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Tavares G, Kelmann G, Tustumi F, Tundisi CN, Silveira BRB, Barbosa BMAC, Winther DB, Boutros EC, Villar GDS, Brunocilla G, Lourenção GRC, Ferreira JGA, Bernardo WM. Cognitive and balance dysfunctions due to the use of zolpidem in the elderly: a systematic review. Dement Neuropsychol 2021; 15:396-404. [PMID: 34630929 PMCID: PMC8485645 DOI: 10.1590/1980-57642021dn15-030013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 04/10/2021] [Indexed: 11/22/2022] Open
Abstract
Zolpidem is one of the most widely prescribed hypnotic (non-benzodiazepine) agents for sleep disorder. Recently, an increase in the demand for this drug has been observed, mainly in the elderly population. Objective This study aims to analyze the acute effect of zolpidem on cognitive and balance dysfunctions in the elderly population. Methods A study was conducted by two independent researchers in four virtual scientific information bases and included randomized controlled trials. The studies evaluated elderly patients using zolpidem. Cognitive and balance dysfunctions were analyzed. Results Six articles were included. The mean age of the participants in the studies was 69 years. The following zolpidem dosages were evaluated: 5, 6.25, 10, and 12.5 mg. Comparing zolpidem and placebo, relating to the cognitive dysfunctions, there is no statistically significant difference between the groups. However, in relation to balance dysfunctions, there is a statistically significant difference between the intervention and the comparison, favoring placebo. Conclusions Zolpidem, even in usual doses (5 mg and 10 mg), has shown to increase the risk for balance dysfunctions. However, this does not occur in relation to cognitive changes.
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Affiliation(s)
- Guilherme Tavares
- Department of Evidence-Based Medicine, Centro Universitário Lusíada - Santos, SP, Brazil
| | - Gizela Kelmann
- Department of Evidence-Based Medicine, Centro Universitário Lusíada - Santos, SP, Brazil
| | - Francisco Tustumi
- Department of Evidence-Based Medicine, Centro Universitário Lusíada - Santos, SP, Brazil.,Department of Evidence-Based Medicine, Universidade de São Paulo - São Paulo, SP, Brazil.,Department of Surgery, Hospital Israelita Albert Einstein - São Paulo, SP, Brazil
| | | | | | | | - Diana Bragança Winther
- Department of Evidence-Based Medicine, Centro Universitário Lusíada - Santos, SP, Brazil
| | - Eduarda Conte Boutros
- Department of Evidence-Based Medicine, Centro Universitário Lusíada - Santos, SP, Brazil
| | | | - Giovanna Brunocilla
- Department of Evidence-Based Medicine, Centro Universitário Lusíada - Santos, SP, Brazil
| | | | | | - Wanderley Marques Bernardo
- Department of Evidence-Based Medicine, Centro Universitário Lusíada - Santos, SP, Brazil.,Department of Evidence-Based Medicine, Universidade de São Paulo - São Paulo, SP, Brazil
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Banerjee S, Kim E, Parker MM, Gilliam LK, Dlott R, Adams A. Clinical Response to Real-Time Patient-Reported Diabetic Peripheral Neuropathy Symptoms. Perm J 2020; 23:18-180. [PMID: 31050645 DOI: 10.7812/tpp/18-180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION To assess clinician response to real-time patient-reported data about diabetic peripheral neuropathy (DPN) symptoms, we analyzed DPN diagnosis and treatment patterns after administration of a 4-question symptom questionnaire in a large vertically integrated health care system. METHODS Retrospective cohort study to analyze data from 160,852 patients screened for DPN symptoms from April 2012 to March 2014. Electronic medical record data were used to study changes in DPN diagnosis, treatment initiation, and treatment intensification. We used logistic regression to study the association of patient characteristics with the odds of clinical response. RESULTS Of patients queried, 50,684 (31.5%) reported symptoms. Patients reporting DPN symptoms experienced a greater increase in new DPN diagnoses (16 percentage points; p < 0.0001) and medication use (4 percentage points; p < 0.0001) compared with those denying symptoms. Among patients reporting symptoms, women and nonwhite patients were less likely to receive a DPN diagnosis, whereas older patients were more likely to receive a DPN diagnosis. Overall, patients who were older, were Asian (hazard ratio = 0.67, 95% confidence interval = 0.63-0.77), and had lower socioeconomic status (hazard ratio = 0.89, 95% confidence interval = 0.80-0.99) were less likely to be treated. However, these racial and socioeconomic differences were not statistically significant for patients with preexisting DPN diagnoses. CONCLUSION Patients' real-time reports of DPN symptoms were associated with increased clinical activity. Patient- and clinician-level factors associated with the likelihood of receiving a DPN diagnosis need further study because a formal diagnosis may be associated with more equitable treatment.
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Affiliation(s)
- Somalee Banerjee
- Hospitalist-Based Specialty Department, Oakland Medical Center, CA
| | - Eileen Kim
- Internal Medicine Department, Oakland Medical Center, CA
| | | | - Lisa K Gilliam
- Endocrinology Department, South San Francisco Medical Center, CA.,Kaiser Permanente Northern California Regional Diabetes Team, Oakland, CA
| | - Rick Dlott
- Endocrinology Department, Walnut Creek Medical Center, CA.,Population Care, Kaiser Permanente Northern California Region, Oakland, CA
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Carr F, Tian P, Chow J, Guzak J, Triscott J, Mathura P, Sun X, Dobbs B. Deprescribing benzodiazepines among hospitalised older adults: quality improvement initiative. BMJ Open Qual 2019; 8:e000539. [PMID: 31523732 PMCID: PMC6711487 DOI: 10.1136/bmjoq-2018-000539] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 06/28/2019] [Accepted: 08/06/2019] [Indexed: 01/09/2023] Open
Abstract
Benzodiazepines are recognised as being potentially inappropriate medications for seniors due to their considerable side-effect profile, yet they are commonly prescribed and infrequently discontinued (deprescribed). The study’s primary objective was the deprescription or the dose reduction of benzodiazepines among newly hospitalised seniors using a patient education intervention. A 3-month duration quality improvement study based on the plan–do–study–act model was conducted across two units (3C and 4D) in the Glenrose Rehabilitation Hospital to improve benzodiazepine deprescribing among newly admitted seniors (65 years or older) who were using benzodiazepines. The primary outcome measure was the number of eligible patients who had benzodiazepine deprescribing initiated. A patient education intervention comprising a structured medication review, written patient education (the Eliminating Medications Through Patient Ownership of End Results (EMPOWER) brochure) and at least one brief supportive counselling session by the clinical pharmacist or physician was applied to all eligible patients. All 12 eligible patients consented to benzodiazepine deprescribing; however, only 11 of them (92%) initiated benzodiazepine deprescribing. Six of the 11 patients (55%) had their benzodiazepines discontinued, with the 5 remaining patients (45%) achieving greater than 50% dosage reduction. Seven patients (64%) experienced side effects during the deprescribing process, with over half (57%, n=4) of these seven patients experiencing worsening anxiety symptoms. Five of the 11 patients (45%) required benzodiazepine substitute medications. The use of a structured patient education intervention involving the use of a structured medication review, written patient education material and one-on-one patient counselling can promote benzodiazepine deprescribing. Although worsening anxiety was frequently observed, this was easily managed by the substitution of a more appropriate and clinically indicated medication, which was well tolerated and acceptable by all of our participants. Targeted screening for the presence of anxiety would help to guide the deprescribing process and the need for medication substitution.
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Affiliation(s)
- Frances Carr
- Division of Geriatrics, Department of Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Peter Tian
- Division of Care of the Elderly, Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jeffrey Chow
- Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada
| | - Jennifer Guzak
- Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada
| | - Jean Triscott
- Division of Care of the Elderly, Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Pamela Mathura
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Xing Sun
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Bonnie Dobbs
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
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Benzodiazepine and z-hypnotic prescribing for older people in primary care: a cross-sectional population-based study. Br J Gen Pract 2016; 66:e410-5. [PMID: 27114208 DOI: 10.3399/bjgp16x685213] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 01/24/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Overall prescribing of benzodiazepines and z-hypnotics (B&Zs) has slowly reduced over the past 20 years. However, long-term prescribing still occurs, particularly among older people, and this is at odds with prescribing guidance. AIM To compare prescribing of B&Zs between care home and non-care home residents ≥65 years old. DESIGN AND SETTING Cross-sectional population-based study in primary care in Scotland. METHOD National patient-level B&Z prescribing data, for all adults aged ≥65 years, were extracted from the Prescribing Information System (PIS) for the calendar year 2011. The PIS gives access to data for all NHS prescriptions dispensed in primary care in Scotland. Data were stratified by health board, residential status, sex, and age (65-74, 75-84, and ≥85 years). To minimise disclosure risk, data from smaller health boards were amalgamated according to geography, thereby reducing the number from 14 to 10 areas. RESULTS A total of 17% (n = 879 492) of the Scottish population were aged ≥65 years, of which 3.7% (n = 32 368) were care home residents. In total, 12.1% (n = 106 412) of older people were prescribed one or more B&Z: 5.9% an anxiolytic, 7.5% a hypnotic, and 1.3% were prescribed both. B&Zs were prescribed to 28.4% (9199) of care home and 11.5% (97 213) of non-care home residents (relative risk = 2.88, 95% CI = 2.82 to 2.95, P<0.001). Estimated annual B&Z exposure reduced with increasing age of care home residents, whereas non-care home residents' exposure increased with age. CONCLUSION B&Zs were commonly prescribed for older people, with care home residents approximately three times more likely to be prescribed B&Zs than non-care home residents. However, overall B&Z exposure among non-care home residents was found to rise with increasing age.
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Kouladjian L, Gnjidic D, Chen TF, Mangoni AA, Hilmer SN. Drug Burden Index in older adults: theoretical and practical issues. Clin Interv Aging 2014; 9:1503-15. [PMID: 25246778 PMCID: PMC4166346 DOI: 10.2147/cia.s66660] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Anticholinergic and sedative medications are commonly used in older adults and are associated with adverse clinical outcomes. The Drug Burden Index was developed to measure the cumulative exposure to these medications in older adults and its impact on physical and cognitive function. This narrative review discusses the research and clinical applications of the Drug Burden Index, and its advantages and limitations, compared with other pharmacologically developed measures of high-risk prescribing.
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Affiliation(s)
- Lisa Kouladjian
- Sydney Medical School, University of Sydney, Kolling Institute of Medical Research and Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, NSW, Australia
| | - Danijela Gnjidic
- Sydney Medical School, University of Sydney, Kolling Institute of Medical Research and Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, NSW, Australia ; Faculty of Pharmacy, University of Sydney, Sydney, NSW, Australia
| | - Timothy F Chen
- Faculty of Pharmacy, University of Sydney, Sydney, NSW, Australia
| | - Arduino A Mangoni
- Department of Clinical Pharmacology, School of Medicine, Flinders University and Flinders Medical Centre, Bedford Park, SA, Australia
| | - Sarah N Hilmer
- Sydney Medical School, University of Sydney, Kolling Institute of Medical Research and Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, NSW, Australia
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Dijkstra A, Hak E, Janssen F. A systematic review of the application of spatial analysis in pharmacoepidemiologic research. Ann Epidemiol 2013; 23:504-14. [PMID: 23830932 DOI: 10.1016/j.annepidem.2013.05.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 05/23/2013] [Accepted: 05/23/2013] [Indexed: 11/18/2022]
Abstract
PURPOSE Although current reviews of the use of spatial analysis in general epidemiologic research illustrate an important and well-established role in exploring and predicting health, its application has not been reviewed in the subspecialty field of pharmacoepidemiology. METHODS We systematically reviewed the scientific literature to assess to what extent spatial analysis has been applied in pharmacoepidemiologic research and explored its potential added value. RESULTS A systematic search in PubMed and Embase/MEDLINE yielded 823 potentially relevant articles; 45 articles met our criteria for review. The studies were reviewed on study objective, applied spatial methods and units of analysis, and author-reported added value of the geographic approach used. Of the 45 included studies, 34 (76%) reported a geographic research objective. Comparative spatial methods were most often used (n = 25; 56%). Eleven studies used spatial statistics (32%); cluster analysis (n = 5) and aggregate data analysis (n = 4) being most common. Mapping was done in 15 studies (33%). The most common added value reported was to aid the planning of health policies and interventions (n = 24; 53%). A minority of pharmacoepidemiologic studies used a geographic approach and the applied methods were less advanced compared with the broader field of epidemiology. CONCLUSIONS Further advancements are needed to incorporate currently available spatial techniques to impact health care planning.
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Affiliation(s)
- Aletta Dijkstra
- Unit of PharmacoEpidemiology & PharmacoEconomics (PE(2)), Department of Pharmacy, University of Groningen, The Netherlands.
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Minimal interventions to decrease long-term use of benzodiazepines in primary care: a systematic review and meta-analysis. Br J Gen Pract 2012; 61:e573-8. [PMID: 22152740 DOI: 10.3399/bjgp11x593857] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Long-term use of benzodiazepines (BZDs) is common. Not only is such use ineffective, but it also has several risks in addition to dependence, and remains a significant problem among the older population. AIM To systematically review randomised controlled trials that evaluate the effectiveness of minimal interventions to reduce the long-term use of BZDs in primary care. DESIGN AND SETTING Systematic review and meta-analysis of randomised controlled trials in UK general practices. METHOD Cochrane Central, MEDLINE, and Embase (1967-2010) were searched for trials of minimal interventions (such as a single letter or one consultation from a GP) for patients in primary care with long-term (>3 months) BZD use. Pooled risk differences were calculated with 95% confidence intervals. RESULTS From 646 potentially relevant abstracts, three studies (615 patients) met all the inclusion criteria. The pooled risk ratio showed a significant reduction/cessation in BZD consumption in the minimal intervention groups compared to usual care (risk ratio [RR] = 2.04, 95% confidence interval [CI] = 1.5 to 2.8, [corrected] P<0.001; RR = 2.4, 95% CI = 1.3 to 4.3, P = 0.008) respectively. Two studies also reported a significant proportional reduction in consumption of BZD from baseline to 6 months in intervention groups compared to the control group. The secondary outcome of general health status was measured in two studies; both showed a significant improvement in the intervention group. CONCLUSION A brief intervention in the form of either a letter or a single consultation by GPs, for long-term users of BZD, is an effective and efficient strategy to decrease or stop their medication, without causing adverse consequences.
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Firmino KF, Abreu MHNGD, Perini É, Magalhães SMSD. Utilização de benzodiazepínicos no Serviço Municipal de Saúde de Coronel Fabriciano, Minas Gerais. CIENCIA & SAUDE COLETIVA 2012; 17:157-66. [DOI: 10.1590/s1413-81232012000100018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Accepted: 02/26/2010] [Indexed: 11/21/2022] Open
Abstract
Neste estudo foram avaliadas as indicações de benzodiazepínicos no Serviço Municipal de Saúde de Coronel FabricianoMG, verificando sua conformidade com o preconizado pela literatura. O estudo avaliou todas as receitas desses medicamentos provenientes das Unidades Municipais de Saúde no período de Setembro a Outubro de 2006, os formulários de indicação clínica preenchidos pelo prescritor e cadastros informatizados do serviço. Analisaram-se 1.866 receitas, sendo 59,7% do Diazepam e o restante do Clonazepam. A Dose Diária Definida por mil habitantes por dia foi de 24,69 para o Diazepam e de 3,58 para o Clonazepam. Cerca de 50% das indicações relatadas pelos médicos foram como hipnótico ou ansiolítico, 21,9% para "uso crônico/dependência" e o restante para outras indicações. Das receitas que atenderam aos critérios de inclusão para análise da adequação da indicação (1618), cerca de 70% foram consideradas não adequadas, tendo em vista a indicação e o tempo de tratamento. Houve um alto percentual de inadequação na utilização de benzodiazepínicos, principalmente pelo uso prolongado e para atender a casos considerados pelos prescritores como uso crônico/dependência. Assim, há responsabilidade do serviço de saúde na manutenção da dependência.
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9
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Hollingworth SA, Siskind DJ. Anxiolytic, hypnotic and sedative medication use in Australia. Pharmacoepidemiol Drug Saf 2010; 19:280-8. [DOI: 10.1002/pds.1899] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Psychotropic medication use among nursing home residents in Austria: a cross-sectional study. BMC Geriatr 2009; 9:18. [PMID: 19460135 PMCID: PMC2697155 DOI: 10.1186/1471-2318-9-18] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Accepted: 05/21/2009] [Indexed: 12/14/2022] Open
Abstract
Background The use of psychotropic medications and their adverse effects in frail elderly has been debated extensively. However, recent data from European studies show that these drugs are still frequently prescribed in nursing home residents. In Austria, prevalence data are lacking. We aimed to determine the prevalence of psychotropic medication prescription in Austrian nursing homes and to explore characteristics associated with their prescription. Methods Cross-sectional study and association analysis in forty-eight out of 50 nursing homes with 1844 out of a total of 2005 residents in a defined urban-rural region in Austria. Prescribed medication was retrieved from residents' charts. Psychotropic medications were coded according to the Anatomical Therapeutic Chemical Classification 2005. Cluster-adjusted multiple logistic regression analysis was performed to investigate institutional and residents' characteristics associated with prescription. Results Residents' mean age was 81; 73% of residents were female. Mean cluster-adjusted prevalence of residents with at least one psychotropic medication was 74.6% (95% confidence interval, CI, 72.0–77.2). A total of 45.9% (95% CI 42.7–49.1) had at least one prescription of an antipsychotic medication. Two third of all antipsychotic medications were prescribed for bedtime use only. Anxiolytics were prescribed in 22.2% (95% CI 20.0–24.5), hypnotics in 13.3% (95% CI 11.3–15.4), and antidepressants in 36.8% (95% CI 34.1–39.6) of residents. None of the institutional characteristics and only few residents' characteristics were significantly associated with psychotropic medication prescription. Permanent restlessness was positively associated with psychotropic medication prescription (AOR 1.54, 95% CI 1.32–1.79) whereas cognitive impairment was inversely associated (AOR 0.70, 95% CI 0.56–0.88). Conclusion Frequency of psychotropic medication prescription is high in Austrian nursing homes compared to recent published data from other countries. Interventions should aim at reduction and optimisation of prescriptions.
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Müller MJ, Eich FX, Regenbogen B, Sachse J, Härtter S, Hiemke C. Amisulpride doses and plasma levels in different age groups of patients with schizophrenia or schizoaffective disorder. J Psychopharmacol 2009; 23:278-86. [PMID: 18562411 DOI: 10.1177/0269881108089806] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Because of a unique pharmacodynamic profile, amisulpride seems appropriate for treatment of elderly patients with schizophrenia. In a large-scale naturalistic therapeutic drug monitoring study, daily amisulpride dose, trough and dose-corrected amisulpride plasma levels, co-medication, clinical effectiveness (CGI) and side effects (UKU) were compared between age groups in 395 patients with schizophrenia or schizoaffective disorder (46% women; mean age 39.1 +/- 14.2 years, range 18-83 years) under amisulpride therapy. Mean amisulpride doses (574 +/- 269 mg/day), plasma levels (304 +/- 274 ng/mL), dose-corrected amisulpride plasma levels (C/D ratios, 0.52 +/- 0.41 ng/mL:mg), clinical response (at least moderate improvement, 71.6%), and side effects (any side effect, 32.2%; extrapyramidal symptoms, 14.9%) were comparable between age groups (P > 0.25). At higher age, significantly more benzodiazepines (P = 0.04), non-benzodiazepine hypnotics (P = 0.004) and non-psychotropic medications (P < 0.0001) were prescribed. The naturalistic study showed higher C/D ratios in women (P = 0.019) and a slight increase of C/D ratios with age (P = 0.026), but no substantial age-dependent effects on amisulpride doses or plasma levels. In patients above 60 years, clinical response was associated with lower amisulpride plasma levels (P = 0.016) at comparable doses. Neither the age-dependent decrease of amisulpride clearance nor the significantly higher prevalence of co-morbidity and co-medication seem to be the reasons for definite clinical concerns against amisulpride treatment of elderly if contraindications are seriously taken.
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Use of antipsychotic medications in older home-care patients. Report from nine European countries. Aging Clin Exp Res 2008; 20:260-5. [PMID: 18594194 DOI: 10.1007/bf03324781] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND AIMS Data on the use of antipsychotics among older people in need of regular home care services are rare. The aim of this study was to ascertain the differences in the use and type of antipsychotic medications between European home-care sites. METHODS A cross-sectional study was designed by means of RAI (Resident Assessment Instrument for Home Care) assessments. A random sample of 3251 assessments was gathered during the period September 2001-January 2002 from home care patients aged 65 and over in nine European countries (Czech Republic, Denmark, Finland, Germany, Iceland, Italy, Netherlands, Norway and United Kingdom). RESULTS Two hundred of the home care patients (6.2%) received antipsychotic medication. The prevalence of the use of one or more antipsychotics varied widely between study sites, ranging from 3.0% in Denmark to 12.4% in Finland. Factors independently associated with the use of antipsychotics were: delusions (OR 3.09, 95% CI 1.66-5.76), any diagnosis of dementia (OR 2.57, 95% CI 1.70-3.87), youngest age group (65-74 yrs) (OR 2.37, 95% CI 1.53-3.66) and hallucinations (OR 2.28, 95% CI 1.17-4.45). Concomitant use of anxiolytics (OR 2.32, 95% CI 1.58- 3.41), hypnotics (OR 2.08, 95% CI 1.44-3.03) and antidepressants (OR 2.06, 95% CI 1.41-3.00) together with signs of depression (OR 1.78, 95% CI 1.24- 2.56), moderate to severe cognitive impairment (OR 1.30, 95% CI 1.12-1.51) and residing in Finland (OR 2.52, 95% CI 1.21-5.24) or Italy (OR 2.15, 95% CI 1.10-4.19) were associated with the use of antipsychotics. The most commonly used antipsychotic agent was risperidone (n=42, 21%). CONCLUSIONS The frequency of antipsychotic drug use in older home-care patients varied considerably among the European countries studied. Antipsychotic drug treatment in older home-care recipients seems to be less common than in residents in long-term institutional care, and more common than among the independently-living elderly.
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Brooks JO, Hoblyn JC. Neurocognitive costs and benefits of psychotropic medications in older adults. J Geriatr Psychiatry Neurol 2007; 20:199-214. [PMID: 18004007 DOI: 10.1177/0891988707308803] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Psychotropic medications are widely used in older adults and may cause neurocognitive deficits. Older adults are at increased risk of developing adverse effects because of age-related pharmacodynamic and pharmacokinetic changes. This article provides a comprehensive review of the undesirable, and at times beneficial, effects of psychotropic medications. The review covers a wide range of medications that impair executive function, memory, and attention, as well as a much smaller group of medications that lead to improved neurocognitive function. Some of the most commonly used psychotropic medications in older adults, namely, antidepressants, sedatives, and hypnotics, are among the drugs that most consistently lead to cognitive impairments. Medications with anticholinergic properties almost invariably lead to neurocognitive dysfunction, despite symptom improvement. The neurocognitive costs and benefits of psychiatric medications should be considered in the context of disease treatment in older adults.
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Affiliation(s)
- John O Brooks
- Palo Alto Veterans Affairs Health Care System and Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA.
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Abstract
Sleep disorders, especially insomnia, are common in older adults. These disorders are frequently treated using non-benzodiazepine hypnotics. Nonetheless, there is a relative lack of data regarding the use of these agents in the elderly, and whether any of these medications is superior to any other in the class when used in the elderly is also unclear. In this article, we review, by way of the published literature, the pharmacodynamics, pharmacokinetics, drug interactions, efficacy and safety of zolpidem, zaleplon, zopiclone, eszopiclone and ramelteon in the elderly. Special emphasis is placed on identifying relevant differences between these medications when used in older adults with insomnia. Based primarily on data from placebo-controlled trials, the non-benzodiazepines reviewed were found to be most effective at improving sleep latency and sleep quality, and least effective at enhancing total sleep time. The efficacy of ramelteon was limited to improving sleep latency, while all other agents, especially at higher doses, were found to produce improvement in both sleep latency and some improvement in total sleep time. All of the medications were found to be well tolerated in the elderly. From pharmacokinetic and drug-drug interaction perspectives, zaleplon and ramelteon offer the advantage of not being primarily metabolised via the cytochrome P450 3A4 isoenzyme. In conclusion, based on relatively limited data, zopiclone, zolpidem, zaleplon, eszopiclone and ramelteon represent modestly effective and generally well tolerated treatments for insomnia in older adults. While some actual and potential differences exist among these medications, more comparative trials are needed.
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Affiliation(s)
- Christian Dolder
- Wingate University School of Pharmacy, Wingate, North Carolina 28174, USA.
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Abstract
This paper reviews the use of sleep-promoting medications in nursing home residents with reference to risks versus benefits. Up to two-thirds of elderly people living in institutions experience sleep disturbance. The aetiology of sleep disturbance includes poor sleep hygiene, medical and psychiatric disorders, sleep apnoea, periodic limb movements and restless leg syndrome. One key factor in the development of sleep disturbance in the nursing home is the environment, particularly with respect to high levels of night-time noise and light, low levels of daytime light, and care routines that do not promote sleep. Clinical assessment should include a comprehensive medical, psychiatric and sleep history including a review of prescribed medications. Nonpharmacological interventions for insomnia are underutilised in many clinical settings despite evidence that they are often highly effective. International studies suggest that 50-80% of nursing home residents have at least one prescription for psychotropic medication. Utilisation rates vary dramatically from country to country and from institution to institution. The most commonly prescribed medications for sleep are benzodiazepines and nonbenzodiazepine hypnotics (Z-drugs). The vast majority of studies of these medications are short-term, i.e. < or =2 weeks, although some longer extension trials have recently been carried out. Clinicians are advised to avoid long-acting benzodiazepines and to use hypnotics for as brief a period as possible, in most cases not exceeding 2-3 weeks of treatment. Patients receiving benzodiazepines are at increased risk of daytime sedation, falls, and cognitive and psychomotor impairment. Zaleplon, zolpidem, zopiclone and eszopiclone may have some advantages over the benzodiazepines, particularly with respect to the development of tolerance and dependence. Ramelteon, a novel agent with high selectivity for melatonin receptors, has recently been approved in the US. Use of the antidepressant trazodone for sleep in nondepressed patients is somewhat controversial. Atypical antipsychotics should not be used to treat insomnia unless there is also evidence of severe behavioural symptoms or psychosis.
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Affiliation(s)
- David K Conn
- Department of Psychiatry, Baycrest Geriatric Health Care System, Toronto, Ontario, Canada.
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Glass J, Lanctôt KL, Herrmann N, Sproule BA, Busto UE. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ 2005; 331:1169. [PMID: 16284208 PMCID: PMC1285093 DOI: 10.1136/bmj.38623.768588.47] [Citation(s) in RCA: 695] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To quantify and compare potential benefits (subjective reports of sleep variables) and risks (adverse events and morning-after psychomotor impairment) of short term treatment with sedative hypnotics in older people with insomnia. DATA SOURCES Medline, Embase, the Cochrane clinical trials database, PubMed, and PsychLit, 1966 to 2003; bibliographies of published reviews and meta-analyses; manufacturers of newer sedative hypnotics (zaleplon, zolpidem, zopiclone) regarding unpublished studies. SELECTION CRITERIA Randomised controlled trials of any pharmacological treatment for insomnia for at least five consecutive nights in people aged 60 or over with insomnia and otherwise free of psychiatric or psychological disorders. RESULTS 24 studies (involving 2417 participants) with extractable data met inclusion and exclusion criteria. Sleep quality improved (effect size 0.14, P < 0.05), total sleep time increased (mean 25.2 minutes, P < 0.001), and the number of night time awakenings decreased (0.63, P < 0.001) with sedative use compared with placebo. Adverse events were more common with sedatives than with placebo: adverse cognitive events were 4.78 times more common (95% confidence interval 1.47 to 15.47, P < 0.01); adverse psychomotor events were 2.61 times more common (1.12 to 6.09, P > 0.05), and reports of daytime fatigue were 3.82 times more common (1.88 to 7.80, P < 0.001) in people using any sedative compared with placebo. CONCLUSIONS Improvements in sleep with sedative use are statistically significant, but the magnitude of effect is small. The increased risk of adverse events is statistically significant and potentially clinically relevant in older people at risk of falls and cognitive impairment. In people over 60, the benefits of these drugs may not justify the increased risk, particularly if the patient has additional risk factors for cognitive or psychomotor adverse events.
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Affiliation(s)
- Jennifer Glass
- University of Toronto, Department of Pharmaceutical Sciences, Toronto, ON, Canada M5S 2S2
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Bessa JM, Oliveira M, Cerqueira JJ, Almeida OFX, Sousa N. Age-related qualitative shift in emotional behaviour: Paradoxical findings after re-exposure of rats in the elevated-plus maze. Behav Brain Res 2005; 162:135-42. [PMID: 15922074 DOI: 10.1016/j.bbr.2005.03.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2004] [Revised: 03/10/2005] [Accepted: 03/13/2005] [Indexed: 10/25/2022]
Abstract
Several variables, including age, are known to influence anxiety. Previous exposure to the elevated-plus maze (EPM) is known to modify emotional behaviour as retesting in the EPM at a standard age of 3 months increases open-arm avoidance and attenuates the effects of anxiolytic drugs. This study analysed whether similar results are obtained when older animals are subjected to these experimental paradigms. Overall, increasing age was associated with more signs of anxiety. Additionally, we observed a paradoxical behaviour pattern in aged-subjects that were re-exposed to the EPM, with mid-aged and old rats failing to display open arm avoidance (OAA) in the second trial; this qualitative shift in emotional behaviour was not associated with decreased locomotion. An examination of how age influences responsiveness to anxiolytic drugs, with or without previous maze experience, was also conducted. Midazolam (0.5 and 1 mg/kg) proved anxiolytic in maize-naive young animals; in marked contrast, in older animals midazolam at 1 mg/kg resulted in sedation but not anxiolyis. One trial tolerance to midazolam was evident in animals of both ages that were subjected to a second EPM trial; the latter phenomenon was apparently accentuated in older animals as they do not show open arm avoidance upon re-exposure to the EPM. These data suggest that the age-associated 'resistance' to anxiolytic drugs might be related to a qualitative shift in emotional behaviour.
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Affiliation(s)
- J M Bessa
- Neuroscience Group, Life and Health Science Research Institute (ICVS), University of Minho, Campus de Gualtar, 4710-057 Braga, Portugal
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Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2004; 12:699-714. [PMID: 14762987 DOI: 10.1002/pds.933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Current awareness in geriatric psychiatry. Int J Geriatr Psychiatry 2003; 18:1149-56. [PMID: 14870737 DOI: 10.1002/gps.794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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