% of those with insomnia, and prescription patterns differed by occupation. CONCLUSIONS These results suggest that military occupation may play a primary role in the onset and management of insomnia. The findings provide a rationale for targeting individuals in insomnia-susceptible occupations with better methods to prevent and/or minimize sleep issues during and after combat deployment.
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Affiliation(s)
- Andrew J MacGregor
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, San Diego, California
| | - Rachel R Markwald
- Warfighter Performance Department, Naval Health Research Center, San Diego, California
| | - Amber L Dougherty
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, San Diego, California.,Leidos, Inc., San Diego, California
| | - Gilbert Seda
- Sleep Clinic, Pulmonary Medicine Department, Naval Medical Center, San Diego, California
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19
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Kelly DL, Syrjala K, Taylor M, Rentscher KE, Hashmi S, Wood WA, Jim H, Barata A, Flynn KE, Burns LJ, Shaw BE, Petersdorf E, Yero AC, Emmrich AD, Morris KE, Costanzo ES, Knight JM. Biobehavioral Research and Hematopoietic Stem Cell Transplantation: Expert Review from the Biobehavioral Research Special Interest Group of the American Society for Transplantation and Cellular Therapy. Transplant Cell Ther 2021; 27:747-757. [PMID: 34139388 DOI: 10.1016/j.jtct.2021.06.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 06/04/2021] [Accepted: 06/07/2021] [Indexed: 01/12/2023]
Abstract
Hematopoietic stem cell transplantation (HCT) is a potentially curative treatment for many hematologic conditions. Despite advances in conditioning and supportive measures, however, there remain significant comorbidities that threaten survivorship. Adverse effects of stress-related biobehavioral processes-defined here as the interactions of behavioral, psychological, and socioenvironmental factors with biology-impact immune recovery and function and are particularly salient in the HCT context, given the importance of immune reconstitution for improved survivorship. However, biobehavioral processes have been underinvestigated in this vulnerable group compared with other cancer populations. Here the Biobehavioral Research Special Interest Group (SIG) of the American Society for Transplantation and Cellular Therapy provides an expert review to inform research directions explicating the biological correlates of behavioral symptoms and evaluate the impact of these on HCT outcomes. The goal of this expert review is to provide a foundation for advancing science that effectively integrates behavioral and biological processes to optimize quality of life and improve clinical outcomes for HCT recipients.
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Affiliation(s)
- Debra Lynch Kelly
- Department of Biobehavioral Nursing Science, College of Nursing, University of Florida and University of Florida Health Cancer Center, Gainesville, Florida
| | - Karen Syrjala
- Biobehavioral Sciences Department, Fred Hutchinson Cancer Research Center and University of Washington School of Medicine, Seattle, Washington
| | - Mallory Taylor
- Division of Hematology-Oncology, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Kelly E Rentscher
- Cousins Center for Psychoneuroimmunology, Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, Los Angeles, California
| | - Shahrukh Hashmi
- Department of Hematology and Onclolgy; Sheikh Shakhbout Medical City/Mayo Clinic, Abu Dhabi, United Arab Emirates
| | - William A Wood
- Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Heather Jim
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Anna Barata
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Kathryn E Flynn
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Linda J Burns
- Center for International Blood and Marrow Transplant Research, Milwaukee, Wisconsin
| | - Bronwen E Shaw
- Center for International Blood and Marrow Transplantation Research, Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Effie Petersdorf
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Anela Carrazana Yero
- Department of Biobehavioral Nursing Science, University of Florida, Gainesville, Florida
| | - Amanda D Emmrich
- Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Keayra E Morris
- Department of Psychiatry, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Erin S Costanzo
- Department of Psychiatry and Carbone Cancer Center, University of Wisconsin-Madison, Madison, Wisconsin
| | - Jennifer M Knight
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, Wisconsin.
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20
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Ardeljan AD, Polisetty TS, Palmer JR, Toma JJ, Vakharia RM, Roche MW. Response to Letter to the Editor on "Impact of Postoperative Zolpidem Use on Primary Total Knee Arthroplasty: A Retrospective Matched-Controlled Analysis of a Private Insurance Database". J Arthroplasty 2021; 36:e45. [PMID: 33931158 DOI: 10.1016/j.arth.2021.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 02/02/2023] Open
Affiliation(s)
- Andrew D Ardeljan
- Nova Southeastern College of Osteopathic Medicine, Fort Lauderdale, FL; Holy Cross Orthopaedic Institute, Department of Orthopaedic Research, Fort Lauderdale, FL
| | - Teja S Polisetty
- Holy Cross Orthopaedic Institute, Department of Orthopaedic Research, Fort Lauderdale, FL; Harvard Medical School, Harvard University, Boston, MA
| | - Joseph R Palmer
- Department of Orthopaedic Surgery, Broward Health Medical Center, Fort Lauderdale, FL
| | - Justin J Toma
- Holy Cross Orthopaedic Institute, Department of Orthopaedic Research, Fort Lauderdale, FL
| | - Rushabh M Vakharia
- Holy Cross Orthopaedic Institute, Department of Orthopaedic Research, Fort Lauderdale, FL
| | - Martin W Roche
- Holy Cross Orthopaedic Institute, Department of Orthopaedic Research, Fort Lauderdale, FL
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21
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Ardeljan AD, Polisetty TS, Palmer JR, Toma JJ, Vakharia RM, Roche MW. Impact of Postoperative Zolpidem Use on Primary Total Knee Arthroplasty: A Retrospective Matched-Controlled Analysis of a Private Insurance Database. J Arthroplasty 2021; 36:1322-1329. [PMID: 33250327 DOI: 10.1016/j.arth.2020.10.058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/23/2020] [Accepted: 10/28/2020] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Zolpidem has gained popularity as a pharmaceutical therapy for insomnia, being the most prescribed hypnotic in the United States today. However, it is associated with increased mortality and morbidity. Literature regarding zolpidem use in the total knee arthroplasty (TKA) population is limited. The aim of the study was to analyze postoperative zolpidem use in the TKA population regarding medical and implant complications, falls, and readmission. METHODS The study group was queried according to zolpidem use. Controls consisted of patients who underwent primary TKA without a history of hypnotic drug use. Study group patients were matched to controls in a 1:5 ratio by demographics and comorbidities. Results yielded 99,178 study participants and 495,795 controls. Primary endpoints included 90-day medical and implant complications, fall risk, and readmission. Chi-squared test was used to compare categorical variables. Multivariate logistic regression was used to calculate odds (OR) for complications, fall risk, and readmission. A P value less than 0.05 was considered statistically significant. RESULTS Study group patients had increased odds of medical complications (OR: 1.76, 95% CI: 1.71-1.82, P < .0001) and implant complications (OR: 1.35, 95% CI: 1.23-1.47, P < .0001) compared to controls. Furthermore, patients in the study group were found to have an increased risk of 90- day falls (OR: 1.16, 95% CI: 1.11-1.21, P < .0001). Readmission was similar to controls (5.10% vs 4.84%, P = .12). CONCLUSION Zolpidem use following primary TKA is associated with the risk of morbidity and falls. The findings are consistent with the literature regarding zolpidem. These findings may affect discussion between orthopedic surgeons and patients in the decision-making process prior to undergoing TKA.
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Affiliation(s)
- Andrew D Ardeljan
- Nova Southeastern College of Osteopathic Medicine, Ft. Lauderdale, FL; Holy Cross Hospital, Orthopaedic Research Institute, Ft. Lauderdale, FL
| | - Teja S Polisetty
- Holy Cross Hospital, Orthopaedic Research Institute, Ft. Lauderdale, FL; Harvard Medical School, Harvard University, Boston, MA
| | - Joseph R Palmer
- Department of Orthopaedic Surgery, Broward Health Medical Center, Ft. Lauderdale, FL
| | - Justin J Toma
- Holy Cross Hospital, Orthopaedic Research Institute, Ft. Lauderdale, FL
| | - Rushabh M Vakharia
- Holy Cross Hospital, Orthopaedic Research Institute, Ft. Lauderdale, FL; Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY
| | - Martin W Roche
- Holy Cross Hospital, Orthopaedic Research Institute, Ft. Lauderdale, FL
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22
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Mainero Rocca L, L’Episcopo N, Gordiani A, Vitali M, Staderini A. A 'Dilute and Shoot' Liquid Chromatography-Mass Spectrometry Method for Multiclass Drug Analysis in Pre-Cut Dried Blood Spots. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:3068. [PMID: 33809736 PMCID: PMC8002310 DOI: 10.3390/ijerph18063068] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/12/2021] [Accepted: 03/13/2021] [Indexed: 01/26/2023]
Abstract
Drugs able to affect the auditory and nervous systems and consumed by workers to treatdifferent pathologies can represent a possible source of risk in the work environment. All the target compounds involved in the presented project show ototoxic and/or narcoleptic side effects and, for these reasons, occupational safety organizations have recognized them as potential causes of work injuries. A multiclass method for the analysis of 15 drugs among the most widespread worldwide (belonging to nine different classes including antihistamines, beta-blockers, antidepressants, Z-drugs and opioids), was developed and validated. This study describes a rapid, sensitive and effective method to analyse these substances in whole blood using tailored pre-cut dried blood spots. Detection was achieved with a triple quadrupole mass spectrometer after an easy and simple 'dilute and shoot' solubilisation followed by an UPLC separation. All the issues linked to the use of the dried blood spots and whole blood, such as haematocrit variability, volumetric evaluation and sample carrier choice were carefully studied and managed during method development. From the validation study results it emerged that this approach can be deemed successful thanks to its few pg µL-1 LOQs, good linear intervals, absolute recoveries of no less than 75%, an almost negligible matrix effect and accuracy and precision in line with the European and American guidelines for validation. All the obtained goals have been specifically pursued in order to encourage method diffusion as a primary prevention intervention, even in small private workplaces.
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Affiliation(s)
- Lucia Mainero Rocca
- Chemical Agents Laboratory, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Italian Workers’ Compensation Authority (INAIL)—, Via Fontana Candida 1, Monte Porzio Catone, 00078 Rome, Italy; (N.L.); (A.G.); (A.S.)
| | - Nunziata L’Episcopo
- Chemical Agents Laboratory, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Italian Workers’ Compensation Authority (INAIL)—, Via Fontana Candida 1, Monte Porzio Catone, 00078 Rome, Italy; (N.L.); (A.G.); (A.S.)
| | - Andrea Gordiani
- Chemical Agents Laboratory, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Italian Workers’ Compensation Authority (INAIL)—, Via Fontana Candida 1, Monte Porzio Catone, 00078 Rome, Italy; (N.L.); (A.G.); (A.S.)
| | - Matteo Vitali
- Department of Public Health and Infectious Diseases, University of Rome La Sapienza, P.le Aldo Moro, 5, 00185 Rome, Italy;
| | - Alessandro Staderini
- Chemical Agents Laboratory, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Italian Workers’ Compensation Authority (INAIL)—, Via Fontana Candida 1, Monte Porzio Catone, 00078 Rome, Italy; (N.L.); (A.G.); (A.S.)
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23
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Herzig SJ, Rothberg MB, Moss CR, Maddaleni G, Bertisch SM, Wong J, Zhou W, Ngo L, Anderson TS, Gurwitz JH, Marcantonio ER. Risk of In-Hospital Falls among Medications Commonly Used for Insomnia in Hospitalized Patients. Sleep 2021; 44:6168917. [PMID: 33710329 DOI: 10.1093/sleep/zsab064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 03/02/2021] [Indexed: 01/19/2023] Open
Abstract
STUDY OBJECTIVES To investigate the risk of in-hospital falls among patients receiving medications commonly used for insomnia in the hospital setting. METHODS Retrospective cohort study of all adult hospitalizations to a large academic medical center from 1/2007 to 7/2013. We excluded patients admitted for a primary psychiatric disorder. Medication exposures of interest, defined by pharmacy charges, included benzodiazepines, non-benzodiazepine benzodiazepine receptor agonists (BZRAs), trazodone, atypical antipsychotics, and diphenhydramine. In-hospital falls were ascertained from an online patient safety reporting system. RESULTS Among the 225,498 hospitalizations (median age = 57 years; 57.9% female) in our cohort, 84,911 (37.7%) had exposure to at least one of the five medication classes of interest; benzodiazepines were the most commonly used (23.5%), followed by diphenydramine (8.3%), trazodone (6.6%), BZRAs (6.4%), and atypical antipsychotics (6.3%). A fall occurred in 2,427 hospitalizations (1.1%). The rate of falls per 1,000 hospital days was greater among hospitalizations with exposure to each of the medications of interest, compared to unexposed: 3.6 versus 1.7 for benzodiazepines (adjusted hazard ratio [aHR] 1.8, 95%CI 1.6-1.9); 5.4 versus 1.8 for atypical antipsychotics (aHR 1.6, 95%CI 1.4-1.8); 3.0 versus 2.0 for BZRAs (aHR 1.5, 95%CI 1.3-1.8); 3.3 versus 2.0 for trazodone (aHR 1.2, 95%CI 1.1-1.5); and 2.5 versus 2.0 for diphenhydramine (aHR 1.2, 95%CI 1.03-1.5). CONCLUSIONS In this large cohort of hospitalizations at an academic medical center, we found an association between each of the sedating medications examined and in-hospital falls. Benzodiazepines, BZRAs, and atypical antipsychotics had the strongest associations.
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Affiliation(s)
- Shoshana J Herzig
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.,Harvard Medical School, Boston, MA
| | - Michael B Rothberg
- Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, OH
| | - Caitlyn R Moss
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Geeda Maddaleni
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Suzanne M Bertisch
- Harvard Medical School, Boston, MA.,Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA
| | - Jenna Wong
- Harvard Medical School, Boston, MA.,Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Wenxiao Zhou
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Long Ngo
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.,Harvard Medical School, Boston, MA
| | - Timothy S Anderson
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.,Harvard Medical School, Boston, MA
| | - Jerry H Gurwitz
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Community Health Plan, Worcester, MA.,University of Massachusetts Medical School, Worcester, MA
| | - Edward R Marcantonio
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.,Harvard Medical School, Boston, MA.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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24
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Richardson K, Savva GM, Boyd PJ, Aldus C, Maidment I, Pakpahan E, Loke YK, Arthur A, Steel N, Ballard C, Howard R, Fox C. Non-benzodiazepine hypnotic use for sleep disturbance in people aged over 55 years living with dementia: a series of cohort studies. Health Technol Assess 2021; 25:1-202. [PMID: 33410736 PMCID: PMC7812417 DOI: 10.3310/hta25010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Sleep disturbance affects around 60% of people living with dementia and can negatively affect their quality of life and that of their carers. Hypnotic Z-drugs (zolpidem, zopiclone and zaleplon) are commonly used to treat insomnia, but their safety and efficacy have not been evaluated for people living with dementia. OBJECTIVES To estimate the benefits and harms of Z-drugs in people living with dementia with sleep disturbance. DESIGN A series of observational cohort studies using existing data from (1) primary care linked to hospital admission data and (2) clinical cohort studies of people living with dementia. DATA SOURCES Primary care study - Clinical Practice Research Datalink linked to Hospital Episode Statistics and Office for National Statistics mortality data. Clinical cohort studies - the Resource Use and Disease Course in Dementia - Nursing Homes (REDIC) study, National Alzheimer's Coordinating Centre (NACC) clinical data set and the Improving Well-being and Health for People with Dementia (WHELD) in nursing homes randomised controlled trial. SETTING Primary care study - 371 primary care practices in England. Clinical cohort studies - 47 nursing homes in Norway, 34 Alzheimer's disease centres in the USA and 69 care homes in England. PARTICIPANTS Primary care study - NHS England primary care patients diagnosed with dementia and aged > 55 years, with sleep disturbance or prescribed Z-drugs or low-dose tricyclic antidepressants, followed over 2 years. Clinical cohort studies - people living with dementia consenting to participate, followed over 3 years, 12 years and 9 months, for REDIC, NACC and WHELD, respectively. INTERVENTIONS The primary exposure was prescription or use of Z-drugs. Secondary exposures included prescription or use of benzodiazepines, low-dose tricyclic antidepressants and antipsychotics. MAIN OUTCOME MEASURES Falls, fractures, infection, stroke, venous thromboembolism, mortality, cognitive function and quality of life. There were insufficient data to investigate sleep disturbance. RESULTS The primary care study and combined clinical cohort studies included 6809 and 18,659 people living with dementia, with 3089 and 914 taking Z-drugs, respectively. New Z-drug use was associated with a greater risk of fractures (hazard ratio 1.40, 95% confidence interval 1.01 to 1.94), with risk increasing with greater cumulative dose (p = 0.002). The hazard ratio for Z-drug use and hip fracture was 1.59 (95% confidence interval 1.00 to 2.53) and for mortality was 1.34 (95% confidence interval 1.10 to 1.64). No excess risks of falls, infections, stroke or venous thromboembolism were detected. Z-drug use also did not have an impact on cognition, neuropsychiatric symptoms, disability or quality of life. LIMITATIONS Primary care study - possible residual confounding because of difficulties in identifying patients with sleep disturbance and by dementia severity. Clinical cohort studies - the small numbers of people living with dementia taking Z-drugs and outcomes not necessarily being measured before Z-drug initiation restricted analyses. CONCLUSIONS We observed a dose-dependent increase in fracture risk, but no other harms, with Z-drug use in dementia. However, multiple outcomes were examined, increasing the risk of false-positive findings. The mortality association was unlikely to be causal. Further research is needed to confirm the increased fracture risk. Decisions to prescribe Z-drugs may need to consider the risk of fractures, balanced against the impact of improved sleep for people living with dementia and that of their carers. Our findings suggest that when Z-drugs are prescribed, falls prevention strategies may be needed, and that the prescription should be regularly reviewed. FUTURE WORK More research is needed on safe and effective management strategies for sleep disturbance in people living with dementia. STUDY REGISTRATION This study is registered as European Union electronic Register of Post-Authorisation Studies (EU PAS) 18006. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 1. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - George M Savva
- School of Health Sciences, University of East Anglia, Norwich, UK
- Quadram Institute, Norwich, UK
| | - Penelope J Boyd
- School of Health Sciences, University of East Anglia, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Clare Aldus
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Ian Maidment
- School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Eduwin Pakpahan
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Yoon K Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Antony Arthur
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Nicholas Steel
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Robert Howard
- Division of Psychiatry, University College London, London, UK
| | - Chris Fox
- Norwich Medical School, University of East Anglia, Norwich, UK
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25
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Morelhão PK, Gobbi C, Galduróz JCF, Tufik S, Andersen ML. Zolpidem for older adults: To prescribe or not to prescribe? Int J Geriatr Psychiatry 2020; 35:689-690. [PMID: 32212184 DOI: 10.1002/gps.5298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 03/07/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Priscila K Morelhão
- Departamento de Psicobiologia, Universidade Federal de São Paulo, Brazil (UNIFESP), São Paulo, Brazil
| | - Cynthia Gobbi
- Departamento de Fisioterapia, Centro de Ensino Superior de Maringá (UNICESUMAR), Maringá, Brazil
| | - José C F Galduróz
- Departamento de Psicobiologia, Universidade Federal de São Paulo, Brazil (UNIFESP), São Paulo, Brazil
| | - Sergio Tufik
- Departamento de Psicobiologia, Universidade Federal de São Paulo, Brazil (UNIFESP), São Paulo, Brazil
| | - Monica L Andersen
- Departamento de Psicobiologia, Universidade Federal de São Paulo, Brazil (UNIFESP), São Paulo, Brazil
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26
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MacMillan TE, Lui P, Wu RC, Cavalcanti RB. Melatonin Increasingly Used in Hospitalized Patients. J Hosp Med 2020; 15:349-351. [PMID: 32490799 DOI: 10.12788/jhm.3408] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/08/2020] [Indexed: 11/20/2022]
Abstract
The frequency of melatonin use for insomnia in hospitalized patients is unknown. This study assessed temporal trends of melatonin use in the hospital and compared them with those of use of zopiclone and lorazepam. We performed a retrospective observational study over 6 years from January 2013 to December 2018 at two academic urban hospitals in Toronto, Canada. We abstracted pharmacy dispensing data and standardized rates of medication use by inpatient days. Melatonin use increased from almost none to more than 70 doses per 1,000 inpatient days during 2013-2018, while zopiclone use decreased by 20 doses per 1,000 inpatient days. Melatonin use was twice as high at one hospital and was higher on internal medicine and critical care. Overall use of the three medications increased by 25.7%, which mainly reflects a marked increase in melatonin use. Melatonin is likely being used in a proportion of patients who would not otherwise have received a sleep medication.
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Affiliation(s)
- Thomas E MacMillan
- Division of General Internal Medicine, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- HoPingKong Centre for Excellence in Education and Practice, University Health Network, Toronto, Ontario, Canada
| | - Philip Lui
- Department of Pharmacy, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Robert C Wu
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- HoPingKong Centre for Excellence in Education and Practice, University Health Network, Toronto, Ontario, Canada
- Division of General Internal Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Rodrigo B Cavalcanti
- Division of General Internal Medicine, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- HoPingKong Centre for Excellence in Education and Practice, University Health Network, Toronto, Ontario, Canada
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27
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Neville HL, Losier M, Pitman J, Gehrig M, Isenor JE, Minard LV, Penny E, Bowles SK. Point Prevalence Survey of Benzodiazepine and Sedative-Hypnotic Drug Use in Hospitalized Adult Patients. Can J Hosp Pharm 2020; 73:193-201. [PMID: 32616945 PMCID: PMC7308153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Benzodiazepines and sedative-hypnotic drugs (BZD/SHDs), such as zopiclone and the antidepressant trazodone, pose risks such as falls, fractures, and confusion, especially for older adults. Use of these drugs in the acute care setting is poorly understood. OBJECTIVES To determine the point prevalence and characteristics of use of BZD/SHDs in hospitals in Nova Scotia, Canada. METHODS A point prevalence survey was conducted for adults admitted to all hospitals with at least 30 acute care beds between May and August 2016. Drugs administered intravenously, patients in long-term care, and patients receiving mental health services, addiction treatment, or critical care were excluded. The proportion of included patients who had received a BZD/SHD within the 24 h before the start of the survey was determined. A descriptive statistical analysis was performed. RESULTS Overall BZD/SHD prevalence was 34.6% (487/1409) across the 16 eligible hospitals. The average age was 70.3 years, and 150 (30.8%) of the patients were 80 years or older. Among the 585 prescriptions for these patients, commonly used drugs were zopiclone (32.0%), lorazepam (21.9%), and trazodone (21.9%). The most common indications for use were bedtime/daytime sedation (60.0%) and anxiety (12.5%). More than half of the prescriptions (55.7%) had been initiated at home, 37.6% were started in hospital, and the place of initiation was unknown for 6.7%. Benzodiazepines were prescribed more frequently to patients under 65 years than those 80 years or older (41.3% versus 22.2%, p < 0.001) whereas trazodone was more frequently prescribed to the older of these 2 age groups (52.7% versus 14.3%, p < 0.001). CONCLUSIONS BZD/SHDs were frequently used by hospitalized adult patients in Nova Scotia. Trazodone appears to have been substituted for benzodiazepines in the oldest age group. Pharmacists should direct their efforts toward preventing inappropriate initiation of BZD/SHDs in hospital, particularly for elderly patients.
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Affiliation(s)
- Heather L Neville
- , BScPharm, MSc, FCSHP, is with the Nova Scotia Health Authority, Halifax, Nova Scotia
| | - Mia Losier
- , BScPharm, ACPR, was, at the time of this study, with the Nova Scotia Health Authority and the College of Pharmacy, Dalhousie University, Halifax, Nova Scotia. She is now with Horizon Health Network, Saint John, New Brunswick
| | - Jennifer Pitman
- , BScMedSc, BScPharm, ACPR, was, at the time of this study, with the Nova Scotia Health Authority and the College of Pharmacy, Dalhousie University, Halifax, Nova Scotia. She is now with the Vancouver Island Health Authority, Victoria, British Columbia
| | - Melissa Gehrig
- , BSc(Hons), BScPharm, MSc, is with the Nova Scotia Health Authority, Halifax, Nova Scotia
| | - Jennifer E Isenor
- , BScPharm, PharmD, is with the College of Pharmacy, Dalhousie University, Halifax, Nova Scotia
| | - Laura V Minard
- , BSc, BScPharm, ACPR, PhD, is with the Nova Scotia Health Authority, Halifax, Nova Scotia
| | - Ellen Penny
- , BScPharm, PharmD, BCGP, is with the Nova Scotia Health Authority, Sydney, Nova Scotia
| | - Susan K Bowles
- , BScPhm, MSc, PharmD, FCSHP, is with the Nova Scotia Health Authority and the College of Pharmacy, Dalhousie University, Halifax, Nova Scotia
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Abstract
Despite decades of fall prevention efforts, patient falls remain a common cause of harm in hospitalized older adults. While fall prevention strategies have been historically championed by nurses, hospitalist physicians, nurse practitioners, and physician assistants play a vital role in the multidisciplinary care team in ensuring the safety of our patients. Multiple fall risk assessment tools exist, but no one tool has demonstrated excellence in predicting patient falls in the hospital. Any fall risk assessment tool should be complemented by a clinician's individualized evaluation of patient-specific, situational, and environmental risk factors. A particular emphasis on medication review is critical, as numerous medication classes can increase the risk of falls, and medications are a potentially modifiable risk factor. Multiple studies of individual and multicomponent nursing-based interventions have failed to demonstrate success in reducing falls or fall injuries. Promising strategies for fall prevention include tailoring interventions to patient risk factors and individualized patient education. In addition to nursing-based interventions, the hospitalist's role in fall prevention is to (1) identify and address potentially modifiable risk factors, (2) reinforce individualized education to patients, and (3) advise behavior choices that promote safe mobility. If a patient does sustain a fall, the hospitalist should partner with the multidisciplinary care team in post fall care to assess for injury, evaluate underlying causes of the fall, and determine plans for secondary prevention.
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Affiliation(s)
- Rachel Keuseman
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Donna Miller
- Division of Hospital Internal Medicine, Division of Geriatrics and Gerontology, Mayo Clinic,Rochester, MN, USA
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Abstract
A post-2000 literature search reviewed prevalence of health consequences associated with zolpidem, plus two salient case reports. Common zolpidem-related harms encompassed accidents, falls, overdoses, delirium, and infections. Risks to others included assaults, vehicular accidents, various crimes, and civil actions that occurred during zolpidem-induced delirium, withdrawal, and other impediments. Remarkably, much harm occurred while patients were taking therapeutic doses of licitly prescribed zolpidem (10-30 mg). Zolpidem-associated health, behavioral, and social problems comprise an international pandemic of preventable heath misfortunes.
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30
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Ramelteon for ICU Delirium Prevention: Is It Time to Melt Away? Crit Care Med 2019; 47:1813-1815. [PMID: 31738252 DOI: 10.1097/ccm.0000000000004052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Yang CW, Li CI, Li TC, Liu CS, Lin CH, Lin WY, Lin CC. Combined Effects of Having Sleep Problems and Taking Sleeping Pills on the Skeletal Muscle Mass and Performance of Community-Dwelling Elders. Sci Rep 2019; 9:13760. [PMID: 31551567 PMCID: PMC6760224 DOI: 10.1038/s41598-019-50295-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 09/01/2019] [Indexed: 12/19/2022] Open
Abstract
This study aimed to explore the combined effects of having sleep problems and taking sleeping pills on the skeletal muscle mass and performance of community-dwelling elders. A total of 826 participants who have complete information regarding dual-energy X-ray absorptiometry examination, questionnaire, and physical performance tests were included. The status of having sleep problems and taking sleeping pills was assessed with a self-reported questionnaire. The prevalence rates of sleep problems among older men and women were 37.4% and 54.5%, respectively. After multivariate adjustment, the mean height-adjusted skeletal muscle indices for elders having sleep problems and taking sleeping pills among men and women were 7.29 and 5.66 kg/m2, respectively, which were lower than those without sleep problems (P = 0.0021 and P = 0.0175). The performance of the older men having sleep problems and taking sleeping pills in terms of walking speed, grip strength, and number of squats, was poorer than those of the older men without sleep problems. The status of having sleep problems and taking sleeping pills was correlated with low skeletal muscle mass and poor physical performance in community-dwelling elders. These findings suggest that having sleep problems and taking sleeping pills are associated with having sarcopenia among community elderly.
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Affiliation(s)
- Chuan-Wei Yang
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Ing Li
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Tsai-Chung Li
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan.,Department of Healthcare Administration, College of Medical and Health Sciences, Asia University, Taichung, Taiwan
| | - Chiu-Shong Liu
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan.,Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chih-Hsueh Lin
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan.,Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Wen-Yuan Lin
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan.,Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Chieh Lin
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan. .,Department of Healthcare Administration, College of Medical and Health Sciences, Asia University, Taichung, Taiwan. .,Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan.
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Miller MA, Renn BN, Chu F, Torrence N. Sleepless in the hospital: A systematic review of non-pharmacological sleep interventions. Gen Hosp Psychiatry 2019; 59:58-66. [PMID: 31170567 PMCID: PMC6620136 DOI: 10.1016/j.genhosppsych.2019.05.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 05/23/2019] [Accepted: 05/23/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Poor sleep is highly prevalent in inpatient medical settings and has been associated with attenuated healing and worsened outcomes following hospitalization. Although nonpharmacological interventions are preferred, little is known about the best way to intervene in hospital settings. METHOD A systematic review of published literature examining nonpharmacological sleep interventions among inpatients in Embase, PsycINFO and PubMed in accordance with PRISMA guidelines. RESULTS Forty-three of the 1529 originally identified manuscripts met inclusion criteria, encompassing 2713 hospitalized participants from 18 countries comprised of psychiatric and older adult patients living in hospital settings. Main outcomes were subjective and objective measures of sleep duration, quality, and insomnia. CONCLUSIONS Overall, the review was unable to recommend any specific intervention due to the current state of the literature. The majority of included research was limited in quality due to lack of controls, lack of blinding, and reliance on self-reported outcomes. However, the literature suggests melatonin and CBT-I likely have the most promise to improve sleep in inpatient medical settings. Additionally, environmental modifications, including designated quiet time and ear plugs/eye masks, could be easily adopted in the care environment and may support sleep improvement. More rigorous research in nonpharmacological sleep interventions for hospitalized individuals is required to inform clinical recommendations.
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Affiliation(s)
- Megan A Miller
- Rehabilitation Care Service, VA Puget Sound -Seattle Division, Seattle, WA, United States of America.
| | - Brenna N Renn
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Frances Chu
- University of Washington Health Sciences Library, Seattle, WA, United States of America
| | - Nicole Torrence
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, United States of America; Geriatrics and Extended Care Service, VA Puget Sound - Seattle Division, Seattle, WA, United States of America
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Stoianovici R, Brunetti L, Adams CD. Comparison of Melatonin and Zolpidem for Sleep in an Academic Community Hospital: An Analysis of Patient Perception and Inpatient Outcomes. J Pharm Pract 2019; 34:44-50. [PMID: 31238791 DOI: 10.1177/0897190019851888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Hospitalizations can significantly disrupt patient sleep patterns and contribute to insomnia, which places patients at a higher risk of altered mental status as well as other complications. Despite attempts to control environmental factors, deliriogenic medications are often prescribed for the management of hospital-related insomnia. The primary objective of this study is to compare patient-perceived effectiveness of zolpidem versus melatonin in hospitalized patients. All inpatients who received melatonin or zolpidem the previous night as asleep aid and had no acute psychological issues or history of substance abuse were eligible for participation in this single-center, prospective, observational cohort study. The Verran and Snyder-Halpern sleep scale was utilized to evaluate sleep perception in 3 domains: sleep disturbance, effectiveness, and supplementation. A total of 439 patients were screened and 100 patients met study criteria and consented to the study. In the melatonin and zolpidem groups, the estimated adjusted means for the total sleep effectiveness (206.8 mm, 95% confidence interval [CI], 168.7-253.5vs 187.4 mm, 95% CI, 152.8-229.7; P=.513), sleep disturbance(362.1 mm, 95% CI, 310.1-422.7 vs 339.54 mm, 95% CI, 290.8-396.4; P=.573), and sleep supplementation (111.4 mm, 95% CI, 86.3-143.8 vs 120.9 mm, 95% CI, 94.1-155.2; P=.661) domains were not statistically different. Both melatonin and zolpidem were well tolerated with grogginess and headache as the only reported adverse effects. Melatonin demonstrated no significant difference in patient-perceived sleep effectiveness, disturbance, supplementation, or adverse effects when compared to zolpidem.
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Affiliation(s)
- Robyn Stoianovici
- Department of Pharmacy Services, 21772UC Davis Medical Center, Sacramento, CA, USA
| | - Luigi Brunetti
- Department of Pharmacy, Robert Wood Johnson University Hospital Somerset, Somerville, NJ, USA.,Ernest Mario School of Pharmacy, 5751Rutgers, The State University of New Jersey, Piscataway, NJ, USA
| | - Christopher D Adams
- Department of Pharmacy, Robert Wood Johnson University Hospital Somerset, Somerville, NJ, USA.,Ernest Mario School of Pharmacy, 5751Rutgers, The State University of New Jersey, Piscataway, NJ, USA
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35
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Song P, Lin H, Li S, Wang L, Liu J, Li N, Wang Y. Repetitive transcranial magnetic stimulation (rTMS) modulates time-varying electroencephalography (EEG) network in primary insomnia patients: a TMS-EEG study. Sleep Med 2019; 56:157-163. [DOI: 10.1016/j.sleep.2019.01.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 12/04/2018] [Accepted: 01/07/2019] [Indexed: 12/11/2022]
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36
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Matsumura T, Terada J, Yoshimura C, Koshikawa K, Kinoshita T, Yahaba M, Nagashima K, Sakao S, Tatsumi K. Single-use suvorexant for treating insomnia during overnight polysomnography in patients with suspected obstructive sleep apnea: a single-center experience. DRUG DESIGN DEVELOPMENT AND THERAPY 2019; 13:809-816. [PMID: 30880914 PMCID: PMC6400124 DOI: 10.2147/dddt.s197237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Purpose Although patients with suspected obstructive sleep apnea (OSA) might suffer difficulty in falling asleep during overnight polysomnography (PSG), standard hypnotics to obtain sleep during PSG have not been established. The aim of this study was to investigate the safety and efficacy of a new hypnotic agent, suvorexant, a dual orexin receptor antagonist, for insomnia in suspected OSA patients during in-laboratory PSG. Patients and methods An observational study was conducted during PSG for 149 patients with suspected OSA who had no insomnia at home. Patients with difficulty in falling asleep during PSG were optionally permitted to take single-use suvorexant. Patients with residual severe insomnia (>1 hour) after taking suvorexant were permitted to take an add-on use zolpidem. Clinical data and sleep questionnaire results were analyzed between a no insomnia group (without hypnotics) and an insomnia group (treated with suvorexant). Results Among 84 patients who experienced insomnia during PSG and required hypnotics (the insomnia group; treated with suvorexant), 44 (52.4%) achieved sufficient subjective sleep with single-use of suvorexant, while the other 40 (47.6%) required suvorexant plus zolpidem. An apnea hypopnea index (AHI) of ≥5 was observed in 144 out of 149 patients with predominantly obstructive respiratory events. Among those patients, 70.8% in the no insomnia group and 63.1% in the insomnia group had severe OSA. Regarding both subjective sleep time and morning mood, significant differences between the no insomnia group and the insomnia group were not observed. No patient taking suvorexant had an adverse event, such as delirium or falling. Conclusion Single-use suvorexant seems to be a safe and effective (but mild) hypnotic agent for suspected OSA patients with insomnia during in-laboratory PSG.
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Affiliation(s)
- Takuma Matsumura
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan,
| | - Jiro Terada
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan,
| | - Chikara Yoshimura
- Department of Respiratory and Sleep Medicine, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Ken Koshikawa
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan,
| | - Taku Kinoshita
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan,
| | - Misuzu Yahaba
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan,
| | - Kengo Nagashima
- Research Center for Medical and Health Data Science, The Institute of Statistical Mathematics, Tokyo, Japan
| | - Seiichiro Sakao
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan,
| | - Koichiro Tatsumi
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan,
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Karttunen N, Taipale H, Hamina A, Tanskanen A, Tiihonen J, Tolppanen AM, Hartikainen S. Concomitant use of benzodiazepines and opioids in community-dwelling older people with or without Alzheimer's disease-A nationwide register-based study in Finland. Int J Geriatr Psychiatry 2019; 34:280-288. [PMID: 30370943 DOI: 10.1002/gps.5018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 10/18/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The study aims to determine the prevalence of concomitant use of benzodiazepines and opioids among community-dwelling older people with or without Alzheimer's disease (AD). An additional aim was to describe the factors associated with prolonged concomitant use, and the most commonly used combinations of these drugs. METHODS This study utilized data from the register-based Medication Use and Alzheimer's disease (MEDALZ) study, including all community-dwelling residents of Finland who received a clinically verified AD diagnosis between 2005 and 2011 (n = 70 718) and their matched comparison persons without AD. After exclusion of individuals who were hospitalized throughout the follow-up, 69 353 persons with and 69 353 without AD were included in this study. RESULTS Benzodiazepines and related drugs (BZDRs) were used by 28 475 (41.1%) of those with and 24 506 (35.3%) of those without AD. Prolonged (greater than or equal to 90 days) concomitant use of BZDRs and opioids was more common among BZDR users without AD (N = 3936; 16.1%) than among those with AD (N = 2963; 10.4%). A shorter duration of concomitant use (1-89 days) revealed similar results, N = 3821; 15.6% and N = 3008; 10.6%, respectively. Prolonged concomitant use of BZDRs and opioids was associated with female sex, low socioeconomic position, most of the common comorbidities and history of substance abuse or long-term benzodiazepine use. The most commonly used combinations were Z-drug (31.7%) or benzodiazepine (29.9%) with a weak opioid. CONCLUSIONS Despite the recommendations and risks, the prevalence of concomitant BZDR and opioid use was common in older persons with or without AD. It is important to develop strategies to reduce unnecessary concomitant use of these drugs.
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Affiliation(s)
- Niina Karttunen
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Heidi Taipale
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Aleksi Hamina
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Antti Tanskanen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland.,Impact Assessment Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - Jari Tiihonen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland.,Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
| | - Anna-Maija Tolppanen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Research Centre for Comparative Effectiveness and Patient Safety (RECEPS), University of Eastern Finland, Kuopio, Finland
| | - Sirpa Hartikainen
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Research Centre for Comparative Effectiveness and Patient Safety (RECEPS), University of Eastern Finland, Kuopio, Finland
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Sandoval-Insausti H, Pérez-Tasigchana RF, López-García E, Banegas JR, Rodríguez-Artalejo F, Guallar-Castillón P. Protein Intake and Risk of Falls: A Prospective Analysis in Older Adults. J Am Geriatr Soc 2018; 67:329-335. [DOI: 10.1111/jgs.15681] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 09/27/2018] [Accepted: 09/27/2018] [Indexed: 12/31/2022]
Affiliation(s)
- Helena Sandoval-Insausti
- Department of Preventive Medicine and Public Health; School of Medicine, Universidad Autónoma de Madrid-IdiPaz; Madrid Spain
- CIBER of Epidemiology and Public Health (CIBERESP); Madrid Spain
- Service of Preventive Medicine; Hospital Universitario de La Princesa; Madrid Spain
| | - Raúl F. Pérez-Tasigchana
- Department of Preventive Medicine and Public Health; School of Medicine, Universidad Autónoma de Madrid-IdiPaz; Madrid Spain
- CIBER of Epidemiology and Public Health (CIBERESP); Madrid Spain
- School of Medicine, Universidad San Francisco de Quito; Quito Ecuador
| | - Esther López-García
- Department of Preventive Medicine and Public Health; School of Medicine, Universidad Autónoma de Madrid-IdiPaz; Madrid Spain
- CIBER of Epidemiology and Public Health (CIBERESP); Madrid Spain
- IMDEA-Food Institute, CEI UAM+CSIC; Madrid Spain
| | - José R. Banegas
- Department of Preventive Medicine and Public Health; School of Medicine, Universidad Autónoma de Madrid-IdiPaz; Madrid Spain
- CIBER of Epidemiology and Public Health (CIBERESP); Madrid Spain
| | - Fernando Rodríguez-Artalejo
- Department of Preventive Medicine and Public Health; School of Medicine, Universidad Autónoma de Madrid-IdiPaz; Madrid Spain
- CIBER of Epidemiology and Public Health (CIBERESP); Madrid Spain
- IMDEA-Food Institute, CEI UAM+CSIC; Madrid Spain
| | - Pilar Guallar-Castillón
- Department of Preventive Medicine and Public Health; School of Medicine, Universidad Autónoma de Madrid-IdiPaz; Madrid Spain
- CIBER of Epidemiology and Public Health (CIBERESP); Madrid Spain
- IMDEA-Food Institute, CEI UAM+CSIC; Madrid Spain
- Welch Center for Prevention; Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health; Baltimore Maryland
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Burke SL, Hu T, Spadola CE, Li T, Naseh M, Burgess A, Cadet T. Mild cognitive impairment: associations with sleep disturbance, apolipoprotein e4, and sleep medications. Sleep Med 2018; 52:168-176. [PMID: 30359892 PMCID: PMC6800075 DOI: 10.1016/j.sleep.2018.09.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/22/2018] [Accepted: 09/04/2018] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Mild cognitive impairment (MCI) is associated with increased memory problems although the ability to complete daily life activities remains relatively intact. This study examined: (1) if sleep disturbance increased the hazard of MCI; (2) if APOE e4 carriers with sleep disturbance experience an increased risk of MCI; and, (3) if prescription sleep medications provide a protective effect against MCI. We hypothesized that sleep disturbance increases the hazard of MCI, this relationship is stronger among APOE e4 carriers reporting a sleep disturbance. Furthermore, we hypothesized that sleep medications decrease the hazard of MCI. METHODS To determine whether sleep medication mediates the risk of developing MCI for individuals with sleep disturbance and/or APOE e4, we analyzed the National Alzheimer's Coordinating Center Uniform Data Set. We selected participants with normal cognition at baseline (n = 6798), and conduced survival analyses. RESULTS Our main findings indicated that the hazard of MCI was significantly associated with sleep disturbance. The hazard remained among those who did not use sleep medication. Trazodone and zolpidem users did not have a significant hazard of MCI, but the significant hazard remained for those who did not use these medications. APOE e4 carriers had a significantly higher hazard of MCI. Among e4 carriers who used trazodone or zolpidem, there was not a statistically significant risk of MCI. CONCLUSION This study demonstrated the potential utilization of trazodone and zolpidem in the treatment of sleep disturbance while potentially mitigating the risk of MCI. While trazodone and zolpidem have been shown to positively impact sleep disturbance in individuals with normal cognition, further research should explore these findings given that these medications are potentially inappropriate for older adults.
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Affiliation(s)
- Shanna L Burke
- Florida International University, Robert Stempel College of Public Health and Social Work, School of Social Work, 11200 S.W. 8th Street, AHC5 585, Miami, FL, 33199, USA.
| | - Tianyan Hu
- Florida International University, Robert Stempel College of Public Health and Social Work, Department of Health Policy and Management, 11200 S.W. 8th Street, AHC5 452, Miami, FL, 33199, USA.
| | - Christine E Spadola
- Florida Atlantic University, Phyllis and Harvey Sandler School of Social Work, 777 Glades Road SO303 Boca Raton, FL, 33431-0991, USA.
| | - Tan Li
- Florida International University, Robert Stempel College of Public Health and Social Work, Department of Biostatistics, 11200 S.W. 8th Street, AHC5464 Miami, FL, 33199, USA.
| | - Mitra Naseh
- Florida International University, Robert Stempel College of Public Health & Social Work, School of Social Work, Miami, FL, 33199, USA.
| | - Aaron Burgess
- Florida International University, Robert Stempel College of Public Health & Social Work, School of Social Work, 11200 S.W. 8th Street, Miami, FL, 33199, USA.
| | - Tamara Cadet
- Simmons University, School of Social Work, Harvard School of Dental Medicine, Oral Health Policy and Epidemiology, Boston, MA 02115 USA.
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Badr AF, Kurdi S, Alshehri S, McManus C, Lee J. Pharmacists' interventions to reduce sedative/hypnotic use for insomnia in hospitalized patients. Saudi Pharm J 2018; 26:1204-1207. [PMID: 30510473 PMCID: PMC6257887 DOI: 10.1016/j.jsps.2018.07.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 07/19/2018] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Hospitalization can contribute to insomnia in many patients and is usually treated symptomatically. However, sedative/hypnotic misuse is associated with complications in this population, especially in the elderly. Such complications include dizziness, falls and over-sedation. Due to the implicit dangers, widespread use of these drugs for insomnia, particularly in older patients, has been discouraged by many hospitals. The aim of this study was to review and evaluate prescribing patterns and to optimize the use of the sedative/hypnotic agents through daily pharmacy interventions at a community hospital. METHODS This was a biphasic before and after study. Data on sedative/hypnotic use was collected retrospectively for a 2-month period and a sample of 100 patients was randomly selected for analysis. A 2-month prospective phase followed, in which daily orders were reviewed by one pharmacy resident and recommendations made to discontinue any unnecessary, newly prescribed sedative/hypnotic orders when appropriate. Finally, results of both phases were compared for any differences in patient demographics, being prescribed more than one sedative/hypnotic, and complications documented. RESULTS During the prospective phase, pharmacist interventions led to the discontinuation of 25% of a total of 97 sedative/hypnotic orders in 97 patients. The number of patients receiving more than one sedative/hypnotic agents in the intervention group was significantly lower than the retrospective control group (15 Vs. 34, P = 0.0026). The incidence of complications was not significantly different between the control and intervention groups for the following: over-sedation, falls and delirium (p = 0.835, p = 0.185, p = 0.697, respectively). CONCLUSION This study suggests that the use of sedative/hypnotics in the inpatient units (excluding the critical care unit), is somewhat prevalent, and many patients may be on more than one sedative/hypnotic, which could potentially cause cumulative harm. During the intervention phase, 25% of the total in-hospital orders for sedative/hypnotics were discontinued following recommendations made by a pharmacist, and significantly lower number of patients receiving duplicate sedative/hypnotics was noted. Further efforts should be implemented to avoid unnecessary sedative/hypnotic initiation in hospitalized patients, and to ensure monitoring by pharmacists is optimized.
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Affiliation(s)
- Aisha F. Badr
- King Abdulaziz University Faculty of Pharmacy, Clinical Pharmacy, Saudi Arabia
| | | | - Samah Alshehri
- King Abdulaziz University Faculty of Pharmacy, Clinical Pharmacy, Saudi Arabia
| | | | - Jeannie Lee
- University of Arizona College of Pharmacy, USA
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Abstract
Dizziness is a common symptom encountered by all physicians. Dizziness and related symptoms are frequently linked to 1 or more of a list of contributors that includes benign paroxysmal positional vertigo, Ménière disease, migraine, acute peripheral vestibulopathy, cerebral ischemia, and anxiety disorders. Awareness of these common clinical patterns increases the likelihood of making a rapid, accurate diagnosis.
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42
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Clarke CL, Sniehotta FF, Vadiveloo T, Donnan PT, Witham MD. Association Between Objectively Measured Physical Activity and Opioid, Hypnotic, or Anticholinergic Medication Use in Older People: Data from the Physical Activity Cohort Scotland Study. Drugs Aging 2018; 35:835-842. [PMID: 30105644 DOI: 10.1007/s40266-018-0578-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Centrally acting medications cause cognitive slowing and incoordination, which could reduce older people's physical activity levels. This association has not been studied previously. OBJECTIVES The aim of this study was to examine the association between opioid, hypnotic and anticholinergic medication, and objectively measured physical activity, in a cohort of older people. METHODS We used data from the Physical Activity Cohort Scotland, a representative cohort of community-dwelling older people aged 65 years and over who were assessed at baseline and again 2-3 years later. Objective physical activity was measured using Stayhealthy RT3 accelerometers over 7 days. Baseline medication use (opioid use, hypnotic use, modified Anticholinergic Risk Scale [mARS]) was obtained from linked, routinely collected community prescribing records. Cross-sectional and longitudinal associations between baseline medication use and both baseline activity and change in activity over time were analysed using unadjusted and adjusted linear regression models. RESULTS Overall, 310 participants were included in the analysis; mean age 77 years (standard deviation 7). No association was seen between baseline use of any medication class and baseline physical activity levels in unadjusted or adjusted models. For change in activity over time, there was no difference between users and non-users of hypnotics or opioids. Higher anticholinergic burden was associated with a steeper decline in activity over the follow-up period (mARS 0: - 7051 counts/24 h/year; mARS 1-2: - 15,942 counts/24 h/year; mARS ≥ 3: - 19,544 counts/24 h/year; p = 0.03) and this remained robust to multiple adjustments. CONCLUSION Anticholinergic burden is associated with greater decline in objectively measured physical activity over time in older people, a finding not seen with hypnotic or opioid use.
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Affiliation(s)
| | - Falko F Sniehotta
- Institute of Health and Society, Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | | | | | - Miles D Witham
- School of Medicine, University of Dundee, Dundee, UK.
- Ageing and Health, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK.
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43
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McKenzie GAG. Evidence-based out-of-hours hospital medicine. Postgrad Med J 2018; 94:588-595. [PMID: 30373909 DOI: 10.1136/postgradmedj-2017-135049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 06/14/2017] [Accepted: 09/28/2018] [Indexed: 11/04/2022]
Abstract
Out-of-hours (OOH) hospital ward cover is generally provided by junior doctors and is typified by heavy workloads, reduced staff numbers and various non-urgent nurse-initiated requests. The present inefficiencies and management problems with the OOH service are reflected by the high number of quality improvement projects recently published. In this narrative review, five common situations peculiar to the OOH general ward setting are discussed with reference to potential areas of inefficiency and unnecessary management steps: (1) prescription of hypnotics and sedatives; (2) overnight fluid therapy; (3) fever; (4) overnight hypotension and (5) chasing outstanding routine diagnostic tests. It is evident that research and consensus guidelines for many clinical situations in the OOH setting are a neglected arena. Many recommendations made herein are based on expert opinion or first principles. In contrast, the management of significant abnormalities in outstanding blood results is based on well-established guidelines using high-quality systematic reviews.
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44
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Abstract
Sleeping pills are one of the most common drugs taken by adults when afflicted by insomnia. Adverse effects of pharmacotherapy, however, should not be overlooked, and monitoring is needed to check for an overdose of sleeping pills. We reviewed zolpidem overdose and patient suicide with benefits and disadvantages of pharmacotherapy. Cases of adverse effects concerning the central nervous system, including delirium and hallucination, as well as abnormal behavior during sleep, are commonly reported among patients who have taken zolpidem for more than 1 year. The serious problem of long-term prescription to medication can lead to a higher mortality rate of insomniac patients. An alternative to medication for treating insomnia is cognitive behavioral therapy, which can improve sleeping habits. Cognitive behavioral therapy induces patients to recognize and change the negative thoughts that affect their sleep. Medical providers should be aware of the adverse effects of sleep inducers and provide sufficient information to their patients about them. When establishing treatment plans, they should encourage patients to make the proper decisions and try to reduce the adverse effects of any medication as much as possible.
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45
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Janto K, Prichard JR, Pusalavidyasagar S. An Update on Dual Orexin Receptor Antagonists and Their Potential Role in Insomnia Therapeutics. J Clin Sleep Med 2018; 14:1399-1408. [PMID: 30092886 DOI: 10.5664/jcsm.7282] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 06/05/2018] [Indexed: 12/21/2022]
Abstract
STUDY OBJECTIVES Current pharmacological options for the treatment of insomnia insufficiently meet the needs of all insomnia patients. Approved treatments are not consistently effective in improving sleep onset and sleep maintenance, while also having complicated safety profiles. These limitations highlight the unmet need for additional medications and treatment strategies. Initial research suggests that the dual orexin receptor antagonists (DORAs) may offer an additional pharmaceutical option to treat insomnia in some patients. METHODS We reviewed the existing literature on dual orexin receptor antagonists in PubMed databases using the search terms "orexin receptor antagonist," "almorexant" "filorexant," "lembroexant" and "suvorexant"; searches were limited to English language primary research articles, clinical trials, and reviews. RESULTS Targeting the orexin receptor system for treatment of insomnia offers an additional and alternative pharmacological approach to more common gamma aminobutyric acid agonist sedative hypnotic treatment. Effectiveness is not well established in the current literature; however, the literature does suggest efficacy. Preclinical reports also suggest the potential for treatment in individuals with comorbid Alzheimer disease and insomnia. CONCLUSIONS DORAs offer an additional treatment option for insomnia. More clinical trials are needed to robustly evaluate their safety and effectiveness in several subclasses of individuals with insomnia. Given the published literature, head-to-head comparisons to existing treatment for insomnia are warranted.
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Affiliation(s)
- Kayla Janto
- Department of Psychology, University of St. Thomas, St. Paul, Minnesota
| | | | - Snigdha Pusalavidyasagar
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, Minneapolis, Minnesota
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46
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Adeola M, Azad R, Kassie GM, Shirkey B, Taffet G, Liebl M, Agarwal K. Multicomponent Interventions Reduce High-Risk Medications for Delirium in Hospitalized Older Adults. J Am Geriatr Soc 2018; 66:1638-1645. [PMID: 30035315 DOI: 10.1111/jgs.15438] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 04/03/2018] [Accepted: 04/10/2018] [Indexed: 12/28/2022]
Abstract
Delirium threatens the functional independence and cognitive capacity of patients. Medications, especially those with strong anticholinergic effects, have been implicated as a preventable cause of delirium. We evaluated the effect of multicomponent interventions aimed at reducing the use of 9 target medications in hospitalized older adults at risk of delirium. This continuous quality improvement program was undertaken at a tertiary care facility and 4 community hospitals in a hospital system. We included 21, 541 hospital admissions with patients aged 70 and older on acute care medical or surgical units from the preintervention (2012) period, and 27,764 from the postintervention (2015) period. Implemented interventions include formulary and policy changes, technology-assisted medication review, age-conditional order set modifications, best practice alerts, and education. The proportion of hospital admissions with individual's receiving at least 1 target medication declined from 45.6% to 31.3% (relative reduction (RR)=31.4%) from before to after the intervention, meaning that target medication exposure was avoided in approximately 4,000 older adults. The greatest effect was observed for zolpidem (11.2% to 5.3%, RR=52.6%) and diphenhydramine (12.9% to 7.1%, RR=45%). Furthermore, the mean number of doses administered during all hospital admissions was reduced for 7 of 9 medications. Multicomponent interventions implemented in our hospital system were effective at reducing exposure to target medications in hospitalized older adults at risk of delirium. These systematic changes applied throughout the medication use process are sustained today.
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Affiliation(s)
- Mobolaji Adeola
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas
| | - Rejena Azad
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas
| | - Gizat M Kassie
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Beverly Shirkey
- Center for Outcomes Research, Department of Surgery, Houston Methodist Hospital Research Institute, Houston, Texas
| | - George Taffet
- Section of Geriatrics, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Michael Liebl
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas
| | - Kathryn Agarwal
- Section of Geriatrics, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Department of Quality and Patient Safety, Houston Methodist Hospital System, Houston, Texas
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47
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Ribeiro TB, Melo DOD, Maia FDOM, Ribeiro E. Medication-related inpatient falls: a critical review. BRAZ J PHARM SCI 2018. [DOI: 10.1590/s2175-97902018000117355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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48
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JoonWoo Han, Young-Jin Ko, Byung-Joo Park, Seonji Kim. Signal Detection of Adverse Drug Reaction of Zolpidem Using the Korea Adverse Event Reporting System Database. ACTA ACUST UNITED AC 2018. [DOI: 10.34161/johta.2018.6.1.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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49
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Owens RL, Huynh TG, Netzer G. Sleep in the Intensive Care Unit in a Model of Family-Centered Care. AACN Adv Crit Care 2018; 28:171-178. [PMID: 28592477 DOI: 10.4037/aacnacc2017393] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The desire for families to be physically present to support their loved ones in the intensive care unit, and guidelines in favor of this open visitation approach, require that clinicians consider both patient and family sleep. This article reviews the causes of poor sleep for patients and their family members in the intensive care unit as well as the expected changes in cognition and emotion that can result from sleep deprivation. Measures are proposed to improve the intensive care unit environment to promote family sleep. A framework to educate family members and engage them in preservation of their and their loved one's circadian rhythm is also presented. Although further research is needed, the proposed framework has the potential to improve outcomes for patients and their families in the intensive care unit.
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Affiliation(s)
- Robert L Owens
- Robert L. Owens is Assistant Professor of Medicine, University of California San Diego, Division of Pulmonary, Critical Care, and Sleep Medicine, La Jolla, CA 92037 . Truong-Giang Huynh is ICU Assistant Nurse Manager, Jacobs Medical Center, University of California, San Diego Health, La Jolla, California. Giora Netzer is Associate Professor of Medicine and Epidemiology, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Truong-Giang Huynh
- Robert L. Owens is Assistant Professor of Medicine, University of California San Diego, Division of Pulmonary, Critical Care, and Sleep Medicine, La Jolla, CA 92037 . Truong-Giang Huynh is ICU Assistant Nurse Manager, Jacobs Medical Center, University of California, San Diego Health, La Jolla, California. Giora Netzer is Associate Professor of Medicine and Epidemiology, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Giora Netzer
- Robert L. Owens is Assistant Professor of Medicine, University of California San Diego, Division of Pulmonary, Critical Care, and Sleep Medicine, La Jolla, CA 92037 . Truong-Giang Huynh is ICU Assistant Nurse Manager, Jacobs Medical Center, University of California, San Diego Health, La Jolla, California. Giora Netzer is Associate Professor of Medicine and Epidemiology, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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50
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Prescriptions for Bedtime Sedatives After the Introduction of a General Admission Order Set at an Academic Health Center: The Potential and Pitfalls of Order Sets. J Patient Saf 2018; 13:232-236. [PMID: 25719816 DOI: 10.1097/pts.0000000000000147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study describes the impact of modifications to a general admission order set on physician prescribing of 2 as-needed or pro re nata (PRN) bedtime sedatives. METHODS The hospitalists at our institution have used a general medical admission order set since 2005. Zolpidem was the only as-needed (PRN) bedtime sedative option on the order set until trazodone was added in December 2008. Trazodone is preferred over zolpidem in the geriatric population. We identified patients admitted by the hospitalists between January 2007 and August 2013 who were prescribed with either zolpidem or trazodone as a PRN sedative. Patient demographics, date and time of the order, and number of sedative doses administered during the hospitalization were recorded. Orders placed within 12 hours of admission were attributed to admission orders. RESULTS Between 2007 and 2013, the number of patients admitted by the hospitalists with an order for PRN trazodone on admission increased by 18-fold. During the same period, the number of admissions by the hospitalists increased by 2.3 times. Zolpidem orders exceeded those for trazodone in all age groups until 2008. After the addition of trazodone, its use exceeded that of zolpidem. Almost half (48%) of all patients did not have a dose of the PRN trazodone administered. CONCLUSIONS Although order sets can be leveraged to align practitioners with established guidelines, the expediency of using medications on an order set may overcome physicians' clinical judgment. The content of an order set therefore deserves careful scrutiny before implementation.
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