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Capiau A, Huys L, van Poelgeest E, van der Velde N, Petrovic M, Somers A. Therapeutic dilemmas with benzodiazepines and Z-drugs: insomnia and anxiety disorders versus increased fall risk: a clinical review. Eur Geriatr Med 2023; 14:697-708. [PMID: 36576689 PMCID: PMC10447278 DOI: 10.1007/s41999-022-00731-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/07/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE The aim of this clinical review was to summarise the existing knowledge on fall risk associated with benzodiazepines (BZDs) and Z-drugs in older people with focus on appropriate prescribing, including deprescribing. METHODS We conducted a literature search in June 2021 in PubMed and Embase with citation and reference checking. Personal reference libraries and international websites were also used. Keywords for the searches included "benzodiazepines", "Z-drugs", "falls", "deprescribing", "fall-risk-increasing-drugs", "inappropriate prescribing", "older people" and matching synonyms. We discuss use of BZDs and Z-drugs, potential fall-related adverse reactions, alternatives for and deprescribing of BZDs and Z-drugs in older persons. RESULTS BZDs and Z-drugs differ in fall-related adverse effect profile. They contribute to fall risk through orthostatic hypotension, dizziness and/or imbalance, sedation, muscular weakness, ataxia, etc. Fall incidents contribute significantly to mortality and morbidity. Therefore, there is a need for appropriate prescribing and use of BZDs and Z-drugs in older people. In practice, this means pertaining to a strict indication, strongly consider to non-pharmacological alternatives, limit use to the lowest dose and the shortest duration possible. Judicious deprescribing should be considered and encouraged as well. Practical resources, tools and algorithms are available to guide and assist clinicians in deprescribing BZDs and Z-drugs. CONCLUSIONS Prescribing BZDs and Z-drugs should be done in a well-considered way in fall-prone older people. A good overview and insight in the fall-related adverse effects of these drugs, as well as the availability of different strategies to increase the appropriate use, including deprescribing initiatives, can assist clinicians in clinical decision-making.
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Affiliation(s)
- Andreas Capiau
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Liesbeth Huys
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| | - Eveline van Poelgeest
- Department of Internal Medicine/Geriatrics, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Nathalie van der Velde
- Department of Internal Medicine/Geriatrics, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Mirko Petrovic
- Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.
- Department of Geriatrics, Ghent University Hospital, Ghent, Belgium.
| | - Annemie Somers
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
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Van der Linden L, Hias J, Liesenborghs A, Walgraeve K, Van Brantegem P, Hellemans L, Milisen K, Tournoy J. The impact of a pharmacist intervention on post-discharge hypnotic drug discontinuation in geriatric inpatients: a before-after study. BMC Geriatr 2023; 23:407. [PMID: 37400758 DOI: 10.1186/s12877-023-04139-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 06/27/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Chronic use of hypnotic agents is prevalent in older adults, who as a result are at increased risk for certain adverse events, such as day-time drowsiness and falls. Multiple strategies to discontinue hypnotics have been tested in geriatric patients, but evidence remains scarce. Hence, we aimed to investigate a multicomponent intervention to reduce hypnotic drug use in geriatric inpatients. METHODS A before-after study was performed on the acute geriatric wards of a teaching hospital. The before group (= control group) received usual care, while intervention patients (= intervention group) were exposed to a pharmacist-led deprescribing intervention, comprising education of health care personnel, access to standardized discontinuation regimens, patient education and support of transitional care. The primary outcome was hypnotic drug discontinuation at one month after discharge. Secondary outcomes among others were sleep quality and hypnotic use at one and two weeks after enrolment and at discharge. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) upon inclusion, two weeks after enrolment and one month after discharge. Determinants for the primary outcome were identified using regression analysis. RESULTS A total of 173 patients were enrolled, with 70.5% of patients taking benzodiazepines. Average age was 85 years (interquartile range 81-88.5) and 28.3% were male. A higher discontinuation rate at one month after discharge was observed in favour of the intervention (37.7% vs. 21.9%, p = 0.02281). No difference in sleep quality was found between both groups (p = 0.719). The average sleep quality was 8.74 (95% confidence interval (CI): 7.98-9.49) and 8.57 (95% CI: 7.75-9.39) in the control and intervention groups respectively. Determinants for discontinuation at one month were: the intervention (odds ratio (OR) 2.36, 95% CI: 1.14-4.99), fall on admission (OR 2.05; 95% CI: 0.95-4.43), use of a z-drug (OR 0.54, 95% CI: 0.23-1.22), PSQI score on admission (OR 1.08, 95% CI: 0.97-1.19) and discontinuation prior to discharge (OR 4.71, 95% CI: 2.26-10.17). CONCLUSIONS A pharmacist-led intervention in geriatric inpatients was associated with a reduction of hypnotic drug use one month after discharge, without any loss in sleep quality. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05521971 (retrospectively registered on 29th of August 2022).
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Affiliation(s)
- Lorenz Van der Linden
- Hospital Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
| | - Julie Hias
- Hospital Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Astrid Liesenborghs
- Hospital Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Karolien Walgraeve
- Hospital Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Pieter Van Brantegem
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Laura Hellemans
- Hospital Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Research Foundation - Flanders (FWO), Brussels, Belgium
| | - Koen Milisen
- Department of Public Health and Primary Care, Academic Center for Nursing and Midwifery, KU Leuven, Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Jos Tournoy
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Public Health and Primary Care, Gerontology and Geriatrics, KU Leuven, Leuven, Belgium
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Perrine E, Damiaens A, Patey AM, Grimshaw JM, Spinewine A. Barriers and enablers towards benzodiazepine-receptor agonists deprescribing in nursing homes: A qualitative study of stakeholder groups. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 9:100258. [PMID: 37124470 PMCID: PMC10130691 DOI: 10.1016/j.rcsop.2023.100258] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/08/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
Background Despite recommendations to deprescribe chronic benzodiazepine receptor agonists (BZRA) among older adults, the prevalence of their use in Belgian nursing homes (NHs) remains above 50%. The use of a behavioral science approach, starting with the evaluation of barriers and enablers for BZRA deprescribing, has the potential to decrease BZRA prescribing. Objectives To identify barriers and enablers for BZRA deprescribing perceived by the different stakeholders involved in nursing home care in Belgium. Methods In a purposive sample of 6 NHs, we conducted face-to-face interviews with general practitioners (GPs), and focus groups with other healthcare providers (HCPs), including nurses, pharmacists, occupational therapists, physical therapists, and with NH residents and relatives. All interviews with HCPs were analyzed through deductive thematic analysis, using the theoretical domains framework (TDF) as the coding framework. Residents' and relatives' interviews were analyzed using an inductive thematic approach. Results We interviewed 13 GPs, 35 other HCPs, 22 nursing home residents, and 5 relatives. Overall, 9 TDF domains were identified as most relevant among HCPs interviewed: Skills, Beliefs about capabilities, Goals, Memory attention and decision processes, Environmental context and resources, Social influences, Knowledge, Social/professional role and identity, and Beliefs about consequences. Five additional themes emerged from residents' and relatives' interviews: knowledge on medications used, communication with NH staff and GPs, perceived efficacy and necessity of BZRA, influence of the environment, and reluctance towards BZRA deprescribing. Some domains and themes differ between stakeholders (e.g., knowledge), while others match between groups (e.g., environmental aspects). Conclusion BZRA deprescribing is influenced by knowledge and skills gaps, automatic BZRA refilling, competing priorities, social challenges, environmental factors and poor nursing home residents involvement. Targeting these barriers will be a key step for implementation of BZRA deprescribing.
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Evrard P, Pétein C, Beuscart JB, Spinewine A. Barriers and enablers for deprescribing benzodiazepine receptor agonists in older adults: a systematic review of qualitative and quantitative studies using the theoretical domains framework. Implement Sci 2022; 17:41. [PMID: 35804428 PMCID: PMC9264665 DOI: 10.1186/s13012-022-01206-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 04/21/2022] [Indexed: 11/17/2022] Open
Abstract
Background Many strategies aimed at deprescribing benzodiazepine receptor agonists (BZRA) in older adults have already been evaluated with various success rates. There is so far no consensus on which strategy components increase deprescribing the most. Yet, despite an unfavourable benefit-to-risk ratio, BZRA use among older adults remains high. We systematically reviewed barriers and enablers for BZRA deprescribing in older adults. Methods Two reviewers independently screened records identified from five electronic databases—Medline, Embase, PsycINFO, CINAHL and the Cochrane library—and published before October 2020. They searched for grey literature using Google Scholar. Qualitative and quantitative records reporting data on the attitudes of older adults, caregivers and healthcare providers towards BZRA deprescribing were included. Populations at the end of life or with specific psychiatric illness, except for dementia, were excluded. The two reviewers independently assessed the quality of the included studies using the mixed-methods appraisal tool. Barriers and enablers were identified and then coded into domains of the theoretical domains framework (TDF) using a combination of deductive and inductive qualitative analysis. The most relevant TDF domains for BZRA deprescribing were then identified. Results Twenty-three studies were included 13 quantitative, 8 qualitative and 2 mixed-method studies. The points of view of older adults, general practitioners and nurses were reported in 19, 9 and 3 records, respectively. We identified barriers and enablers in the majority of TDF domains and in two additional themes: “patient characteristics” and “BZRA prescribing patterns”. Overall, the most relevant TDF domains were “beliefs about capabilities”, “beliefs about consequences”, “environmental context and resources”, “intention”, “goals”, “social influences”, “memory, attention and decision processes”. Perceived barriers and enablers within domains differed across settings and across stakeholders. Conclusion The relevant TDF domains we identified can now be linked to behavioural change techniques to help in the design of future strategies and health policies. Future studies should also assess barriers and enablers perceived by under-evaluated stakeholders (such as pharmacists, psychiatrists and health care professionals in the hospital setting). Trial registration This work was registered on PROSPERO under the title “Barriers and enablers to benzodiazepine receptor agonists deprescribing”. Registration number: CRD42020213035 Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01206-7.
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Affiliation(s)
- Perrine Evrard
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium.
| | - Catherine Pétein
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
| | - Jean-Baptiste Beuscart
- Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, F-59000, Lille, France
| | - Anne Spinewine
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium.,Pharmacy Department, CHU UCL Namur, Yvoir, Belgium
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Sibille FX, Spinewine A, Zerah L, Maljean L, Schoevaerdts D, de Saint-Hubert M. Current practice in benzodiazepine receptor agonists deprescribing on acute geriatric wards: a cohort study. BMC Geriatr 2022; 22:88. [PMID: 35100982 PMCID: PMC8805235 DOI: 10.1186/s12877-022-02753-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 12/20/2021] [Indexed: 11/10/2022] Open
Abstract
Background Benzodiazepine receptor agonist (BZRA) use is highly prevalent in hospitalised older people although these drugs are associated with numerous and serious adverse events. Deprescribing can reduce risks associated with chronic BZRA use. The aim of this study was to measure the prevalence of, and factors associated with, BZRA deprescribing in acute geriatric units. Methods During a one-year period, this multicentre retrospective study included patients aged ≥70 years, hospitalised in acute geriatric units, and using ≥1 BZRA on admission. BZRA deprescribing at discharge was defined as: ≥25% decrease in lorazepam-equivalent admission dose; discontinuation of all BZRAs; or cessation of a rescue prescription at discharge. BZRA cessation was defined as discontinuation of all BZRAs at discharge. We identified social, medical, geriatric and medication factors associated with BZRA deprescribing using logistic regression. Results In total, 561 patients were included (mean age: 85.3±5.9 years, 70% of women). BZRA deprescribing occurred in 240 (42.8%), including 85 with BZRA cessation (15.2%). Deprescribing occurred more frequently in patients with a BZRA-related adverse event on admission or during hospital stay (odds ratio (OR) 4.5; 95% confidence interval [2.6; 7.9]), with an antidepressant (1.6 [1.1; 2.4]) and a higher lorazepam-equivalent dosage on admission (OR 1.2 [1; 1.4]), and less frequently in patients with antipsychotic drug (OR 0.5 [0.3; 0.8]). BZRA cessation was more likely in patients with a BZRA-related adverse event (OR 2.2 [1.2; 4.3]) and a lower lorazepam-equivalent dosage on admission (OR 0.5 [0.3; 0.6]). Conclusions During hospitalisation in the acute geriatric units of our hospital, BZRA deprescribing occurred in 42.8% of the patients. Identification of an BZRA-related adverse event by the treating physician appears to be a major factor: this reactive deprescribing accounted for 74% of cases in our study. Further prospective studies are needed to measure long-term persistence of in-hospital deprescribing and encourage proactive management.
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Affiliation(s)
- François-Xavier Sibille
- Department of Geriatric Medicine, CHU Dinant Godinne UCL Namur, Avenue Dr Gaston Therasse, 1, 5530, Yvoir, Belgium. .,Institute of Health and Society, Université Catholique de Louvain, Clos Chapelle aux Champs, 30 Bte B1. 30.13, 1200, Brussels, Belgium. .,Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Avenue Mounier, 72 bte B1.72.02, 1200, Brussels, Belgium.
| | - Anne Spinewine
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Avenue Mounier, 72 bte B1.72.02, 1200, Brussels, Belgium.,Department of Pharmacy, CHU Dinant Godinne UCL Namur, Avenue Dr Gaston Therasse, 1, 5530, Yvoir, Belgium
| | - Lorène Zerah
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Avenue Mounier, 72 bte B1.72.02, 1200, Brussels, Belgium
| | - Laurentine Maljean
- Department of Pharmacy, CHU Dinant Godinne UCL Namur, Avenue Dr Gaston Therasse, 1, 5530, Yvoir, Belgium
| | - Didier Schoevaerdts
- Department of Geriatric Medicine, CHU Dinant Godinne UCL Namur, Avenue Dr Gaston Therasse, 1, 5530, Yvoir, Belgium.,Institute of Health and Society, Université Catholique de Louvain, Clos Chapelle aux Champs, 30 Bte B1. 30.13, 1200, Brussels, Belgium
| | - Marie de Saint-Hubert
- Department of Geriatric Medicine, CHU Dinant Godinne UCL Namur, Avenue Dr Gaston Therasse, 1, 5530, Yvoir, Belgium.,Institute of Health and Society, Université Catholique de Louvain, Clos Chapelle aux Champs, 30 Bte B1. 30.13, 1200, Brussels, Belgium.,NARILIS, Namur, Belgium
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da Silva LGR, da Silva Pinto AW, de Queiroz WE, Coelho CC, Blatt CR, Oliveira MG, de Lima Pimentel AC, Elseviers M, Baldoni AO. Deprescribing clonazepam in primary care older patients: a feasibility study. Int J Clin Pharm 2022; 44:489-498. [PMID: 35022954 DOI: 10.1007/s11096-021-01371-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 12/16/2021] [Indexed: 12/23/2022]
Abstract
Background Inappropriate use of clonazepam by older adults is associated with cognitive impairment, delirium, and falls. Strategies to optimize its use are important to increase patient safety. Objective To evaluate the feasibility of a clonazepam deprescription protocol in the elderly. Methods This is a quasi-experimental study. Elderly people with chronic use of clonazepam and attended in primary care units in two Brazilian municipalities were selected. A deprescription protocol was used, which included five fortnightly meetings between the older adults and the research team, to reduce the dose by 25%. Patients received instructions on sleep hygiene behaviors and the advantages of clonazepam deprescription; family physicians followed a flowchart for gradual dose reduction. In the 1st and 5th meetings, there were medical appointments for anamnesis and discharge. The monitoring of patients and the application of tests were carried out by the research team. Results Of the 35 elderly people included in the study, 27 reached the end; 81.5% achieved deprescription: 22.2% stopped completely and 59.3% decreased the dose. At the last meeting, 20% of elderly patients reported an increase in blood pressure. Conclusion The high rate of deprescription and the little relevance of clonazepam withdrawal reactions, showed that the use of the protocol was effective. However, the increase in blood pressure and the worsening of sleep quality in the last meeting show the need for adjustment in the last stage of the deprescription process.
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Affiliation(s)
- Luanna Gabriella Resende da Silva
- Center for Teaching and Research in Clinical Pharmacy, Federal University of São João del-Rei, Campus Centro-Oeste Dona Lindu, Sebastião Gonçalves Coelho Street, 400, Chanadour, Divinópolis City, Minas Gerais, 35501-296, Brazil.
| | - Athos Wellington da Silva Pinto
- Center for Teaching and Research in Clinical Pharmacy, Federal University of São João del-Rei, Campus Centro-Oeste Dona Lindu, Sebastião Gonçalves Coelho Street, 400, Chanadour, Divinópolis City, Minas Gerais, 35501-296, Brazil
| | | | | | - Carine Raquel Blatt
- Department of Pharmacosciences, Federal University of Health Sciences of Porto Alegre, Porto Alegre City, Rio Grande do Sul, Brazil
| | - Marcio Galvão Oliveira
- Master's Program in Collective Health, Multidisciplinary Institute for Health, Federal University of Bahia, Vitória da Conquista City, Bahia, Brazil
| | | | - Monique Elseviers
- Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
- Centre for Research and Innovation in Care (CRIC), University of Antwerp, Antwerp, Belgium
| | - André Oliveira Baldoni
- Center for Teaching and Research in Clinical Pharmacy, Federal University of São João del-Rei, Campus Centro-Oeste Dona Lindu, Sebastião Gonçalves Coelho Street, 400, Chanadour, Divinópolis City, Minas Gerais, 35501-296, Brazil
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Geriatric Depression and Inappropriate Medication: Benefits of Interprofessional Team Cooperation in Nursing Homes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182312438. [PMID: 34886164 PMCID: PMC8657238 DOI: 10.3390/ijerph182312438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 11/18/2021] [Accepted: 11/20/2021] [Indexed: 11/26/2022]
Abstract
An investigation of inappropriate medication use in treatment of depressivity in institutionalized older adults, based on a nurse-led evaluation of functional status and depressive symptoms in nursing home residents. Methods: A cross-sectional multicenter study was performed using records from 1087 residents cared for in fifteen nursing homes (NHs) in the Czech Republic. Inclusion criteria were being a permanent resident of one of the facilities, being 60 years of age or older, having a Geriatric Depression Scale score of 6 or more, and having a Mini Mental State examination score 10 or more. The final sample for analysis included 317 depressed NH residents. Results: 52 percent of NH residents with depressivity had no antidepressant treatment. Benzodiazepines were the only medication in 16 percent of depressed residents, and were added to antidepressant treatment in 18 percent of residents. Benzodiazepine users had significantly higher GDS scores compared to non-users (p = 0.007). Conclusion: More than half of depressed NH residents remained without antidepressant treatment. Residents inappropriately treated with benzodiazepines were more depressed than residents treated with antidepressants only, or even not treated at all. Cooperation of the interprofessional team in the screening of depressive symptoms has the potential to improve the quality of care.
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Clinical impact of antipsychotic and benzodiazepine reduction: findings from a multicomponent psychotropic reduction program within long-term aged care. Int Psychogeriatr 2021; 33:587-599. [PMID: 32618535 DOI: 10.1017/s1041610220000940] [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] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To explore the relationships between dose changes to antipsychotic and/or benzodiazepine medications and resident outcomes, including variations in neuropsychiatric symptoms, quality of life (QoL), and social withdrawal, within a multicomponent, interdisciplinary antipsychotic and benzodiazepine dose reduction program. DESIGN Prospective, observational, longitudinal study. INTERVENTION The Reducing Use of Sedatives (RedUSe) project involved 150 Australian Long-Term Care Facilities (LTCFs) incorporating auditing and benchmarking of prescribing, education, and multidisciplinary sedative reviews. SETTING A convenience sample of LTCFs (n = 28) involved in RedUSe between January 2015 and March 2016. PARTICIPANTS Permanent residents (n = 206) of LTCFs involved in RedUSe taking an antipsychotic and/or benzodiazepine daily. Residents were excluded if they had a severe psychiatric condition where antipsychotic therapy should generally be maintained long-term (e.g., bipolar disorder, schizophrenia) or were considered end-stage palliative. MEASUREMENTS Neuropsychiatric symptoms (Neuropsychiatric Inventory, Cohen-Mansfield Agitation Inventory (CMAI)), QoL (Assessment of Quality of Life-4D), and social withdrawal (Multidimensional Observation Scale for Elderly Subjects-withdrawal subscale) were measured at baseline and 4 months where nursing staff completed psychometric tests as proxy raters. RESULTS There was no evidence that psychometric measures were worsened following dose reductions. In fact, dose reduction was associated with small, albeit non-statistically significant, improvements in behavior, particularly less physically non-aggressive behavior with both drug groups (-0.36 points per 10% reduction in antipsychotic dose, -0.17 per 10% reduction in benzodiazepine dose) and verbally agitated behavior with benzodiazepine reduction (-0.16 per 10% dose reduction), as measured with the CMAI. Furthermore, antipsychotic reduction was associated with non-statistically significant improvements in QoL and social withdrawal. CONCLUSIONS Antipsychotic and benzodiazepine dose reduction in LTCFs was not associated with deterioration in neuropsychiatric symptoms, QoL, or social withdrawal. Trends toward improved agitation with antipsychotic and benzodiazepine dose reduction require further evaluation in larger, prospective, controlled studies.
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Foubert K, Muylaert P, Mehuys E, Somers A, Petrovic M, Boussery K. Application of the GheOP 3S-tool in nursing home residents: acceptance and implementation of pharmacist recommendations. Acta Clin Belg 2020; 75:388-396. [PMID: 31241000 DOI: 10.1080/17843286.2019.1634323] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background and objective: The prevalence of potentially inappropriate prescribing (PIP) among nursing home (NH) residents is high. This study aimed to investigate the acceptance and implementation of pharmacist recommendations based on a screening tool for PIP, the Ghent Older People's Prescriptions community Pharmacy Screening (GheOP3S)-tool. Setting and method: Prospective observational study in NH residents (≥ 70 years, using ≥ 5 medications) with a 3-month follow-up period. A pharmacist screened the medication lists using the GheOP3S-tool and formulated recommendations to reduce PIP. The acceptance of recommendations discussed during face-to-face pharmacist-general practitioner (GP) meetings was recorded. Implementation was examined by comparing baseline and follow-up medication lists. A pre-post comparison of the number of chronic medications and GheOP3S-criteria; the anticholinergic and sedative burden quantified by the Drug Burden Index (DBI); and medication costs was performed. Results: Screening with the GheOP3S-tool resulted in 168 pharmacist recommendations for 50 NH residents, mainly to stop (78.0%) and to substitute (14.3%) medications. Ninety-three % (156/168) of recommendations were considered relevant. GPs acceptance rate was 44.9%. Fifty-four % of all accepted recommendations were implemented. At follow-up, the number of chronic medications (p = 0.007), and DBI scores (p = 0.004) significantly differed from baseline. There was no significant decrease in the number of GheOP3S-criteria (p = 0.075) and medication costs (p > 0.05). Conclusion: The acceptance and implementation of pharmacist recommendations were relatively low. Future studies should increase the involvement of patients and all health-care providers. Interdisciplinary collaboration with sufficient education for all disciplines and patients is essential.
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Affiliation(s)
- Katrien Foubert
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Peter Muylaert
- Department of Family Medicine and Primary Health Care, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Els Mehuys
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Annemie Somers
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| | - Mirko Petrovic
- Department of Internal Medicine and Pediatrics, section of Geriatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Koen Boussery
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
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Moreno-Gutíerrez PA, Gaviria-Mendoza A, Ochoa-Orozco SA, Yepes-Echeverri MC, Machado-Alba JE. Long-term users of benzodiazepines in Colombia: Patterns of use and cessation of treatment. Drug Alcohol Depend 2020; 210:107962. [PMID: 32220698 DOI: 10.1016/j.drugalcdep.2020.107962] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 03/09/2020] [Accepted: 03/16/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Benzodiazepines have low abuse potential, but patients often develop physical dependence and neurological impairments. The objective of this study was to investigate treatment cessation and use of high doses in long-term benzodiazepine users in Colombia. METHODS Retrospective study. Patients who used benzodiazepines for at least six months (long-term) were selected from a prescription database and followed from initiation of benzodiazepine treatment for up to 30 months. We investigated treatment duration and compared patients who received normal and high (≥2 mean prescribed daily dose) doses. RESULTS Only 1255 (6.1 %) out of 20,567 patientsprescribed benzodiazepines became long-term users; their mean age was 60.6 years (SD=20.0) and 61.7 % were women. Mean high doses were used by 42.5 % (n=534) of the sample. Age under 20 years was a protector, whereas the long half-life benzodiazepines and use of other neurological medications were predictors of high dosage. Overall, 44.8 % (n=563) of the sample was still using benzodiazepines at the end of the study period. The use of antidepressants, antipsychotics, and anticonvulsants were negatively associated with cessation of benzodiazepine treatment. CONCLUSIONS A low proportion of patients starting benzodiazepines became long-term users. Nearly half of them used high doses and continued the medication for up to 30 months. Use of concomitant neurological drugs was associated with higher doses and less cessation.
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Affiliation(s)
- Paula Andrea Moreno-Gutíerrez
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira, Audifarma S.A., Pereira, Colombia; Grupo de Investigación Biomedicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
| | - Andrés Gaviria-Mendoza
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira, Audifarma S.A., Pereira, Colombia; Grupo de Investigación Biomedicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
| | - Sergio Andrés Ochoa-Orozco
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira, Audifarma S.A., Pereira, Colombia
| | - María Camila Yepes-Echeverri
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira, Audifarma S.A., Pereira, Colombia
| | - Jorge Enrique Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira, Audifarma S.A., Pereira, Colombia.
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11
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Does Deprescribing Improve Quality of Life? A Systematic Review of the Literature. Drugs Aging 2019; 36:1097-1110. [DOI: 10.1007/s40266-019-00717-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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12
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Weatherburn CJ. Benzodiazepines and non-benzodiazepine hypnotics - impact of a cluster adopted protocol on primary care prescribing. Scott Med J 2019; 64:97-102. [PMID: 31081466 DOI: 10.1177/0036933019849369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIMS Reduction of benzodiazepines and non-benzodiazepine hypnotics (BZDs and Z-drugs) prescribing is a priority. Dundee, Scotland, has a total of 25 general practices, split into four clusters. The cluster with the highest recorded prescribing of BZDs and Z-drugs adopted a prescribing protocol that aimed to reduce such prescribing. This paper evaluates the impact of this protocol. METHODS Quarterly prescribing data were obtained from Information Service Division, NHS Scotland from Q1 2015/16 to Q4 2017/18. Data were split into four clusters and standardised to Defined Daily Dose (DDDs) per 1000 registered patients. Interrupted time series (ITS) analysis was performed to assess prescribing one year after this protocol was introduced. RESULTS There was a crude reduction in prescribing of BZDs and Z-drugs across all GP practice clusters, but this related to an ongoing downward trend in prescribing. Allowing for this, in the cluster that adopted the protocol, ITS revealed there was no significant reduction attributable to the intervention in prescribing of DDD equivalent doses (-0.4%, 95% CI: -7.2 to 7.6). CONCLUSIONS Introduction of a cluster-wide prescribing protocol did not provide significant reduction of prescribing. Although crude figures might suggest an improvement, ITS analysis revealed this not to be the case.
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13
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Byrne CJ, Walsh C, Cahir C, Ryan C, Williams DJ, Bennett K. Anticholinergic and sedative drug burden in community-dwelling older people: a national database study. BMJ Open 2018; 8:e022500. [PMID: 29982221 PMCID: PMC6045724 DOI: 10.1136/bmjopen-2018-022500] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES The Drug Burden Index (DBI) tool quantifies individual exposure to anticholinergic and sedative medications. The DBI has been internationally validated against adverse health outcomes in older people. DBI exposure has not been reported in the Irish older population. This study aimed to: (1) develop a list of drugs with clinically significant anticholinergic and/or sedative effects (DBI medications) relevant to Ireland; (2) examine, using the DBI formula, the prevalence of exposure to DBI medications in Irish older people and (3) explore patient factors associated DBI exposure. DESIGN A cross-sectional national pharmacy claims database study. SETTING Community setting using the General Medical Services (GMS) scheme pharmacy claims database maintained by the Health Service Executive Primary Care Reimbursement Services. PARTICIPANTS Irish older individuals (aged ≥65 years) enrolled in the GMS scheme and dispensed at least one prescription item in 2016 (n=428 516). MAIN OUTCOME MEASURES Prevalence of exposure to DBI medications and patient factors associated with DBI exposure. RESULTS 282 874 (66%) of the GMS population aged ≥65 years were exposed to at least one DBI medication in 2016. Prevalence of exposure to DBI medications was significantly higher in females than males (females 71.6% vs males 58.7%, adjusted OR 1.65, 95% CI 1.63 to 1.68). Prevalence of DBI exposure increased progressively with the number of chronic drugs used, rising from 42.7% of those prescribed 0-4 chronic drugs to 95.4% of those on ≥12 chronic drugs (adjusted OR 27.8, 95% CI 26.7 to 29.0). The most frequently used DBI medications were codeine/paracetamol combination products (20.1% of patients), tramadol (11.5%), zopiclone (9.5%), zolpidem (8.5%), pregabalin (7.9%) and alprazolam (7.8%). CONCLUSIONS The majority of older people in Ireland are exposed to medications with anticholinergic and/or sedative effects, particularly females and those with multiple comorbidities. The high use of low-dose codeine/paracetamol combination products, Z-drugs and benzodiazepines, suggests there are opportunities for deprescribing.
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Affiliation(s)
- Catherine J Byrne
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Caroline Walsh
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Caitriona Cahir
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Cristín Ryan
- School of Pharmacy and Pharmaceutical Sciences, University of Dublin Trinity College, Dublin, Ireland
| | - David J Williams
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland and Beaumont Hospital, Dublin, Ireland
| | - Kathleen Bennett
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
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14
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Baandrup L, Ebdrup BH, Rasmussen JØ, Lindschou J, Gluud C, Glenthøj BY. Pharmacological interventions for benzodiazepine discontinuation in chronic benzodiazepine users. Cochrane Database Syst Rev 2018; 3:CD011481. [PMID: 29543325 PMCID: PMC6513394 DOI: 10.1002/14651858.cd011481.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Prolonged treatment with benzodiazepines is common practice despite clinical recommendations of short-term use. Benzodiazepines are used by approximately 4% of the general population, with increased prevalence in psychiatric populations and the elderly. After long-term use it is often difficult to discontinue benzodiazepines due to psychological and physiological dependence. This review investigated if pharmacological interventions can facilitate benzodiazepine tapering. OBJECTIVES To assess the benefits and harms of pharmacological interventions to facilitate discontinuation of chronic benzodiazepine use. SEARCH METHODS We searched the following electronic databases up to October 2017: Cochrane Drugs and Alcohol Group's Specialised Register of Trials, CENTRAL, PubMed, Embase, CINAHL, and ISI Web of Science. We also searched ClinicalTrials.gov, the WHO ICTRP, and ISRCTN registry, and checked the reference lists of included studies for further references to relevant randomised controlled trials. SELECTION CRITERIA We included randomised controlled trials comparing pharmacological treatment versus placebo or no intervention or versus another pharmacological intervention in adults who had been treated with benzodiazepines for at least two months and/or fulfilled criteria for benzodiazepine dependence (any criteria). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 38 trials (involving 2543 participants), but we could only extract data from 35 trials with 2295 participants. Many different interventions were studied, and no single intervention was assessed in more than four trials. We extracted data on 18 different comparisons. The risk of bias was high in all trials but one. Trial Sequential Analysis showed imprecision for all comparisons.For benzodiazepine discontinuation, we found a potential benefit of valproate at end of intervention (1 study, 27 participants; risk ratio (RR) 2.55, 95% confidence interval (CI) 1.08 to 6.03; very low-quality evidence) and of tricyclic antidepressants at longest follow-up (1 study, 47 participants; RR 2.20, 95% CI 1.27 to 3.82; low-quality evidence).We found potentially positive effects on benzodiazepine withdrawal symptoms of pregabalin (1 study, 106 participants; mean difference (MD) -3.10 points, 95% CI -3.51 to -2.69; very low-quality evidence), captodiame (1 study, 81 participants; MD -1.00 points, 95% CI -1.13 to -0.87; very low-quality evidence), paroxetine (2 studies, 99 participants; MD -3.57 points, 95% CI -5.34 to -1.80; very low-quality evidence), tricyclic antidepressants (1 study, 38 participants; MD -19.78 points, 95% CI -20.25 to -19.31; very low-quality evidence), and flumazenil (3 studies, 58 participants; standardised mean difference -0.95, 95% CI -1.71 to -0.19; very low-quality evidence) at end of intervention. However, the positive effect of paroxetine on benzodiazepine withdrawal symptoms did not persist until longest follow-up (1 study, 54 participants; MD -0.13 points, 95% CI -4.03 to 3.77; very low-quality evidence).The following pharmacological interventions reduced symptoms of anxiety at end of intervention: carbamazepine (1 study, 36 participants; MD -6.00 points, 95% CI -9.58 to -2.42; very low-quality evidence), pregabalin (1 study, 106 participants; MD -4.80 points, 95% CI -5.28 to -4.32; very low-quality evidence), captodiame (1 study, 81 participants; MD -5.70 points, 95% CI -6.05 to -5.35; very low-quality evidence), paroxetine (2 studies, 99 participants; MD -6.75 points, 95% CI -9.64 to -3.86; very low-quality evidence), and flumazenil (1 study, 18 participants; MD -1.30 points, 95% CI -2.28 to -0.32; very low-quality evidence).Two pharmacological treatments seemed to reduce the proportion of participants that relapsed to benzodiazepine use: valproate (1 study, 27 participants; RR 0.31, 95% CI 0.11 to 0.90; very low-quality evidence) and cyamemazine (1 study, 124 participants; RR 0.33, 95% CI 0.14 to 0.78; very low-quality evidence). Alpidem decreased the proportion of participants with benzodiazepine discontinuation (1 study, 25 participants; RR 0.41, 95% CI 0.17 to 0.99; number needed to treat for an additional harmful outcome (NNTH) 2.3 participants; low-quality evidence) and increased the occurrence of withdrawal syndrome (1 study, 145 participants; RR 4.86, 95% CI 1.12 to 21.14; NNTH 5.9 participants; low-quality evidence). Likewise, magnesium aspartate decreased the proportion of participants discontinuing benzodiazepines (1 study, 144 participants; RR 0.80, 95% CI 0.66 to 0.96; NNTH 5.8; very low-quality evidence).Generally, adverse events were insufficiently reported. Specifically, one of the flumazenil trials was discontinued due to severe panic reactions. AUTHORS' CONCLUSIONS Given the low or very low quality of the evidence for the reported outcomes, and the small number of trials identified with a limited number of participants for each comparison, it is not possible to draw firm conclusions regarding pharmacological interventions to facilitate benzodiazepine discontinuation in chronic benzodiazepine users. Due to poor reporting, adverse events could not be reliably assessed across trials. More randomised controlled trials are required with less risk of systematic errors ('bias') and of random errors ('play of chance') and better and full reporting of patient-centred and long-term clinical outcomes. Such trials ought to be conducted independently of industry involvement.
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Affiliation(s)
- Lone Baandrup
- Mental Health Centre Glostrup, Mental Health Services of the Capital RegionCentre for Neuropsychiatric Schizophrenia ResearchNordre Ringvej 29‐67GlostrupDenmark2600
- Mental Health Services of the Capital RegionMental Health Centre BallerupMaglevænget 2BallerupDenmarkDK‐2750
| | - Bjørn H Ebdrup
- Mental Health Centre Glostrup, Mental Health Services of the Capital RegionCentre for Neuropsychiatric Schizophrenia ResearchNordre Ringvej 29‐67GlostrupDenmark2600
| | - Jesper Ø Rasmussen
- Mental Health Services of the Capital RegionMental Health Centre AmagerCopenhagenDenmark
- Mental Health Services of the Capital RegionMental Health Centre Sct. HansRoskildeDenmark
| | - Jane Lindschou
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Birte Y Glenthøj
- Mental Health Centre Glostrup, Mental Health Services of the Capital RegionCentre for Neuropsychiatric Schizophrenia ResearchNordre Ringvej 29‐67GlostrupDenmark2600
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15
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Mestres Gonzalvo C, Milosevic V, van Oijen BPC, de Wit HAJM, Hurkens KPGM, Mulder WJ, Janknegt R, Schols JMGA, Verhey FR, Winkens B, van der Kuy PHM. The use of an electronic clinical rule to discontinue chronically used benzodiazepines and related Z drugs. Eur J Clin Pharmacol 2017; 74:227-231. [PMID: 29127459 DOI: 10.1007/s00228-017-2369-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 11/05/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE The chronic use of benzodiazepines and benzodiazepine-related drugs (BZ/Z) in older people is common and not without risks. The objective of this study was to evaluate whether the implementation of a clinical rule promotes the discontinuation of chronically used BZ/Z for insomnia. METHODS A clinical rule, generating an alert in case of chronic BZ/Z use, was created and applied to the nursing home (NH) setting. The clinical rule was a one-off intervention, and alerts did not occur over time. Reports of the generated alerts were digitally sent to NH physicians with the advice to phase out and eventually stop the BZ/Z. In cases where the advice was adopted, a follow-up period of 4 months on the use of BZ/Z was taken into account in order to determine whether the clinical rule alert led to a successful discontinuation of BZ/Z. RESULTS In all, 808 NH patients were screened. In 161 (19.1%) of the patients, BZ/Z use resulted in a clinical rule alert. From these, the advice to phase out and stop the BZ/Z was adopted for 27 patients (16.8%). Reasons for not following the advice consisted of an unsuccessful attempt in the past (38 patients), patients family and/or patient resistance (37 patients), the non-continuous use of BZ/Z (32 patients) and indication still present (27 patients). Of the 12 NH physicians, seven adopted the advice. CONCLUSIONS The success rate of a clinical rule for discontinuation of chronically used BZ/Z for insomnia was low, as reported in the present study. Actions should be taken to help caregivers, patients and family members understand the importance of limiting BZ/Z use to achieve higher discontinuation rates.
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Affiliation(s)
- C Mestres Gonzalvo
- Department of Clinical Pharmacy, Pharmacology and Toxicology, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands.
- Department of Clinical Pharmacy, Elkerliek Hospital, Helmond, The Netherlands.
| | - V Milosevic
- Department of Clinical Pharmacy, Pharmacology and Toxicology, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - B P C van Oijen
- Department of Clinical Pharmacy, Pharmacology and Toxicology, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - H A J M de Wit
- Department of Clinical Pharmacy, Canisius-Wilhelmina Ziekenhuis, Nijmegen, The Netherlands
| | - K P G M Hurkens
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - W J Mulder
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - R Janknegt
- Department of Clinical Pharmacy, Pharmacology and Toxicology, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - J M G A Schols
- Department of Family Medicine and Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - F R Verhey
- Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands
| | - B Winkens
- Department of Methodology and Statistics, Maastricht University, Maastricht, The Netherlands
| | - P H M van der Kuy
- Department of Clinical Pharmacy, Pharmacology and Toxicology, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
- Department of Hospital Pharmacy, Erasmus Medical Center, Rotterdam, The Netherlands
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16
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Reeve E, Ong M, Wu A, Jansen J, Petrovic M, Gnjidic D. A systematic review of interventions to deprescribe benzodiazepines and other hypnotics among older people. Eur J Clin Pharmacol 2017; 73:927-935. [DOI: 10.1007/s00228-017-2257-8] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 04/18/2017] [Indexed: 01/10/2023]
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17
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Wolter DK. [Discontinuation of benzodiazepines in old age : When and if so, how?]. Z Gerontol Geriatr 2017; 50:115-122. [PMID: 28105500 DOI: 10.1007/s00391-016-1171-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 12/02/2016] [Accepted: 12/14/2016] [Indexed: 10/20/2022]
Abstract
Although viewed critically in geriatrics, benzodiazepine use is still common among old people. Before reducing the dosage the following questions must be considered: 1. Are there indications for benzodiazepine treatment and will discontinuation cause relevant rebound symptoms of the initial disorder treated? 2. To what extent do the patient and other key persons consider discontinuation to be reasonable and will they support discontinuation? 3. Is the target complete withdrawal, a dose reduction or shift to another benzodiazepine drug which is more suitable in old age for pharmacokinetic reasons? This article provides assistance in answering these questions and some guidelines for the practical management of discontinuation. It is mandatory 1) to periodically address the problem of long-term benzodiazepine use when counseling the patient and key persons and 2) to be aware that several intermediate steps exist between continuation and complete discontinuation, which may be considered successful treatment.
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Affiliation(s)
- Dirk K Wolter
- Gerontopsykiatrisk Afdeling, Psykiatrien, Kresten Philipsens Vej 15 B, 6200, Aabenraa, Dänemark.
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18
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Tsunoda T, Yamada M, Akiyama T, Minami T, Yoshii T, Kondo Y, Satoh S, Terauchi Y. The Effects of Ramelteon on Glucose Metabolism and Sleep Quality in Type 2 Diabetic Patients With Insomnia: A Pilot Prospective Randomized Controlled Trial. J Clin Med Res 2016; 8:878-887. [PMID: 27829954 PMCID: PMC5087628 DOI: 10.14740/jocmr2754w] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2016] [Indexed: 01/13/2023] Open
Abstract
Background Insomnia is associated with the onset and development of diabetes. Melatonin affects sleep quality and glucose metabolism in diabetic patients with insomnia. We administered ramelteon, an agonist of melatonin, to type 2 diabetic patients and investigated its effects on glucose metabolism and insomnia. Methods This multicenter, prospective, randomized, and observational pilot study was performed between April 2014 and April 2015 at three institutes in Japan. Patients were prescribed ramelteon 8 mg/day for 3 months (first period). And patients were divided at random into the continuation group that continued taking ramelteon and the discontinuation group that discontinued taking ramelteon for 3 additional months (second period). The primary endpoint was change in glycated hemoglobin (HbA1c) level. Secondary endpoints were changes in global Pittsburgh sleep questionnaire index (PSQI) score and other glucose metabolism makers. Results We enrolled 42 patients, and 32 patients completed the first period. Their mean HbA1c was 6.7%, and global PSQI score was 8.1 on average. HbA1c level did not change but global PSQI score improved from 8.1 to 7.2 by ramelteon (P = 0.030). Thirty-one patients completed the second period. HbA1c level did not change in the continuation group, but it increased from 6.7% to 6.9% (P = 0.003) in the discontinuation group. Global PSQI score did not change in each group. There was no rebound insomnia. Conclusion Treatment with ramelteon did not change the HbA1c level but improved sleep quality in type 2 diabetic patients with insomnia. Discontinuation of ramelteon slightly increased the HbA1c level and did not worsen sleep quality.
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Affiliation(s)
- Tetsuji Tsunoda
- Division of Metabolism and Endocrinology, Department of Internal Medicine, Yokohama Sakae Kyosai Hospital, Federation of National Public Service Personnel Mutual Associations, Yokohama, Japan; Department of Endocrinology and Metabolism, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Masayo Yamada
- Division of Metabolism and Endocrinology, Department of Internal Medicine, Yokohama Sakae Kyosai Hospital, Federation of National Public Service Personnel Mutual Associations, Yokohama, Japan
| | - Tomoaki Akiyama
- Division of Metabolism and Endocrinology, Department of Internal Medicine, Yokohama Sakae Kyosai Hospital, Federation of National Public Service Personnel Mutual Associations, Yokohama, Japan
| | - Taichi Minami
- Division of Metabolism and Endocrinology, Department of Internal Medicine, Yokohama Sakae Kyosai Hospital, Federation of National Public Service Personnel Mutual Associations, Yokohama, Japan
| | - Taishi Yoshii
- Department of Endocrinology and Metabolism, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Yoshinobu Kondo
- Department of Endocrinology and Metabolism, Graduate School of Medicine, Yokohama City University, Yokohama, Japan; Department of Endocrinology and Metabolism, Chigasaki Municipal Hospital, Chigasaki, Japan
| | - Shinobu Satoh
- Department of Endocrinology and Metabolism, Chigasaki Municipal Hospital, Chigasaki, Japan
| | - Yasuo Terauchi
- Department of Endocrinology and Metabolism, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
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Airagnes G, Pelissolo A, Lavallée M, Flament M, Limosin F. Benzodiazepine Misuse in the Elderly: Risk Factors, Consequences, and Management. Curr Psychiatry Rep 2016; 18:89. [PMID: 27549604 DOI: 10.1007/s11920-016-0727-9] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Benzodiazepine (BZD) inappropriate use (i.e., misuse and overuse) is a worldwide public health problem. Despite current knowledge about increased sensitivity to side effects in the elderly, that should lead to more caution, only a third of BZD prescriptions in this age group are considered appropriate. The most frequent inadequate situations are excessive duration and/or dosage of a medical prescription or self-medication, especially in a context where it would be contraindicated, e.g., long-acting BZD in the elderly. Polypharmacy and comorbidities are major risk factors. Consequences of BZD inappropriate use are falls, delirium and other cognitive dysfunction, acute respiratory failure, car accidents, dependence, and withdrawal symptoms. An emerging concern is a potentially increased risk of dementia. Contrary to most clinicians' belief, discontinuation of chronic BZD use in elderly patients is feasible, with adequate psychotherapeutic or pharmacological strategies, and can lead to long-term abstinence. Brief cognitive therapy mostly relies on psychoeducation and motivational enhancement and is particularly useful in this context. Further research is needed, notably in three areas: (1) assessing the impact of public health programs to prevent BZD inappropriate use in the elderly, (2) developing alternative strategies to treat anxiety and insomnia in elderly patients, and (3) exploring the association between chronic BZD use and dementia.
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Affiliation(s)
- Guillaume Airagnes
- AP-HP, Hôpitaux Universitaires Paris Ouest, Pôle Psychiatrie Addictions, Paris, France. .,Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France. .,Centre Ambulatoire d'Addictologie, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75908, Paris, Cedex 15, France.
| | - Antoine Pelissolo
- AP-HP, Service de Psychiatrie, Hôpital Henri-Mondor, Université Paris-Est Créteil, INSERM U955, IMRB, Fondation FondaMental, Créteil, France
| | - Mélanie Lavallée
- Université Laval, Département de Psychiatrie et Neurosciences, Québec, Canada.,Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale, Québec, Canada.,Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada
| | - Martine Flament
- University of Ottawa Institute of Mental Health Research, Royal Ottawa Mental Health Centre, Ottawa, Ontario, Canada
| | - Frédéric Limosin
- AP-HP, Hôpitaux Universitaires Paris Ouest, Pôle Psychiatrie Addictions, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France.,Inserm, U894, Centre Psychiatrie et Neurosciences, Paris, France
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20
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Potentially inappropriate prescribing in nursing home residents detected with the community pharmacist specific GheOP(3)S-tool. Int J Clin Pharm 2016; 38:1063-8. [PMID: 27503282 DOI: 10.1007/s11096-016-0366-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 07/25/2016] [Indexed: 10/21/2022]
Abstract
Background The Ghent Older People's Prescriptions community Pharmacy Screening (GheOP³S-)tool was recently developed to screen for potentially inappropriate prescribing (PIP). Objective We aimed (1) to determine PIP prevalence in older nursing home (NH) residents with polypharmacy using the GheOP³S-tool and (2) to identify those PIPs that are most frequently detected. Method A cross-sectional study was carried out between February and June 2014 in 10 NHs in Belgium, supplied by a community pharmacy chain. For each NH, 40 residents (≥70 years, using ≥5 chronic drugs) were included. PIP prevalence was determined using the GheOP³S-tool. Results 400 NH residents were included [mean age (±SD) 86.2 (±6.3) years; median number of drugs (±IQR) 10 (7-12)]. A total of 1728 PIPs were detected in 387 (97 %) participants (Median 4; IQR 2-6). The most prevalent items can be assigned to three categories: long-term use of central nervous system drugs (i.e. benzodiazepines, antidepressants and antipsychotics), use of anticholinergic drugs (mutual combinations and with underlying constipation/dementia) and underuse of osteoporosis prophylaxis. Conclusion Screening for PIP by means of the GheOP³S-tool revealed a high prevalence of PIP among older NH residents with polypharmacy. This finding urges for initiatives on the patient-level, but also on a broader, institutional level.
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Page AT, Clifford RM, Potter K, Schwartz D, Etherton-Beer CD. The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis. Br J Clin Pharmacol 2016; 82:583-623. [PMID: 27077231 DOI: 10.1111/bcp.12975] [Citation(s) in RCA: 287] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 03/23/2016] [Accepted: 04/12/2016] [Indexed: 12/31/2022] Open
Abstract
AIMS Deprescribing is a suggested intervention to reverse the potential iatrogenic harms of inappropriate polypharmacy. The review aimed to determine whether or not deprescribing is a safe, effective and feasible intervention to modify mortality and health outcomes in older adults. METHODS Specified databases were searched from inception to February 2015. Two researchers independently screened all retrieved articles for inclusion, assessed study quality and extracted data. Data were pooled using RevMan v5.3. Eligible studies included those where older adults had at least one medication deprescribed. The primary outcome was mortality. Secondary outcomes were adverse drug withdrawal events, psychological and physical health outcomes, quality of life, and medication usage (e.g. successful deprescribing, number of medications prescribed, potentially inappropriate medication use). RESULTS A total of 132 papers met the inclusion criteria, which included 34 143 participants aged 73.8 ± 5.4 years. In nonrandomized studies, deprescribing polypharmacy was shown to significantly decrease mortality (OR 0.32, 95% CI: 0.17-0.60). However, this was not statistically significant in the randomized studies (OR 0.82, 95% CI 0.61-1.11). Subgroup analysis revealed patient-specific interventions to deprescribe demonstrated a significant reduction in mortality (OR 0.62, 95% CI 0.43-0.88). However, generalized educational programmes did not change mortality (OR 1.21, 95% CI 0.86-1.69). CONCLUSIONS Although nonrandomized data suggested that deprescribing reduces mortality, deprescribing was not shown to alter mortality in randomized studies. Mortality was significantly reduced when applying patient-specific interventions to deprescribe in randomized studies.
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Affiliation(s)
- Amy T Page
- School of Medicine and Pharmacology, University of Western Australia, 35 Stirling Highway, Crawley, 6009, Western Australia, Australia
| | - Rhonda M Clifford
- School of Medicine and Pharmacology, University of Western Australia, 35 Stirling Highway, Crawley, 6009, Western Australia, Australia
| | - Kathleen Potter
- School of Medicine and Pharmacology, University of Western Australia, 35 Stirling Highway, Crawley, 6009, Western Australia, Australia
| | - Darren Schwartz
- School of Medicine and Pharmacology, University of Western Australia, 35 Stirling Highway, Crawley, 6009, Western Australia, Australia.,Graylands Hospital, Mt Claremont, Western Australia, Australia
| | - Christopher D Etherton-Beer
- School of Medicine and Pharmacology, University of Western Australia, 35 Stirling Highway, Crawley, 6009, Western Australia, Australia.,Royal Perth Hospital, Perth, Western Australia, Australia
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