Safety analysis of zolpidem in elderly subjects 80 years of age or older: adverse event monitoring in Japanese subjects

Geriatrics on beers criteria medications at risk of adverse drug events using real-world data

OBJECTIVES

The established Beers Criteria consider side effects and safety concerns when prescribing drugs to the elderly. As the criteria suggest that attention should be paid toward prescriptions rather than prescription prohibition lists, these Beers Criteria medications (BCMs) are used appropriately under unavoidable circumstances.

METHODS

Patients aged ≥ 65 years and with an experience of being prescribed inappropriate medications at Konyang University Hospital, South Korea, were selected. We analyzed data from the Korea Adverse Event Reporting System (KAERS) and the Food and Drug Administration Adverse Event Reporting System (FAERS) of the United States to identify medication-induced adverse drug events (ADEs). The actual incidence was predicted by multiplying the incidence and number of BCMs prescribed to the patients. The proportional reporting ratio (PRR) and reporting odds ratio (ROR) were calculated using KAERS and FAERS data.

RESULTS

We predicted that the incidence of ADEs would be higher for metoclopramide, chlorpheniramine, and amitriptyline in patients using medications for more than 1 day and metoclopramide, chlorpheniramine, and ketoprofen in patients using medications only for 1 day. Among the ADEs reported to KAERS and FAERS, significant ROR and PRR values were noted for clonazepam (drowsiness), nortriptyline (sleepiness), and zolpidem (amnesia, somnambulism, agitation, dependence, nightmare, and dysgeusia).

CONCLUSION

This study highlighted the actual status of BCM prescriptions in clinical institutions and predicted the incidence of ADEs. We concluded that greater care must be taken while prescribing BCMs to the elderly and indicators, such as PRR and ROR should be monitored regularly.

More than a quarter century of the most prescribed sleeping pill: Systematic review of zolpidem use by older adults

Zolpidem is widely used to treat insomnia of older adults despite that few randomized controlled studies were conducted in this group. We systematically reviewed the relevant literature on efficacy/effectiveness and safety of zolpidem use by elderly individuals in relevant databases completed with a manual search of key journals. Studies were required to include individuals aged ≥60 years under intervention with zolpidem compared to placebo or other hypnosedatives. Outcomes were either objectively- or subjectively-assessed improvements in specific sleep parameters and safety for clinical use. The 31 reports selected for review were mostly of low-quality. The evidence suggests that zolpidem is useful typically by reducing sleep latency and episodes of wake after sleep onset, and increasing total sleep time and sleep efficiency. Regarding safety and tolerability, analyses suggest a low risk of daytime sleepiness and of deleterious effects on memory or psychomotor performance, provided that recommended dosage and precautions are followed. Few retrospective studies associate zolpidem use with risk of falls, fractures, dementia, cancer, and stroke. Zolpidem appears effective at lower doses and for short-term treatment among the elderly. Rigorous, new clinical trials are warranted to further document the specific effects of zolpidem in older individuals.

Combined Effects of Having Sleep Problems and Taking Sleeping Pills on the Skeletal Muscle Mass and Performance of Community-Dwelling Elders

This study aimed to explore the combined effects of having sleep problems and taking sleeping pills on the skeletal muscle mass and performance of community-dwelling elders. A total of 826 participants who have complete information regarding dual-energy X-ray absorptiometry examination, questionnaire, and physical performance tests were included. The status of having sleep problems and taking sleeping pills was assessed with a self-reported questionnaire. The prevalence rates of sleep problems among older men and women were 37.4% and 54.5%, respectively. After multivariate adjustment, the mean height-adjusted skeletal muscle indices for elders having sleep problems and taking sleeping pills among men and women were 7.29 and 5.66 kg/m², respectively, which were lower than those without sleep problems (P = 0.0021 and P = 0.0175). The performance of the older men having sleep problems and taking sleeping pills in terms of walking speed, grip strength, and number of squats, was poorer than those of the older men without sleep problems. The status of having sleep problems and taking sleeping pills was correlated with low skeletal muscle mass and poor physical performance in community-dwelling elders. These findings suggest that having sleep problems and taking sleeping pills are associated with having sarcopenia among community elderly.

Treatment of Sleep Disturbance May Reduce the Risk of Future Probable Alzheimer's Disease

OBJECTIVE

This study explored two research questions: (a) Does sleep medication neutralize or provide a protective effect against the hazard of Alzheimer's disease (AD)? (b) Do apolipoprotein (APOE) e4 carriers reporting a sleep disturbance experience an increased risk of AD?

METHOD

This study is a secondary analysis of the National Alzheimer's Coordinating Center's Uniform Data Set ( n = 6,782) using Cox proportional hazards regression.

RESULTS

Sleep disturbance was significantly associated with eventual AD development. Among the subset of participants taking general sleep medications, no relationship between sleep disturbance and eventual AD was observed. Among individuals not taking sleep medications, the increased hazard between the two variables remained. Among APOE e4 carriers, sleep disturbance and AD were significant, except among those taking zolpidem.

DISCUSSION

Our findings support the emerging link between sleep disturbance and AD. Our findings also suggest a continued need to elucidate the mechanisms that offer protective factors against AD development.

South Korean geriatrics on Beers Criteria medications at risk of adverse drug events

Background

The Beers Criteria released by the American Geriatrics Society includes a list of drugs to avoid in the geriatric population and is frequently used as a safety resource in geriatric pharmacotherapy.

Objective

To evaluate the exposure of South Korean geriatrics to potentially inappropriate medications according to the Beers Criteria and the risk of adverse events from these medications.

Methods

This study included medications recommended to be avoided in patients 65 years or older regardless of concomitant drug therapy or disease. The exposure of South Korean geriatrics to each of the study medications were examined using health claims data of 2011. The number of South Korean geriatrics at risk of experiencing adverse drug events from the study medications were estimated by multiplying the number of patients exposed to the medication in 2011 and the incident rate of the event obtained from literature sources.

Results

This study examined 166,822 geriatrics for Beers Criteria medication exposure and adverse drug event risk. The most prevalent Beers Criteria medication prescribed in South Korean geriatrics >1 day was chlorpheniramine (53.9%) and the adverse drug event with the highest number of this geriatric population at risk of was amitriptyline related dry mouth (4.9%). The proportion of South Korean geriatrics on chronic Beers Criteria medications >1 day at risk of adverse drug events from these medications was significantly higher than in US geriatrics (0.005 vs. 0.001, 2-way ANOVA post hoc pairwise t-test P<0.0001).

Conclusions

In 2011, over half of South Korean geriatrics was exposed to medications recommended to be avoided in geriatrics and their adverse drug event risk warrants close monitoring of their occurrence.

Effects of a primary care intervention to improve the quality of zolpidem prescriptions in elderly patients

PURPOSE

The objective of this study was to measure the impact of an intervention on the prescription habits of general practitioners (GPs) in order to improve the quality of zolpidem prescriptions in patients aged 75 or older.

METHODS

A prospective multicentric non-randomized trial was performed in the Metropolitan Granada Primary Healthcare Area (Andalusian Public Healthcare Service, Spain), which serves a total population of approximately 675,000 inhabitants. All health centers volunteering to participate in the trial were included. The intervention consisted of training sessions, individualized feedback, clinical information, and financial incentives. A daily dose over 5 mg was considered non-safe. Reduction in non-safe prescriptions of zolpidem in the elderly population became a quality prescribing indicator in a pay-for-performance scheme.

RESULTS

Statistically significant differences versus baseline were found between the intervention and control groups in mean zolpidem prescription prevalence (28.5 vs. 37.5‰, respectively; p = 0.008) and mean non-safe zolpidem prescription prevalence (16.5 vs. 34.2‰, respectively; p < 0.001). At the end of the study period, the total number of non-safe prescriptions was 1309, 35% lower versus baseline, with a significant difference of p < 0.001; the number in the intervention (510 vs. 1118; p < 0.001) and control (799 vs. 893; p = 0.0064) groups was also significantly lower, with a significantly greater percentage reduction in the intervention group (54.4 vs. 10.5%, p < 0.001).

CONCLUSION

The quality prescribing indicator in our area was improved by the intervention developed. Further studies that include an intervention group of GPs who receive no financial incentive are required to evaluate the relative importance of an economic reward in achieving this improvement.

Potentially inappropriate psychotropic prescription at discharge is associated with lower functioning in the elderly psychiatric inpatients. A cross-sectional study

OBJECTIVE

The objectives are to determine the rate of potentially inappropriate psychotropic (PIP) prescription at discharge in the elderly psychiatric inpatients and to determine whether PIP is associated with lowered functioning outcomes.

METHODS

Sociodemographic, clinical, and treatment data for all inpatients aged ≥ 65 years consecutively hospitalized during 1 year in 13 psychiatry departments was analyzed. PIP+/PIP- groups were defined according to the French-updated Beers criteria. Daily functioning was evaluated by the daily living (ADL) scale. Logistic regression analysis was used to estimate odds ratios for the association between PIP administration at discharge and respectively functioning and potential confounding factors.

RESULTS

Data was obtained for 327 patients. Overall, 124 (37.9 %) patients were males, and the mean age was 73.9 years (SD = 5.6); 163 (49.8 %) patients were diagnosed with affective disorders and 89 (27.2 %) with schizophrenia/schizotypal/delusional disorders. Overall, 249 (76.1 %) had one or more PIP medications, mainly anxiolytics (69.9 %) and hypnotics (17.2 %). In a multivariate analysis, PIP prescription at discharge has been associated with patient lowered personal care functioning, independently of age, gender, and psychiatric or somatic diagnoses (OR = 0.88 (0.79-0.97, p = 0.01).

CONCLUSION

In the current increasingly fragmented health care systems, special attention must be given to PIP prescription in older population suffering from psychiatric disorders. Using the Beers criteria, the present study demonstrates the high prevalence of PIP prescription, which concerns a large panel of drugs but mostly anxiolytics and hypnotics independently of psychiatric or somatic diagnoses and sociodemographic characteristics. Our study has demonstrated for the first time an association between PIP prescription and lowered patient functioning. Further longitudinal studies should confirm a potential causal relation.

Insomnia in the Military: Application and Effectiveness of Cognitive and Pharmacologic Therapies

Insomnia is one of the most common complaints of US armed service members. Diagnosis and treatment of insomnia in active duty and veteran populations are often complicated by comorbid disorders experienced by military personnel, such as post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). Cognitive behavioral therapy for insomnia (CBTi), pharmacologic interventions, and alternative therapies are discussed as relevant to their applications within military populations. Future directions in research are suggested.