Psychotropic drug use in community-dwelling elderly people—characteristics of persistent and incident users

Antipsychotic prescribing and drug-related readmissions in multimorbid older inpatients: a post-hoc analysis of the OPERAM population

BACKGROUND

Limited data are available on characteristics associated with antipsychotic use in multimorbid older adults.

AIM

Primary: to identify patient characteristics associated with antipsychotic prescribing in a multimorbid population of older inpatients with polypharmacy. Secondary: (1) to observe if antipsychotics use during an index hospitalisation was associated with a drug related admission (DRA) within one year, and (2) to describe these cases of antipsychotic-related readmissions.

METHOD

This was a secondary analysis of the OPERAM randomized controlled trial. Multivariate analysis assessed the association between characteristics and comorbidities with antipsychotic use. An expert team assessed DRA occurring during the one-year follow-up.

RESULTS

Antipsychotics were prescribed to 5.5% (n = 110) patients upon admission while 7.7% (n = 154) inpatients received antipsychotics at any time (i.e. upon admission, during hospitalisation, and/or at discharge). The most frequently prescribed antipsychotics were quetiapine (n = 152), haloperidol (n = 48) and risperidone (n = 22). Antipsychotic prescribing was associated with dementia (OR = 3.7 95%CI[2.2;6.2]), psychosis (OR = 26.2 [7.4;92.8]), delirium (OR = 6.4 [3.8;10.8]), mood disorders (OR = 2.6 [1.6;4.1]),  ≥ 15 drugs a day (OR = 1.7 [1.1;2.6]), functional dependency (Activities of Daily Living score < 50/100) (OR = 3.9 [2.5;6.1]) and < 2 units of alcohol per week (OR = 2.2 [1.4;3.6]). DRA occurred in 458 patients (22.8%) within one year. Antipsychotic prescribing at any time was not associated with DRA (OR = 1.0 [0.3;3.9]) however contributed to 8 DRAs, including 3 falls.

CONCLUSION

In this European multimorbid polymedicated older inpatients, antipsychotics were infrequently prescribed, most often at low dosage. Besides neuro-psychiatric symptoms, risk factors for inhospital antipsychotic prescribing were lower functional status and polymedication.

Benzodiazepines utilization in Brazilian older adults: a population-based study

OBJECTIVE

To evaluate the utilization of benzodiazepines (BZD) in Brazilian older adults, based on the Pesquisa Nacional de Acesso, Utilização e Promoção do Uso Racional de Medicamentos (PNAUM - National Survey of Access, Use and Promotion of Rational Use of Medicines).

METHODS

The PNAUM is a cross-sectional study conducted between 2013 and 2014, representing the Brazilian urban population. In the present study, we included 60 years or older (n = 9,019) individuals. We calculated the prevalence of BZD utilization in the 15 days prior to survey data collection according to independent variables, using a hierarchical Poisson regression model. A semistructured interview performed empirical data collection (household interview).

RESULTS

The prevalence of BZD utilization in the older adults was 9.3% (95%CI: 8.3-10.4). After adjustments, BZD utilization was associated with female sex (PR = 1.88; 95%CI: 1.52-2.32), depression (PR = 5.31; 95%CI: 4.41-6, 38), multimorbidity (PR = 1.44; 95%CI: 1.20-1.73), emergency room visit or hospitalization in the last 12 months (PR = 1.42; 95%CI: 1.18-1.70 ), polypharmacy (PR = 1.26; 95%CI: 1.01-1.57) and poor or very poor self-rated health (PR = 4.16; 95%CI: 2.10-8.22). Utilization was lower in the North region (PR = 0.18; 95%CI: 0.13-0.27) and in individuals who reported abusive alcohol consumption in the last month (PR = 0.42; 95%CI: 0.19-0.94).

CONCLUSION

Despite contraindications, results showed a high prevalence of BZD utilization in older adults, particularly in those with depression, and wide regional and sex differences.

Potentially inappropriate medicines for older adults with intellectual disability: Clinical implications from a medication audit

OBJECTIVE

To investigate medications that have the potential to be inappropriately prescribed for people with intellectual disability (ID) and to explore possible issues surrounding the potential harm that can result from the use of groups of medicines for people with ID who are ageing and living longer.

METHODS

An audit of medical case records of 350 patients under the care of an organisation in New Zealand was undertaken to examine existing medication profiles.

RESULTS

Of the 350 patients, 95% were prescribed at least five or more medicines, with 7% of patients have 10 or more medicines. Increasing prescriptions are evident for those 56 years old and above.

CONCLUSIONS

Medicines that may have been appropriate for people with intellectual disability when they were younger may have the potential to cause harm when they age. It is therefore important that monitoring and evaluation of medications for ageing individuals with intellectual disability are regularly undertaken.

Association between prescribed central nervous system depressant drugs, comorbidity and cognition among hospitalised older patients: a cross-sectional study

OBJECTIVES

Central nervous system depressants (CNSDs) such as opioids, benzodiazepine and Z-hypnotics are commonly used. However, CNSDs may influence cognitive function, especially in older hospitalised patients with comorbidities. The aim was to examine the association between CNSD use and cognitive function in older patients. We assessed global and domain specific cognitive function, among hospitalised older patients, including covariates for comorbidity, anxiety and depression.

DESIGN

Cross-sectional hospital-based study.

SETTINGS

Data was collected consecutively from inpatients at somatic wards of a general university hospital.

PARTICIPANTS

Older patients between 65 and 90 years with/without CNSD use for ≥4 weeks.

OUTCOME MEASURES

The main outcome was cognitive function assessed by Cognistat. Secondary outcomes were routine clinical tests in the wards (mini-mental state examination (MMSE), trail making test (TMT) A and B, and clock drawing tests). Analyses were bivariate and multiple linear regression, adjusted for age, gender, and education. Covariates were comorbidity, depression and anxiety scores.

RESULTS

The main result indicated that CNSD users (n=100) had (β=-3.4, 95% CI 6.27 to -0.58, p=0.017) lower Cognistat score than non-users (n=146), adjusted for age, gender, education, anxiety and depression, but not significant when including covariate for comorbidity (β= -2.50 - 5.45; -0.46, p=0.097). Comorbidity was associated with cognitive function (β=-0.77, 95% CI -1.22 to -0.14, p=0.014). Cognistat subdimensions associated with CNSD use were language (p=0.017) and calculation (p=0.003). In clock drawing test, users had lower scores than non-users (β=-0.80, 95% CI 1.24 to -0.36, p=0.004), but no significant difference was found with MMSE and TMT A or B. Z-hypnotics were associated with reduced cognitive function.

CONCLUSION

Among older hospitalised patients, global cognition and specific cognitive functions were associated with long-term use of CNSD medication as well as with somatic comorbidity.

TRIAL REGISTRATION NUMBER

NCT03162081, 22 May 2017.

Helpful approaches to older people experiencing mental health problems: a critical review of models of mental health care

Despite growing concerns for the mental health of the older generation most studies focus on mental health care for younger people and there is a lack of knowledge about helpful treatment approaches and models of care for older people. Therefore, the purpose of this review was to answer the question what health care approaches are most helpful for older people experiencing mental health problems. Databases from 2000 to July 2017 were searched with focus on outcome studies, experts' opinions and treatment descriptions. Critical interpretive synthesis was used to analyse and interpret the findings. Four main models of care were found: the medical-psychiatric model which mostly focuses on antipsychotic medication for the treatment of symptoms. Psychotherapeutic and social interventions take into consideration the psychosocial perspectives of mental health problems, but little research has been done on their lasting effect. Research indicates that psychotherapy needs to be adapted to the special needs of older people. Few old people have access to psychotherapy which limits its usefulness. Holistic or integrated models of health care have emerged in recent years. These models focus on both physical and psychosocial well-being and have shown promising outcomes. To reduce antipsychotic medication older people need to be given better access to psychotherapy and social interventions. This presupposes training health care professionals in such treatment methods. The holistic models need to be developed and studied further and given high priority in health care policy.

Associations between the use of specific psychotropic drugs and all-cause mortality among older adults in Germany: Results of the mortality follow-up of the German National Health Interview and Examination Survey 1998

BACKGROUND

Use of psychotropic drugs is common among older adults. Population-based studies on the associations of psychotropic drug use with mortality are sparse.

OBJECTIVES

To investigate the associations between the use of specific psychotropic drug groups (opioids, antipsychotics, antidepressants and benzodiazepines) and all-cause mortality among community-dwelling older adults in Germany.

METHODS

Participants of the German National Health Interview and Examination Survey 1998 were followed up for mortality from 1997 to 2011. Persons aged 60-79 years with complete data on psychotropic drug use at baseline and on mortality follow-up were considered as study population (N = 1,563). Associations between the use of opioids, antipsychotics, antidepressants and benzodiazepines and all-cause mortality were examined by Cox proportional hazards models adjusted for sociodemographics (sex, age, community size, region, socioeconomic status), life style (smoking, sports, risky alcohol drinking) and health conditions (obesity, disability, history of cardiovascular diseases, diabetes, hyperlipidemia, hypertension, any cancers, any mental disorders) at baseline.

RESULTS

After a median follow-up of 11.4 years, 21, 18, 23 and 26 deaths were documented among those who used at baseline opioids (n = 39), antipsychotics (n = 30), antidepressants (n = 53) and benzodiazepines (n = 54) with an unadjusted mortality rate (MR) of 57.7, 59.1, 44.6 and 53.7 per 1000 person-years, respectively. Meanwhile, 400 deaths were documented among 1,406 nonusers of any of the above mentioned psychotropic drugs with a MR of 26.7 per 1000 person-years. The age and sex adjusted mortality rate ratios in comparison with nonusers were 2.20 (95% confidence intervals 1.42-3.41), 1.66(1.03-2.70), 1.56(1.06-2.28), and 1.57(1.07-2.31) for the use of opioids, antipsychotics, antidepressants and benzodiazepines, respectively. In the fully adjusted Cox models, use of opioids (hazardous ratio 2.04, 95% confidence intervals 1.07-3.89), antipsychotics (2.15, 1.11-4.15) and benzodiazepines (1.76, 1.09-2.82), but not antidepressants, were significantly associated with an increased risk of mortality.

CONCLUSIONS

Use of opioids, antipsychotics, benzodiazepines is significantly associated with an increased risk of all-cause mortality among community-dwelling older adults in Germany. Clinicians should be careful in prescribing these psychotropic drugs to older adults while patients already under psychotropic therapy should well balance the risks and benefits of drug use. Further studies with a larger sample size and information on specific indications for psychotropic drug use and mental comorbidities are required to confirm the findings of the present study.

Patterns, predictors and persistence of chronic sedative use: a population-based observational study of older adults in British Columbia, Canada

BACKGROUND

Benzodiazepines and benzodiazepine-like sedatives (zopiclone, zolpidem and zaleplon) are commonly prescribed to treat anxiety and insomnia but are contraindicated for chronic use. We sought to study the persistence, over multiple years, of chronic use of benzodiazepines and benzodiazepine-like sedatives among community-dwelling adults in British Columbia, Canada.

METHODS

This is a retrospective analysis of linked health data for adults aged 50 to 69 in 2004 who resided in British Columbia, Canada, between 2004 and 2013. We assigned subjects to one of four groups according to the total number of days of benzodiazepines and benzodiazepine-like sedatives that they were dispensed from retail pharmacies in each observation year. We estimated logistic regression models to measure associations between the odds of chronic sedative use and explanatory variables. We computed transition probability matrices that depict likelihood of changes in sedative utilization levels across years.

RESULTS

Nearly one in ten (9.4%) community-dwelling older adults in British Columbia filled prescriptions with more than 90 days' worth of benzodiazepines or benzodiazepine-like sedatives in 2013. The odds of such chronic sedative use were higher for people who were older, had lower income, were sicker, or lived in rural communities; odds were lower for people with Chinese or South Asian surnames and for men who were married. Controlling for other factors, chronic users of sedatives in 2008 were 15 times more likely than non-users of sedatives in 2008 to be chronic sedative users in 2013 (OR = 14.73; 95% CI = [14.24, 15.24]). Approximately two out of every five older British Columbians who were chronic sedative users in 2013 had been chronic users of sedatives 10 years prior. Two out of every three chronic sedative users in 2004 were either chronic users (57%) or dead (16%) by 2013.

INTERPRETATION

Chronic use of sedatives is prevalent and persistent among older adults in British Columbia. The persistence of chronic sedative use between when patients were 50 to 59 years old and when they were 60 to 69 years old suggests that earlier interventions to curb chronic sedative use may be warranted even if patients do not experience significant risks until later ages.

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

Aim To investigate whether the use of long-acting benzodiazepines, in individuals aged 65 and over is mediated by physical or psychological factors.

BACKGROUND

Long-acting benzodiazepine consumption among older people has implications for mortality, morbidity and cost-effective prescribing. Two models explain benzodiazepine use in this age group, one linked to physical illness and disability and one to psychological factors.

METHODS

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

Time Trend in Psychotropic Medication Use in Spain: A Nationwide Population-Based Study

Background: We performed an epidemiologic study to analyze nationwide time trends in adult psychotropic drug use over a period from 2006 to 2012, and to identify those factors associated with the likelihood of consumption of these drugs during the study period; Methods: Cross-sectional study on psychotropic medication in the Spanish adult population. We used secondary individualized data drawn from the 2006 and 2012 Spanish National Health Surveys (SNHS). The dependent variable was the use of psychotropic drugs in the previous two weeks. Independent variables included socio-demographic characteristics, comorbidity, lifestyles and healthcare resource utilization. Using logistic multivariate regression models, we analyzed the temporal evolution of psychotropic medication consumption between 2006 and 2012 in both sexes; Results: The prevalence of psychotropic drug use was significantly greater in women (18.14% vs. 8.08% in 2012 (p < 0.05). In Spanish women, the variables associated with a greater probability of psychotropic use were, age, unemployment (adjusted odds ratio (AOR), 1.60; 95% CI, 1.24–2.07), negative perception of health or taking non-psychotropic drugs. Among men, psychotropic use is associated with presence of chronic disease, negative perception of health (AOR, 3.27; 95% CI, 2.62–4.07 in 2012) or inactive status; Conclusions: Between 2006 and 2012, the probability of having taken psychotropic drugs increased by 16% among women. Unemployed women aged ≥45 years with a negative perception of their health constitute a clear risk profile in terms of psychotropic drug use. Inactive men who have a negative perception of their health are the group most likely to consume psychotropic drugs.

Central Nervous System-Acting Medicines and Risk of Hospital Admission for Confusion, Delirium, or Dementia

BACKGROUND

Most studies assessing the effect of central nervous system (CNS)-acting medicines on cognitive disturbances have focused on the use of individual medicines. The impact on cognitive function when another CNS-acting medicine is added to a patient's treatment regimen is not well known.

OBJECTIVE

To determine risk of hospitalization for confusion, delirium, or dementia in older people associated with increasing numbers of CNS-acting medicines taken concurrently, as well as the number of standard doses taken each day (measured as defined daily doses).

DESIGN

Retrospective cohort study, from July 2011 to June 2012, using health claims data.

SETTING

Australian veteran population.

PARTICIPANTS

A total of 74,321 community-dwelling individuals aged 65 years and over, who were dispensed at least 1 CNS-acting medicine in the year before study entry. Patients with prior hospitalization for confusion or delirium, and those with dementia or receiving palliative care, were excluded.

MAIN OUTCOME MEASURE

Hospitalization for confusion, delirium, or dementia.

RESULTS

Over the 1-year study period, 401 participants were hospitalized with confusion, delirium, or dementia. Adjusted analyses showed the risk of hospitalization was 2.4 times greater with the use of 2 CNS-acting medicines compared with no use [incident rate ratio (IRR) 2.39, 95% confidence interval (CI) 1.79-3.19, P < .001], and more than 19 times greater when 5 or more CNS-acting medicines were taken concurrently (IRR 19.35, 95% CI 11.10-33.72, P < .001). Similarly, the risk of hospitalization was significantly increased among patients taking between 1.0 and 1.9 standard doses per day (IRR 2.64, 95% CI 1.99-3.50, P < .001) and between 2.0 and 2.9 standard doses per day (IRR 3.43, 95% CI 2.07-5.69, P < .001) compared with no use.

CONCLUSIONS

Use of multiple CNS-acting medicines or higher doses is associated with an increased risk of hospitalization for confusion, delirium, or dementia. Health care professionals need to be alert to the contribution of CNS-acting medicines among patients presenting with confusion or delirium and consider strategies to reduce treatment burden where possible.

Influence of central nervous system-acting drugs on results of cognitive testing in geriatric inpatients

INTRODUCTION

Growing evidence shows a high correlation between extensive use of central nervous system-acting drugs (CNSADs) in elderly patients and adverse drug reactions (ADRs) such as falls, fractures, and mortality.

RESEARCH QUESTION

Are results of cognitive testing with the Mini Mental Status Examination (MMSE) influenced by use of CNSADs?

SETTING

Geriatric inpatient service for acute, subacute, and rehabilitation care.

METHODS

Secondary combined analysis of two prospective, single-center study cohorts (PROPSYC, 2011 and AGE OUT, 2012) with identical procedure for the MMSE at a tertiary hospital.

RESULTS

Overall, 395 patients were included, 144 male (M) and 251 female (F). Mean age was 80.0 ± 8.4 years (M 76.7 ± 9.1, F 81.9 ± 7.3, p = 0.0000). Mean MMSE points were 22.9 ± 4.8 (M 23.2 ± 4.6, F 22.6 ± 5.0, p = 0.211). In total, 258 patients (65.3 %) used drugs with potential adverse cognitive properties. Analgesics with central activity were given to 117 of 395 patients (29.6 %). Low-potency opioids (tramadol hydrochloride, tilidine) were identified in 60 patients and high-potency opioids in 57 patients. Antidepressants were used in 66 patients, benzodiazepines in 26, and hypnotics in 11, while 38 patients received other CNSADs. We only found significant correlations with the results of cognitive testing for sedatives (diazepam and oxazepam, Pearson's r - 0.79, p = 0.05), but not for lorazepam.

CONCLUSION

Our analysis shows an influence of sedatives (diazepam and oxazepam, but not lorazepam) on cognitive testing with the MMSE in users of CNSADs.

Considerations in psychotropic treatments in dementia--can polypharmacy be avoided?

Physicians treating demented individuals are confronted with complex clinical presentations. This complexity results from the multi-factorial nature of clinical phenomena, the aetiologies of these phenomena, which differ from similar symptoms in younger populations, limited physiological reserves and the multiple co-morbidities and medications. This intricacy is well exemplified within the clinical presentation and management of psychological and behavioural symptoms of dementia. The latter are associated with a poor quality of life, increased burden for both patient and caregivers. A further challenge and source for frustration is the fact that many of the medications used to treat cognitive and behavioural symptoms of dementia are only marginally effective or not effective at all, on the one hand, and associated with increased risk for morbidity and mortality on the other hand. In the present review, we discuss these factors in the context of polypharmacy and suggest further clinical and research strategies that may enable more accurate and less harmful therapeutic strategies.

Measuring psychotropic drug exposures in register-based studies--validity of a dosage assumption of one unit per day in older Finns

Pharmacoepidemiological studies provide valuable information on the relationships between psychotropic drug use and adverse outcomes in older people. To minimize the influence of misclassification bias in pharmacoepidemiological studies, more emphasis should be given to methodological aspects of exposure assessment. This study evaluated the validity of a dosage assumption of one unit per day for measuring legend duration of psychotropic drug exposures among older people. Using data from the Finnish Prescription Register, the study analysed 62,320 psychotropic drug prescriptions dispensed for people aged ≥ 75 years (n = 52,729) in September 2009. The proportions of prescriptions in which the prescribed dose deviated from one unit per day were assessed for categories and subcategories of psychotropic drugs. The prescription was considered misclassified (a) if the prescribed drug was intended for "as needed" use, (b) if the prescription included a dose range, or (c) if the prescribed dose was below or above one unit per day. Among antidepressants, less than every fourth (23.7%) prescription was misclassified. The proportions of misclassification varied substantially across subcategories, being 13.1% for selective serotonin reuptake inhibitors (SSRIs), 25.3% for other antidepressants and 53.8% for tricyclic antidepressants. Of the benzodiazepine and antipsychotic prescriptions, 79.9% and 57.6%, respectively, were misclassified. In conclusion, the dosage assumption of one unit per day is valid for measuring the legend duration of SSRI and other antidepressant exposures among older people. Among other psychotropic drugs, the dosage assumption is likely to lead to severe exposure misclassification.

Prospective associations between benzodiazepine use and later life satisfaction, somatic pain and psychological health among the elderly

OBJECTIVE

This study aimed to investigate prospective associations between benzodiazepine use and later life satisfaction, sleep difficulties, perceived general health, anxiety symptoms and somatic pain among the elderly.

METHODS

A 13-year prospective cohort study was conducted in a Norwegian population-based sample of 15 830 elderly individuals. Baseline control measures of the investigated psychological constructs and a wide range of demographic and health-relevant covariates were obtained from the Nord-Trøndelag Health Study (HUNT 2, 1995-1997). Follow-up data were obtained from the third wave (HUNT 3, 2006-2008) of the same epidemiological study. The Norwegian Prescription Database (2004-2008) was used to link pharmacy prescription records of benzodiazepines for each case to the HUNT 2 and HUNT 3 materials.

RESULTS

Use of benzodiazepines was associated with less life satisfaction and more sleep difficulties at follow-up. These tendencies increased by more frequent patterns of use. Benzodiazepine use had relatively weak relations to perceived general health, but intermittent and chronic use was related to higher anxiety symptoms at follow-up. Such patterns were also modestly related to somatic pain at follow-up.

DISCUSSION AND CONCLUSION

Benzodiazepines should be dispensed at a high-threshold policy among the elderly. By developing clear-cut discontinuation plans, clinicians could avoid chronic use and focus on psychosocial treatment for psychological disorders.

National trends (2003-2009) and factors related to psychotropic medication use in community-dwelling elderly population

BACKGROUND

We aimed to analyze the prevalence of prescription anxiolytics and antidepressants in elderly individuals in Spain between the years 2003 and 2009, and to identify those factors associated with the likelihood of consumption of these drugs during the study period.

METHODS

We used individualized secondary data retrieved from the 2003 and 2006 Spanish National Health Surveys (SNHS) and the 2009 European Health Interview Survey (EHIS) for Spain to conduct a nationwide, descriptive, cross-sectional pharmacoepidemiology study on psychotropic medication in the population aged 65 years and over in Spain. A total of 12,228 interviews were analyzed (5,117 from 2003; 7,084 from 2006; and 5,144 from 2009). The dichotomous dependent variables chosen were the answers "yes" or "no" to the question "In the last two weeks have you taken the following medicines and were they prescribed for you by a doctor?" referring to intake of anxiolytics and antidepressants. Independent variables were sociodemographic, comorbidity, and healthcare resources.

RESULTS

Multivariate analysis highlighted the association between increased psychoactive drug intake and female gender, depression, polypharmacy, and negative perception of health. We observed a significant increase in the consumption of prescription anxiolytics (AOR, 1.08 [95% CI, 1.06-1.10]) and antidepressants (AOR, 1.11 [95% CI, 1.08-1.14]) in individuals aged ≥65 years in Spain between the years 2003 and 2009.

CONCLUSIONS

The prevalence of anxiolytics and antidepressants consumption is higher in elderly women than men, and increases with negative perception of health. The Spanish elderly individuals taking antidepressants reported having problems to manage these medicines in their own homes.

Hospitalization as a turning point for sleep medication use in older adults: prospective cohort study

BACKGROUND

Use of sleep medications as a result of hospitalization among older adults is common and has been shown to result in chronic use and increased risks for adverse effects such as falls and cognitive decline. However, few studies have explored in-hospital sleep medication use or disuse as a possible factor related to subsequent home use.

OBJECTIVE

The aim of this study was to examine changes in sleep medication use pre- to post-hospitalization as a function of in-hospital use.

METHODS

The study was designed as a prospective cohort study, and included 485 acute medical patients aged 70 years and older, hospitalized in a large, Israeli, teaching medical centre. Sleep medication use was assessed by patient interviews regarding patterns of use prior to, during and at 1 and 3 months after discharge. Post-discharge using patterns were assessed as a function of in-hospital discontinuation or initiation of sleep medications; background demographic and clinical characteristics were assessed as well. Logistic regressions were modelled separately for discontinuation and initiation of sleep medication use at each follow-up.

RESULTS

Of those patients who used sleep medications prior to admission, 37 (18% of 206 prior users) discontinued use during the hospital stay. Non-use of sleep medications during hospitalization was the main significant characteristic associated with post-hospitalization discontinuation among prior users, when comparing patients who continued with those who discontinued using sleep medications in bivariate analyses. Discontinuation was associated with an adjusted odds ratio (AOR, adjusted for cognitive status) of 3.91 (95% confidence interval [CI] 1.64, 9.30) for non-use at the 1-month follow-up. Of those who did not use sleep medications prior to admission, 39 (14% of 279 non-prior users) initiated use during hospitalization. Again, sleep medication initiation at time of hospitalization was the main correlate of change in post-hospitalization medication use status, when comparing post-discharge users and non-users, among the non-prior users. Hospital initiation of sleep medications was associated with an AOR (adjusted for levels of education and morbidity, readmission, and functional status) of 4.65 (95% CI 1.95, 11.09) for post-discharge use. Similar results were obtained for the 3-month follow-up, reaching significance levels only for the discontinuation group.

CONCLUSIONS

Though overall prevalence rates of sleep medication use pre- and post-hospitalization are fairly similar, rigorous scrutiny of the findings demonstrates that in-hospital sleep medication use and disuse may be a significant turning point both for initiation and discontinuation of sleep medications, especially in the short post-discharge time frame. Thus, in-hospital sleep medication prescribing policies should acknowledge the potential for changes in the post-discharge sleep medication regimen.

Walk on the sunny side of life--epidemiology of hypovitaminosis D and mental health in elderly nursing home residents

OBJECTIVES

Old age is a well-known risk factor for both depression and hypovitaminosis D, and an association between both conditions has been postulated. We document the prevalence of vitamin D deficiency in nursing home residents, and we examine the link with self-reported depressive symptoms and pharmacotherapy for depression.

DESIGN

Cross- sectional.

SETTING

nursing homes in Antwerp, Belgium.

PARTICIPANTS

Healthy elderly (n=589), with a mean age of 84 years.

MEASUREMENTS

We detected depressive symptoms by means of SF-36, a validated quality of life assessment; we registered the use of antidepressants and anxiolytics, and we measured serum 25(OH)D concentrations in all participants.

RESULTS

Almost our entire study population appeared to be vit D deficient. Comparison of the most severely and least deficient subgroups showed a consistent tendency towards more depressive symptoms and more use of antidepressants in the group with the lowest vit D level.

CONCLUSION

Nursing home residents are particularly vulnerable to preventable vit D deficiency. The relevance of the association with depressive symptoms and the possibilities for treatment are critically reviewed in the discussion.

Prevalence and predictors of anticholinergic agents in elderly outpatients with dementia

BACKGROUND

Anticholinergic medications, although frequently used in elderly populations, are associated with cognitive impairment and constitute significant concern for patients with dementia.

OBJECTIVE

The purpose of our study was to examine patterns and predictors of prescribing anticholinergic agents for elderly outpatients with dementia.

METHODS

We combined data from the 2006-2007 National Ambulatory Medical Care Survey and the outpatient department component of National Hospital Ambulatory Medical Care Survey to analyze patient visits by elderly persons (aged ≥65 years) with dementia. Anticholinergic drugs were identified using the Anticholinergic Drug Scale, which classifies anticholinergic drugs into four levels (0-3) in increasing order of anticholinergic activity. Descriptive analysis using sampling weights was used to evaluate patterns of anticholinergic drug prescription, especially prescribing of medications with clinically significant anticholinergic activity (ie, levels 2 or 3). Multiple logistic regression was used in the conceptual framework of the Andersen Behavioral Model to examine the predisposing, enabling, and need factors associated with prescribing of medications with clinically significant anticholinergic activity.

RESULTS

According to the national surveys there were a total of 6.8 million (95% CI, 5.27-8.44 million; 0.32%) ambulatory care visits for dementia. Approximately 43% (42.86%; 95% CI, 35.24-50.48) of these visits involved prescribing at least one anticholinergic drug; and 10.07% of visits involved prescribing levels 2 or 3 anticholinergic medications. The predisposing factor, age (75-84 years; odds ratio [OR] = 0.25; 95% CI, 0.07-0.87), and the need factors, acetylcholinesterase inhibitor use (OR = 0.25; 95% CI, 0.07-0.86) and comorbid mood disorders (OR = 0.12; 95% CI, 0.02-0.73), were associated with decreased likelihood of prescribing medications with clinically significant anticholinergic activity. The need factor total number of medications prescribed (OR = 1.45, 95% CI, 1.20-1.75) increased the likelihood of these prescriptions being administered.

CONCLUSIONS

One in 10 outpatient visits by elderly persons with dementia involved prescribing medications with clinically significant anticholinergic activity. Given their adverse cognitive effects, there is a strong need to optimize anticholinergic drug prescribing in vulnerable elderly outpatients with dementia.