Benzodiazepine Prescribing in Older Adults in U.S. Ambulatory Clinics and Emergency Departments (2001-10)

Prevalence and Treatment of Substance Misuse in Older Adults: Beyond Early Adulthood

Substance misuse, traditionally seen as a problem of early to mid-adulthood, is becoming increasingly prevalent among the older adult population (ages ≥65). Diagnosing and treating substance misuse in this vulnerable population is challenging because of multiple pre-existing medical comorbidities as well as polypharmacy. As such, it remains underdiagnosed and underrepresented in the literature. This review provides an overview of the three most commonly misused substances in older adults: alcohol, cannabis, and prescription drugs. It examines epidemiology, societal trends, and treatment options, highlighting the need for targeted research to address the unique challenges faced by older adults. This review also briefly comments on the prevalence and treatment of other illicit drugs in this population.

Benzodiazepine Discharge Prescriptions From Emergency Departments Across the United States Between 2012 and 2019: A National Analysis

OBJECTIVES

Benzodiazepines are commonly misused medications frequently implicated in overdose deaths. Data show that benzodiazepine prescribing is associated with increased misuse. We sought to determine national trends in benzodiazepine prescribing from the emergency department (ED).

METHODS

This is a retrospective review of the National Hospital Ambulatory Medical Care Survey from 2012 to 2019. Our primary outcome was to evaluate trends in ED visits where a benzodiazepine was prescribed at discharge. Secondarily, we identified commonly prescribed benzodiazepines and assessed trends over time. We examined demographic data and used descriptive statistics and Spearman rho or Pearson correlation coefficient as applicable.

RESULTS

Between 2012 and 2019, there were 13,848,578 visits where benzodiazepines were prescribed at ED discharge. In 2012 and 2019, there were 1,407,478 visits (1.1% of all ED visits) and 1,361,372 visits (0.9%), respectively, where benzodiazepines were prescribed (mean [SD], 1,731,072 [287,623] [1.26%]), with no trend ( P = 0.31). Common benzodiazepines prescribed were diazepam (5,980,279 visits, 43.2% of all prescriptions), alprazolam (3,306,549, 23.9%), and clonazepam (2,105,963, 15.2%), with no changes over time. Fifteen percent of prescriptions were for patients 65 years or older.

CONCLUSION

Despite reports of increased misuse, there was no change in ED discharge benzodiazepine prescribing. Concerningly, alprazolam, a benzodiazepine with high misuse potential, was frequently prescribed despite limited ED indications, and there was a large percentage of visits where benzodiazepines were prescribed to older adults despite warnings for adverse effects in this population. Future studies should assess rational prescribing and the role of targeted interventions to curb inappropriate use.

Prescribing Benzodiazepines and Opioids and Clinical Characteristics Associated With 30-Day Hospital Return in Patients Aged ≥75 Years: Secondary Data Analysis

PURPOSE

The current study compared prevalence of opioid or benzodiazepine (BZD) prescription and co-prescription of opioids and BZD at discharge and return to a community hospital within 30 days, as well as identified clinical characteristics associated with hospital return in patients aged ≥75 years.

METHOD

A secondary analysis of a database created during implementation of the Safe Transitions for At Risk Patients program at a 400-bed community teaching hospital in south Florida was conducted. Multivariable logistic regression analyses were performed to identify significant demographic and clinical characteristics associated with return to the hospital within 30 days of discharge.

RESULTS

A total of 24,262 participants (52.6% women) with a mean age of 85.3 (SD = 6.42) years were included. More than 20% in each central nervous system prescription group (i.e., opioids only, BZD only, opioids and BZD) returned to the hospital within 30 days of discharge. Demographic and chronic conditions (e.g., congestive heart failure, chronic obstructive pulmonary disease, diabetes) and poly-pharmacy were significant factors of a 30-day return to the hospital.

CONCLUSION

Findings highlight the importance of hospital nurses' role in identifying high-risk patients, educating patients and caregivers, monitoring them closely, communicating with primary care physicians and specialists, and conducting intensive follow up via telephone to avoid 30-day rehospitalization. [Journal of Gerontological Nursing, 50(4), 25-33.].

An Analysis of Benzodiazepine Prescribing to Primary Care Patients in a Large Healthcare System from 2019-2020

We sought to quantify benzodiazepine prescribing by primary care providers from 2019 to 2020 and identify correlates of prescribing. We hypothesized prescribing would increase post-COVID-19 lockdown. We conducted a retrospective cohort study of adult patients with primary care visits in 2019 or 2020 in a large Ohio healthcare system. Demographics, diagnosis codes, and receipt of benzodiazepine prescriptions were collected. Using multivariable logistic regression, we examined factors associated with benzodiazepine prescription receipt during the whole study period and post-lockdown. 455,537 adult patients had 1,643,473 visits. Benzodiazepines were prescribed in 3.2% (53,049/1,643,473) of visits. Effect sizes for positive associations with benzodiazepine prescription were largest for anxiety disorders. For negative associations, they were largest for Black patients and patients with cocaine use disorder. Benzodiazepine prescribing was positively associated with multiple groups having contraindications, though effect sizes were small. Contrary to our hypothesis, odds of receiving a prescription were 8.8% lower post-lockdown. Benzodiazepine prescribing rates in our system compared favorably to national rates. Year over year odds of receiving a prescription were slightly lower post-lockdown. Racial disparities were present and deserve further study. Strategies to reduce benzodiazepine prescribing to patients with anxiety may yield the largest reductions for benzodiazepine prescribing in primary care settings.

Discontinuation of benzodiazepines and Z-drugs in hospitalised population at the age of 60 and above. An open-label randomized controlled trial

BACKGROUND

Treating insomnia with hypnotic drugs in elderly patients has many adverse effects. This study aims to assess the effect of two discontinuation methods of hypnotic drugs during acute hospitalization.

METHODS

We conducted an open-label randomized controlled trial that included participants aged 60 and above taking benzodiazepines or Z-Drugs for at least 3 months as a treatment for insomnia and were admitted to the hospital. In the prospective arm, patients were randomly assigned into two intervention groups. In the Minimal Intervention (MI) group, patients received an explanation of the dangers of long-term treatment and a recommendation to stop the treatment. In the Tapering Down Intervention (TDI) group, in addition to the explanation, patients received a tapering down table. In the retrospective arm (control group), we examined the use of hypnotic drugs among hospitalized patients 3 months after hospitalization, similar to the patients in the prospective arm.

RESULTS

46 patients were enrolled in the MI group, 55 patients in the TDI group, and 114 patients in the control group. The mean age in the three groups was 75.0 ± 8.2, 75.9 ± 9.0, and 75.0 ± 7.9 years respectively (p = 0.85). After 3 months, seven (15.2%) of the patients in the MI group, 15 (27.3%) in the TD group, and 2 (1.8%) in the control group (p = 0.00003) were weaned from the hypnotic drugs treatment, without a significant difference between the intervention groups (p = 0.221).

CONCLUSIONS

A short intervention during hospitalization results in a significant decrease in hypnotic drug use.

Use of High-Risk Medications Among Older Adults Enrolled in Medicare Advantage Plans vs Traditional Medicare

Importance

Limiting the use of high-risk medications (HRMs) among older adults is a national priority to provide a high quality of care for older beneficiaries of both Medicare Advantage and traditional fee-for-service Medicare Part D plans.

Objective

To evaluate the differences in the rate of HRM prescription fills among beneficiaries of traditional Medicare vs Medicare Advantage Part D plans and to examine the extent to which these differences change over time and the patient-level factors associated with higher rates of HRMs.

Design, Setting, and Participants

This cohort study used a 20% sample of Medicare Part D data on filled drug prescriptions from 2013 to 2017 and a 40% sample from 2018. The sample comprised Medicare beneficiaries aged 66 years or older who were enrolled in Medicare Advantage or traditional Medicare Part D plans. Data were analyzed between April 1, 2022, and April 15, 2023.

Main Outcomes and Measures

The primary outcome was the number of unique HRMs prescribed to older Medicare beneficiaries per 1000 beneficiaries. Linear regression models were used to model the primary outcome, adjusting for patient characteristics and county characteristics and including hospital referral region fixed effects.

Results

The sample included 5 595 361 unique Medicare Advantage beneficiaries who were propensity score-matched on a year-by-year basis to 6 578 126 unique traditional Medicare beneficiaries between 2013 and 2018, resulting in 13 704 348 matched pairs of beneficiary-years. The traditional Medicare vs Medicare Advantage cohorts were similar in age (mean [SD] age, 75.65 [7.53] years vs 75.60 [7.38] years), proportion of males (8 127 261 [59.3%] vs 8 137 834 [59.4%]; standardized mean difference [SMD] = 0.002), and predominant race and ethnicity (77.1% vs 77.4% non-Hispanic White; SMD = 0.05). On average in 2013, Medicare Advantage beneficiaries filled 135.1 (95% CI, 128.4-142.6) unique HRMs per 1000 beneficiaries compared with 165.6 (95% CI, 158.1-172.3) HRMs per 1000 beneficiaries for traditional Medicare. In 2018, the rate of HRMs had decreased to 41.5 (95% CI, 38.2-44.2) HRMs per 1000 beneficiaries in Medicare Advantage and to 56.9 (95% CI, 54.1-60.1) HRMs per 1000 beneficiaries in traditional Medicare. Across the study period, Medicare Advantage beneficiaries received 24.3 (95% CI, 20.2-28.3) fewer HRMs per 1000 beneficiaries per year compared with traditional Medicare beneficiaries. Female, American Indian or Alaska Native, and White populations were more likely to receive HRMs than other groups.

Conclusion and Relevance

Results of this study showed that HRM rates were consistently lower among Medicare Advantage than traditional Medicare beneficiaries. Higher use of HRMs among female, American Indian or Alaska Native, and White populations is a concerning disparity that requires further attention.

No short-term mortality from benzodiazepine use post-acute ischemic stroke after accounting for bias

BACKGROUND AND OBJECTIVES

Older adults receive benzodiazepines for agitation, anxiety, and insomnia after acute ischemic stroke (AIS). No trials have been conducted to determine if benzodiazepine use affects poststroke mortality in the elderly.

METHODS

We examined the association between initiating benzodiazepines within 1 week after AIS and 30-day mortality. We included patients ≥65 years, admitted for new nonsevere AIS (NIH-Stroke-Severity[NIHSS]≤ 20), 2014-2020, with no recorded benzodiazepine use in the previous 3 months and no contraindication for use. We linked a stroke registry to electronic health records, used inverse-probability weighting to address confounding, and estimated the risk difference (RD). A process of cloning, weighting, and censoring was used to avoid immortal time bias.

RESULTS

Among 2,584 patients, 389 received benzodiazepines. The crude 30-day mortality risk from treatment initiation was 212/1,000 among patients who received benzodiazepines, while the 30-day mortality was 34/1,000 among those who did not. When follow-up was aligned on day of AIS admission and immortal time was assigned to the two groups, the estimated risks were 27/1,000 and 22/1,000, respectively. Upon further adjustment for confounders, the RD was 5 (-12 to 19) deaths/1,000 patients.

CONCLUSION

The observed higher 30-day mortality associated with benzodiazepine initiation within 7 days was largely due to bias.

Supporting safe and gradual reduction of long‐term benzodiazepine receptor agonist use: Development of the SAFEGUARDING‐BZRAs toolkit using a codesign approach

Introduction

Long‐term benzodiazepine receptor agonist (BZRA) use persists in healthcare settings worldwide and poses risks of patient harm.

Objective

This study aimed to develop an intervention to support discontinuation of long‐term BZRA use among willing individuals.

Methods

The intervention development process aligned with the UK Medical Research Council's complex intervention framework. This involved a previous systematic review of brief interventions targeting long‐term BZRA use in primary care and qualitative interviews based on the Theoretical Domains Framework that explored barriers and facilitators to discontinuing long‐term BZRA use. A codesign approach was used involving an active partnership between experts by experience, researchers and clinicians. Intervention content was specified in terms of behaviour change techniques (BCTs).

Results

The SAFEGUARDING‐BZRAs (Supporting sAFE and GradUAl ReDuctIon of loNG‐term BenZodiazepine Receptor Agonist uSe) toolkit comprises 24 BCTs and includes recommendations targeted at primary care‐based clinicians for operationalizing each BCT to support individuals with BZRA discontinuation.

Conclusion

The SAFEGUARDING‐BZRAs toolkit has been developed using a systematic and theory‐based approach that addresses identified limitations of previous research. Further research is needed to assess its usability and acceptability by service users and clinicians, as well as its potential to effectively support safe and gradual reduction of long‐term BZRA use.

Patient or Public Contribution

The qualitative interview phase included patients as participants. The codesign process included ‘experts by experience’ with either current or previous experience of long‐term BZRA use as collaborators.

Cognitive Behavioral Therapy and Acceptance and Commitment Therapy for the Discontinuation of Long-Term Benzodiazepine Use in Insomnia and Anxiety Disorders

Benzodiazepines have proven to be highly effective for treating insomnia and anxiety. Although considered safe when taken for a short period of time, a major risk–benefit dilemma arises in the context of long-term use, relating to addiction, withdrawal symptoms, and potential side effects. For these reasons, benzodiazepines are not recommended for treating chronic sleep disorders, anxiety disorders, nor for people over the age of 65, and withdrawal among long-term users is a public health issue. Indeed, only 5% of patients manage to discontinue using these drugs on their own. Even with the help of a general practitioner, this rate does not exceed 25 to 30% of patients, of which approximately 7% manage to remain drug-free in the long term. Cognitive Behavioral Therapies (CBT) offer a crucial solution to this problem, having been shown to increase abstinence success to 70–80%. This article examines traditional and novel CBT techniques in this regard, such as Acceptance and Commitment Therapy, which address both the underlying condition (insomnia/anxiety) and the substance-related disorder. The theoretical framework and evidence supporting the use of these approaches are reviewed. Finally, current research gaps are discussed, and key research perspectives are proposed.

Patterns of benzodiazepine administration and prescribing to older adults in U.S. emergency departments

OBJECTIVES

Benzodiazepine use in older adults is associated with adverse effects including delirium, mechanical falls, fractures, and memory disturbances. In this study we examine the overall utilization of benzodiazepines in the older adult population in U.S. EDs.

METHODS

Data were compiled from the National Hospital Ambulatory Medical Care Survey 2005-2015. Variables were created to identify all patients over 60 years of age who had and had not been administered benzodiazepines. Bivariate statistical tests were utilized to examine patient demographics, hospital course events and ED/hospital resource allocation and compare older adults administered (in the ED) and prescribed (from the ED) benzodiazepines to those not receiving these agents.

RESULTS

Between 2005 and 2015 approximately 280 million adults over 60 years of age were seen in EDs throughout the U.S. Overall, benzodiazepines were administered in the ED (only) during 8.5 million visits, and prescribed as a prescription (only) during over 1.3 million visits, with the rate increasing from 2.7% in 2005 to 3.5% in 2015 for benzodiazepines were administered in the ED (only). Overall 42.1% (95% CI 38.8-45.2, p < 0.001) of older adults administered benzodiazepines in the ED were subsequently admitted to the hospital. Rates of co-administration and co-prescription of opioid analgesics were high at 19.0% (95% CI 7.3-19.7) and 17.0% (95% CI 7.9-17.4) for those administered benzodiazepines in the ED, and 21.8% (95% CI 16.3-28.5) and 34.5% (95% CI 27.7-42.0) amongst those prescribed benzodiazepines at discharge. In both cases, these groups were no less likely to be administered opioids in the ED than those not receiving benzodiazepines. A total of 1.1% (95% CI 0.69-1.7, p < 0.001) of older adults administered (in the ED) benzodiazepines were diagnosed with delirium in the ED, compared to 0.0004% who were not (95% CI 0.0038-0.0052).

CONCLUSION

Despite the documented risks associated with the utilization of benzodiazepines in older adults, the rate of use in EDs continues to increase. Older adults administered benzodiazepines in the ED were more likely to be admitted to the hospital than those not receiving these agents. Despite the risks associated with co-prescription of benzodiazepines with opioids, those receiving these agents were no less likely to be administered opioids than those who did not. Older adults administered benzodiazepines in the ED were substantially more likely to be diagnosed with delirium in the ED.

Brief interventions targeting long-term benzodiazepine and Z-drug use in primary care: a systematic review and meta-analysis

AIMS

To assess the effectiveness of brief interventions in primary care aimed at reducing or discontinuing long-term benzodiazepine/Z-drug (BZRA) use.

METHOD

Systematic review of randomized controlled trials of brief interventions in primary care settings aimed at reducing or discontinuing long-term BZRA use in adults taking BZRAs for ≥ 3 months. Four electronic databases were searched: PubMed, EMBASE, PsycINFO and CENTRAL. The primary outcome was BZRA use, classified as discontinuation or reduction by ≥ 25%. The Theoretical Domains Framework (TDF) was used to retrospectively code behavioural determinants targeted by the interventions. The Behaviour Change Technique (BCT) Taxonomy was used to identify the interventions' active components. Study-specific estimates were pooled, where appropriate, to yield summary risk ratios (RRs) and 95% confidence intervals (CIs). Pearson's correlations were used to determine the relationship between intervention effect size and the results of both the TDF and BCT coding.

RESULTS

Eight studies were included (n = 2071 patients). Compared with usual care, intervention patients were more likely to have discontinued BZRA use at 6 months (eight studies, RR = 2.73, 95% CI = 1.84-4.06) and 12 months post-intervention (two studies, RR = 3.41, 95% CI = 2.22-5.25). TDF domains 'knowledge', 'memory, attention and decision processes', 'environmental context and resources' and 'social influences' were identified as having been included in every intervention. Commonly identified BCTs included 'information about health consequences', 'credible source' and 'adding objects to the environment'. There was no detectable relationship between effect size and the results of either the TDF or BCT coding.

CONCLUSION

Brief interventions delivered in primary care are more effective than usual care in reducing and discontinuing long-term benzodiazepine/Z-drug use.

Trends in the consumption rates of benzodiazepines and benzodiazepine-related drugs in the health region of Lleida from 2002 to 2015

Background

The high prevalence and long-term use of benzodiazepines (BZDs) treatment are debated topics because of the risk they can cause to the patients. Despite the current information on the risk-benefit balance of these drugs, their consumption remains particularly high. We determined the trend in the consumption prevalence of benzodiazepines (BZDs) and drugs related to BZDs (Z-drugs) in the population of the Health Region of Lleida to explore patterns of use and the associated characteristics associated between 2002 and 2015.

Methods

An analysis of secular trends was carried out between 2002 and 2015; the databased included all individuals from the Health Region of Lleida, which had 358,157 inhabitants in 2015, that consumed BZDs. The consumption of BZDs was evaluated using prescription billing data from the Public Health System. All types of BZDs and BZD analogues that had been approved by the drug agency were included. Trends by age and sex were investigated.

Results

Over the whole study period, a total of 161,125 individuals accounted for 338,148 dispensations. Overall, 59% were women, and the mean age was 56 years. The dispensing prevalence of BZDs use in 2015 was 14.2% overall —18.8% in women and 9.6% in men—and was 36% in those over 65 years. According to the half-life of BZDs, the prevalence of short-intermediate BZD use, intermediate-long BZD use, and Z-drugs use was 9.7, 5.5 and 0.8%, respectively. The evolution of the annual prevalence of BZD dispensing showed a progressive decline, from 15.3% in 2002 to 14.2% in 2015, which was attributed to a decrease in the consumption of intermediate-long half-life BZDs (8.0% vs. 5.5%) and Z-drugs (1.4% vs. 0.8%).

Conclusion

The dispensing prevalence of BZDs and Z-drugs was high, although a small reduction was observed during this time period. The dispensing prevalence was especially high in the population over 65, despite the risk of cognitive decline and falls. Integral actions are required to lower the BZD prescription rate.

The Effects of Benzodiazepine Use and Abuse on Cognition in the Elders: A Systematic Review and Meta-Analysis of Comparative Studies

OBJECTIVE

Benzodiazepines (BZD) are one of the most frequently prescribed drugs worldwide. However, the cognitive effects of benzodiazepines in the elderly are highly debated. This systematic review and meta-analysis aims to explore the following two questions in the elderly population: (i) Do BZD lead to any impairments in cognitive functions in elderly users? and (ii) Which specific cognitive domains are most affected by BZD use and abuse?

METHODS

First, we performed a literature search following the PRISMA guidelines. Electronic databases, including PubMed, PsycINFO, EMBASE, Cochrane Library, and Web of Science were searched until May 14^th, 2020. After selecting the relevant articles, we integrated the results of the selected studies with a standardized cognitive classification method. Next, we performed meta-analyses with the random-effects model on the cognitive results. Finally, we specifically examined the cognitive impairments of BZD in the abuse subgroup.

RESULTS

Of the included studies, eight of the thirteen had meta-analyzable data. Compared to the controls, elderly BZD users had significantly lower digital symbol test scores (n=253; SMD: -0.61, 95% CI: -0.91 to 0.31, I² = 0%, p < 0.0001). There was no significant difference in Mini-Mental State Examination, Auditory Verbal Learning Test, and Stroop Color and Word Test scores between BZD users and controls. According to the subgroup analyses, BZD abusers performed significantly worse than controls in Mini-Mental State Examination (n=7726; SMD: -0.23, 95% CI: -0.44 to -0.03, I² = 86%, p = 0.02), while there was no significant difference between the regular BZD users and the controls (n=1536; SMD: -0.05, 95% CI: -0.59 to 0.48, I² = 92%, p =0.85).

CONCLUSION

In the elderly population, the processing speed (digital symbol test scores) was significantly impaired in BZD users; global cognition (Mini-Mental State Examination scores) was significantly impaired in BZD abusers but not in BZD regular users. This study provides insight into the factors that interact with BZD cognitive effects, such as aging, testing tools, and abuse. Clinicians should be cautious when prescribing BZD for the elderly.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, identifier CRD42019124711.

Is the Long-Term Use of Benzodiazepines Associated With Worse Cognition Performance in Highly Educated Older Adults?

Background: Benzodiazepines (BZD) are common medications for sedative, hypnotic, and anxiolytic that are especially prevalent in older adults. Previous studies have shown that BZD use could impair users' cognition, significantly affecting their quality of life. Past research has shown that higher education might play a protective role in the process of cognitive decline. Very few studies had examined the cognitive effects of BZD on highly educated older adults. The study aimed to explore how cognitive functions would be affected by benzodiazepines among highly educated older adults. Method: 140 older adults with an average education period of 14.8 years were included in this study. The subjects were divided into three separate groups, the long-term BZD users (≥180 days), short-term BZD users (<180 days), and non-users. Demographics and cognitive assessments for the three groups were analyzed using the analysis of variance (ANOVA), the chi-squared test, and the analysis of covariance (ANCOVA). To examine the association between BZD use and cognition a multiple linear aggression approach was used. Result: All three groups were significantly different from each other when looking at executive functioning in the Trail Making Test B (TMT-B). Compared to the control group, short-term BZD users showed significant defects in TMT-B time (p = 0.002) and TMT-B errors (p < 0.001); long-term BZD users showed significant defect on TMT-B time (p = 0.041). Compared to short-term BZD users, long-term BZD users showed significant merit on TMT-B errors (p = 0.001). No significant differences were found in other cognitive tasks that reflected general cognition, verbal memory, language fluency, and visual memory. After adjusting for demographic, increased BZD use over time was positively associated with scores for the revised Brief Visuospatial Memory Test (r = 0.377, p = 0.012). Conclusion: BZD use may be significantly associated with worse executive functioning in highly educated older adults. However, there is no association between the duration of BZD use and increased cognitive deficits in highly educated older adults. This study identified future experimental directions including potential longitudinal studies, within-subject studies comparing mood disorder patients' cognitive performance before and after onset of BZD use, and between-subject studies that directly compare BZD's effect on subjects with the same baseline of cognitive functioning.

Development and Application of a Measurement Framework to Evaluate Safe, Effective and Efficient Medication Use Among Older Adults

BACKGROUND

A majority of older adults in the United States (US) use prescription medications. Comprehensive population-level approaches to examine medication safety, effectiveness, and costs among older adults are needed.

OBJECTIVES

The objectives of this study were to develop a framework of quality measures spanning the domains of safety, effectiveness, and efficiency of prescription medication use among older adults, and to apply those measures using pharmacy claims data.

METHODS

We performed a retrospective study among adults age 65 years and older of a US East Coast state who filled at least one prescription from a particular pharmacy chain during 2016 (N = 99,056). Firstly, we performed an environmental scan to identify quality measures and potentially relevant measures addressing prescription medication use. These measures were reviewed and rated by local geriatric pharmacotherapy experts. After evaluating feasibility, evidence, and relevance, a total of 19 measures representing the domains of safety (n = 7), effectiveness (n = 7), and efficiency (n = 5) were identified. These measures were then applied to an older adult population using prescription data for the year 2016 provided by a national pharmacy chain. All measures were configured such that a score of 100% corresponded to optimal performance.

RESULTS

For the domain of safety, 12.8% of patients received a benzodiazepine chronically, 23.6% received central nervous system depressants, 16.7% received fluoroquinolones as first-line antibiotic therapy, and 21.9% of those who were prescribed opioids received them in excessive quantities. For the domain of effectiveness, one-fourth of the diabetes patients did not receive statins and angiotensin-acting medications, while 18.0% were not adherent to oral anticoagulant medications and 54% were not adherent to respiratory inhalers. For the domain of efficiency, 12.0% of the patients received prescriptions from five or more unique prescribers. Overall, 85.7%, 76.1%, and 87.9% of the older adults showed safe, effective, and efficient prescription medication use, respectively.

CONCLUSION

A novel approach to comprehensively examine the quality of medication use among older adults using prescription claims data is provided in our study. A considerable proportion of the older adults in our study received safe, effective, and efficient prescription medications. However, within each domain, several opportunities for improving the alignment of prescription medication use with current recommendations were identified.

Factors associated with the use of potentially inappropriate medication by elderly patients prescribed at hospital discharge

Objective

To analyze the frequency of use of potentially inappropriate medication prescribed to elderly at hospital discharge from a public hospital, considering the Brazilian Consensus on Potentially Inappropriate Medication for Elderly, and to identify the associated factors.

Methods

Patients aged ≥60 years, admitted in clinical and geriatric units of a public hospital were invited to participate in the study. The information about the use of medicines was collected from the patient’s electronic record and through telephone contact. The Brazilian Consensus on Potentially Inappropriate Medication for Elderly was used to classify the medication, regardless of the clinical condition.

Results

A total of 255 elders were included in this study. The frequency of use of potentially inappropriate medication by elderly was 58.4%. The potentially inappropriate medication use in elderly was positively associated with the presence of depression (odds ratio of 2.208) and polypharmacy (odds ratio of 2.495). The hospitalization in a geriatric unit showed an inverse association with the potentially inappropriate medication use in elderly (odds ratio of 0.513).

Conclusion

The frequency of potentially inappropriate medication prescription to elderly upon hospital discharge was high. The presence of depression and polypharmacy were directly associated with use of potentially inappropriate medication in the elderly. Admission to the geriatric clinic has become a protection factor for the use of potentially inappropriate medication in elderly. Strategies to improve the elderly pharmacotherapy should implemented aiming at healthcare quality and safety in the transition of care.

History of Benzodiazepine Prescriptions and Risk of Dementia: Possible Bias Due to Prevalent Users and Covariate Measurement Timing in a Nested Case-Control Study

Previous estimates of whether long-term exposure to benzodiazepines increases dementia risk are conflicting and are compromised by the difficulty of controlling for confounders and by reverse causation. We investigated how estimates for the association between benzodiazepine use and later dementia incidence varied based on study design choices, using a case-control study nested within the United Kingdom's Clinical Practice Research Datalink. A total of 40,770 dementia cases diagnosed between April 2006 and July 2015 were matched on age, sex, available data history, and deprivation to 283,933 control subjects. Benzodiazepines and Z-drug prescriptions were ascertained in a drug-exposure period 4-20 years before dementia diagnosis. Estimates varied with the inclusion of new or prevalent users, with the timing of covariate ascertainment, and with varying time between exposure and outcome. There was no association between any new prescription of benzodiazepines and dementia (adjusted odds ratio (OR) = 1.03, 95% confidence interval (CI): 1.00, 1.07), whereas an inverse association was observed among prevalent users (adjusted OR = 0.91, 95% CI: 0.87, 0.95), although this was likely induced by unintentional adjustment for colliders. By considering the choice of confounders and timing of exposure and covariate measurement, our findings overall are consistent with no causal effect of benzodiazepines or Z-drugs on dementia incidence.

Patterns in Outpatient Benzodiazepine Prescribing in the United States

IMPORTANCE

Benzodiazepines are implicated in a growing number of overdose-related deaths.

OBJECTIVES

To quantify patterns in outpatient benzodiazepine prescribing and to compare them across specialties and indications.

DESIGN, SETTING, AND PARTICIPANTS

This serial cross-sectional study (January 1, 2003, through December 31, 2015) used nationally representative National Ambulatory Medical Care Survey data. The yearly population-based sample of outpatient visits among adults, ranging from 20 884 visits in 2003 (representing 737 million visits) to 24 273 visits in 2015 (representing 841 million visits) was analyzed. Prescribing patterns were examined by specialty and indication and used to calculate the annual coprescribing rate of benzodiazepines with other sedating medications. Data were analyzed from July 1, 2017, through November 30, 2018.

MAIN OUTCOMES AND MEASURES

Annual benzodiazepine visit rate.

RESULTS

Among the 386 457 ambulatory care visits from 2003 through 2015, a total of 919 benzodiazepine visits occurred in 2003 and 1672 in 2015, nationally representing 27.6 million and 62.6 million visits, respectively. The benzodiazepine visit rate doubled from 3.8% (95% CI, 3.2%-4.4%) to 7.4% (95% CI, 6.4%-8.6%; P < .001) of visits. Visits to primary care physicians accounted for approximately half of all benzodiazepine visits (52.3% [95% CI, 50.0%-54.6%]). The benzodiazepine visit rate did not change among visits to psychiatrists (29.6% [95% CI, 23.3%-36.7%] in 2003 to 30.2% [95% CI, 25.6%-35.2%] in 2015; P = .90), but increased among all other physicians, including primary care physicians (3.6% [95% CI, 2.9%-4.4%] to 7.5% [95% CI, 6.0%-9.5%]; P < .001). The benzodiazepine visit rate increased slightly for anxiety and depression (26.6% [95% CI, 22.6%-31.0%] to 33.5% [95% CI, 28.8%-38.6%]; P = .003) and neurologic conditions (6.8% [95% CI, 4.8%-9.5%] to 8.7% [95% CI, 6.2%-12.1%]; P < .001), but more so for back and/or chronic pain (3.6% [95% CI, 2.6%-4.9%] to 8.5% [95% CI, 6.0%-11.9%]; P < .001) and other conditions (1.8% [95% CI, 1.4%-2.2%] to 4.4% [95% CI, 3.7%-5.2%]; P < .001); use did not change for insomnia (26.9% [95% CI, 19.3%-36.0%] to 25.6% [95% CI, 15.3%-39.6%]; P = .72). The coprescribing rate of benzodiazepines with opioids quadrupled from 0.5% (95% CI, 0.3%-0.7%) in 2003 to 2.0% (95% CI, 1.4%-2.7%) in 2015 (P < .001); the coprescribing rate with other sedating medications doubled from 0.7% (95% CI, 0.5%-0.9%) to 1.5% (95% CI, 1.1%-1.9%) (P < .001).

CONCLUSIONS AND RELEVANCE

The outpatient use of benzodiazepines has increased substantially. In light of increasing rates of overdose deaths involving benzodiazepines, understanding and addressing prescribing patterns may help curb the growing use of benzodiazepines.

The prevalence of benzodiazepines utilization and its association with falls among Saudi older adults; results from the Saudi national survey for elderly Health (SNSEH)

PURPOSE

First, to determine benzodiazepines prevalence (BDZs) among Saudi older adults (SOA); Second, to quantify the association between BDZs use and falls among SOA. Third, to determine falls effect on all-cause mortality among SOA.

METHODS

This is a cross-sectional study that used the Saudi National Survey for Elderly Health; a nationally-representative, population-based survey. Participants were asked about BDZs use and falls history during the 12 months prior to the interview. Demographics, medications, comorbidities and housing conditions were used as covariates. Multiple imputation was used to impute missing data. Modified poisson multivariable regression was used to study the association between BDZs and falls. Cox- proportional hazard regression was used to determine falls effect on mortality over nine years period.

RESULTS

Among 2946 SOA, BDZs prevalence was 4%. Around 13% reported falls. In the multivariable regression, relative risk (RR) of falls was 2 comparing BDZs users to non-users (95CI%: 1.02-3.99). Antidepressants (RR = 1.72; 95%CI: 1.10-2.74), laxatives (RR = 1.38; 95%CI: 1.11-1.7), low body mass index (RR = 1.94; 95%CI: 1.33-2.84), mild cognitive impairment (RR = 1.56; 95%CI: 1.21-2.03), high door steps (RR = 1.54; 95%CI: 1.23-1.93) and insufficient illumination (RR = 1.38; 95%CI: 1.11-1.71) increased falls risk. Lastly, the hazard ratio of falls on death was 1.48 (95%CI: 1.17, 1.89) over nine years.

CONCLUSION

Despite the recommendation against BDZs use among older adults, still there were subjects who were prescribed these drugs. falls are common among SOA. Preventive strategies such medication therapy management, nutrition improvement, elderly-friendly housing structures can reduce the prevalence of falls and consequent increase in mortality among SOA.

Behavioral Health Needs of Older Adults in the Emergency Department

Behavioral health disorders are common among older adults and, owing to limited access to resources for mental health care in the community, emergency department providers are often on the front lines of mental health crises. This article reviews the available literature regarding the care of behavioral health emergencies in older adults and provides a framework for navigating the evaluation and management of older adults presenting to the emergency department with behavioral health concerns.

Trends in Ambulatory Management of Urinary Incontinence in Women in the United States

OBJECTIVES

Urinary incontinence (UI) is a common condition, but despite the availability of guidelines, variations exist in the care of patients. We sought to assess the changes in assessment and management of women with UI over time in the United States.

METHODS

The National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey are annual surveys from a nationally representative sample of visits to physicians. From 1999 through 2010, we identified visits by women to physicians where the chief complaint was UI using reason-for-visit and International Classification of Diseases, Ninth Revision codes.

RESULTS

Using 2-year intervals between 1999-2000 and 2009-2010, the number of visits by women with UI to physicians increased (5.3 million to 6.8 million). There was no difference in patient age, race/ethnicity, or physician specialty (primary care, urology, gynecology). The majority did not have their incontinence characterized (42.4%-47.4%). The use of urinalysis significantly decreased (53%-37.2%, P = 0.02), whereas antimuscarinic use significantly increased (16.7%-35%, P = 0.006). There was an overall increased trend in number of referrals to another physician (5.8%-14.7%, P = 0.06). Urologists had a significant increase in antimuscarinic use (23.5%-44.2%, P = 0.003). All physician specialties demonstrated a decreased trend in use of urinalysis between 1999 and 2010. Although imaging rates were low, they were at highest rates among urologists.

CONCLUSIONS

The majority of women do not have the type of UI characterized, whereas there is underutilization of urinalysis. Given the widespread prevalence of UI and its implications on quality of life, greater adherence to guidelines is warranted.

Benzodiazepine and Z-drug prescribing in Ireland: analysis of national prescribing trends from 2005 to 2015

AIMS

The aim of this study was to examine prescribing trends for benzodiazepines and Z-drugs to General Medical Services (GMS) patients in Ireland.

METHODS

A repeated cross-sectional analysis of the national pharmacy claims database was conducted for GMS patients aged ≥16 years from 2005 to 2015. Prescribing rates per 1000 eligible GMS population were calculated with 95% confidence intervals (CIs). Negative binomial regression was used to determine longitudinal trends and compare prescribing rates across years, gender and age groups. Duration of supply and rates of concomitant benzodiazepine and Z-drug prescribing were determined. Age (16-44, 45-64, ≥65 years) and gender trends were investigated.

RESULTS

Benzodiazepine prescribing rates decreased significantly from 225.92/1000 population (95% CI 224.94-226.89) in 2005 to 166.07/1000 population (95% CI 165.38-166.75) in 2015 (P < 0.0001). Z-drug prescribing rates increased significantly from 95.36/1000 population (95% CI 94.73-96.00) in 2005 to 109.11/1000 population (95% CI 108.56-109.67) in 2015 (P = 0.048). Approximately one-third of individuals dispensed either benzodiazepines or Z-drugs were receiving long-term prescriptions (>90 days). The proportion of those receiving >1 benzodiazepine and/or Z-drug concomitantly increased from 11.9% in 2005 to 15.3% in 2015. Benzodiazepine and Z-drug prescribing rates were highest for older women (≥65 years) throughout the study period.

CONCLUSIONS

Benzodiazepine prescribing to the GMS population in Ireland decreased significantly from 2005 to 2015, and was coupled with significant increases in Z-drug prescribing. The study shows that benzodiazepine and Z-drug prescribing is common in this population, with high proportions of individuals receiving long-term prescriptions. Targeted interventions are needed to reduce potentially inappropriate long-term prescribing and use of these medications in Ireland.

The Effect of Computerized Physician Order Entry Template Modifications on the Administration of High-Risk Medications in Older Adults in the Emergency Department

BACKGROUND

Older adults are more susceptible to adverse events when administered certain medications at doses appropriate for younger adults.

OBJECTIVE

The aim of this study was to investigate the effect of default geriatric dosing on computerized physician order entry (CPOE) templates on the subsequent administration of recommended starting doses of opioids, benzodiazepines (BZDs) and non-steroidal anti-inflammatory drugs (NSAIDs) to older adults in the emergency department (ED).

METHODS

This was a before-after comparison of the frequency of the recommended starting doses of high-risk medications to adults aged 65 years and older. Computerized records were queried for the administration of the above medication classes in two academic EDs over two similar 4-month periods in 2015 and 2016. Between study periods, the doses of high-risk medications on ED CPOE templates were adjusted for older adults based on established pharmacy guidelines and expert consensus.

RESULTS

There was a significant improvement in the rate of recommended dose administration of all medications of interest (27.3 vs. 32.5%, p < 0.001). Not surprisingly, the medications that were maximally impacted were also those most frequently prescribed, with a significant increase in the recommended dosing of opioids (29.0 vs. 35.2%, p < 0.001) accounting for the majority of the change. Although there were no differences in BZDs as a group, there were significant differences in selected BZDs such as midazolam and diazepam. Changes in the recommended dosing of NSAIDs could not be determined due to low numbers of administered doses in both phases of the study.

CONCLUSION

Simple changes in the CPOE template resulted in increased administration of the recommended starting doses of high-risk medications to older adults in the ED.

Sociodemographic Influences of Emergency Department Care for Anxiety Disorders

This study examines variations in content of care for anxiety-related emergency department (ED) visits in the USA across various sociodemographic strata. The 2009-2012 National Hospital Ambulatory Medical Care Survey was used to identify all visits to general hospital EDs in which an anxiety diagnosis was recorded (n = 1930). Content and equitability of care was assessed utilizing logistic regression models. There were an estimated 1,856,000 ED visits with anxiety-related discharge diagnoses in the USA annually. Content of care and disposition varied by age, race/ethnicity, and insurance status. Visits by Medicaid patients were more likely than visits by privately insured patients to include a toxicology screen (OR = 1.67, p < .05) and visits by patients with either Medicaid or Medicare were less likely to include an EKG (OR = 0.53, p < .05 and OR = 0.52, p < .05, respectively). Understanding variations in ED care for anxiety can identify opportunities for intervention, both in the ED and upstream in appropriate healthcare settings.

Suicidal drug overdose following stroke in elderly patients: a retrospective population-based cohort study

PURPOSE

The purpose of this study was to investigate the incidence and risk of suicidal drug overdose (SDO) after stroke in older patients.

METHODS

We enrolled patients aged 60-99 years who were diagnosed with new-onset stroke between 2002 and 2013 and age-, sex-, and index-year-matched controls who did not have stroke. Patients with a history of SDO before enrollment were excluded. Both groups were observed until December 31, 2013. The primary end point was the occurrence of newly diagnosed SDO. The cumulative incidence rates of the study and control groups were estimated using the Kaplan-Meier method. Furthermore, we used the Cox proportional hazards model to identify risk factors for SDO.

RESULTS

We selected 22,770 individuals. Among them, 11,385 were older patients (aged 60-99 years) who had newly diagnosed stroke and 11,385 were controls. Of the 22,770 individuals, 275 (1.21%) had SDO during a mean follow-up period of 5.33±3.30 years, comprising 191 (1.68%) from the stroke group and 84 (0.74%) from the control group. Older patients with stroke had a significantly higher risk of SDO than the controls (adjusted hazard ratio: 2.288, 95% confidence interval [CI]: 1.746-2.999, p<0.001). Moreover, in older patients with stroke, the risk significantly increased with the number of stroke events. Patients with depressive disorder or coronary disease had an increased risk of SDO. Additionally, benzodiazepines and anticoagulants were the two most commonly prescribed medications for SDO.

CONCLUSION

Clinicians should be aware of the risk of SDO and risk factors in older patients with stroke. Psychological assessment and medication monitoring should be incorporated into current clinical diagnoses in neurology and treatments following stroke.

Regular Benzodiazepine and Z-Substance Use and Risk of Dementia: An Analysis of German Claims Data

BACKGROUND

While acute detrimental effects of benzodiazepine (BDZ), and BDZ and related z-substance (BDZR) use on cognition and memory are known, the association of BDZR use and risk of dementia in the elderly is controversially discussed. Previous studies on cohort or claims data mostly show an increased risk for dementia with the use of BDZs or BDZRs. For Germany, analyses on large population-based data sets are missing.

OBJECTIVE

To evaluate the association between regular BDZR use and incident any dementia in a large German claims data set.

METHODS

Using longitudinal German public health insurance data from 2004 to 2011 we analyzed the association between regular BDZR use (versus no BDZR use) and incident dementia in a case-control design. We examined patient samples aged≥60 years that were free of dementia at baseline. To address potential protopathic bias we introduced a lag time between BDZR prescription and dementia diagnosis. Odds ratios were calculated applying conditional logistic regression, adjusted for potential confounding factors such as comorbidities and polypharmacy.

RESULTS

The regular use of BDZRs was associated with a significant increased risk of incident dementia for patients aged≥60 years (adjusted odds ratio [OR] 1.21, 95% confidence interval [CI] 1.13-1.29). The association was slightly stronger for long-acting substances than for short-acting ones. A trend for increased risk for dementia with higher exposure was observed.

CONCLUSION

The restricted use of BDZRs may contribute to dementia prevention in the elderly.

Gender Differences in Pain Experience and Treatment after Motor Vehicle Collisions: A Secondary Analysis of the CRASH Injury Study

PURPOSE

Little is known about gender differences in the treatment of pain after motor vehicle collisions (MVCs) in an emergency department (ED). We aimed to describe gender differences in pain experiences and treatment, specifically the use of opioids and benzodiazepines after ED discharge, for MVC-related pain.

METHODS

This was a secondary analysis of previously collected data from the CRASH Injury studies. We included patients who were seen and discharged from an ED after an MVC and who were enrolled in 1 of 2 multicenter longitudinal prospective cohort studies (1 black/non-Hispanic and 1 white/non-Hispanic). First, we compared the experience of pain as defined by self-reported moderate-to-severe axial pain, widespread pain, number of somatic symptoms, pain catastrophizing, and peritraumatic distress between women and men using bivariate analyses. We then determined whether there were gender differences in the receipt of prescription medications for post-MVC pain symptoms (opioids and benzodiazepines) using multivariate logistic regression adjusting for demographic characteristics, pain, and collision characteristics.

FINDINGS

In total, 1878 patients were included: 61.4% were women. More women reported severe symptoms on the pain catastrophizing scale (36.8% vs 31.0%; P = 0.032) and peritraumatic distress following the MVC (59.7% vs 42.5%; P < 0.001), and women reported more somatic symptoms than men (median, 3.9; interquartile range, 3.7-4.0 vs median, 3.3; interquartile range, 3.1-3.5; P < 0.001). Unadjusted, similar proportions of women and men were given opioids (29.2% vs 29.7%; P = 0.84). After adjusting for covariates, women and men remained equally likely to receive a prescription for opioids (relative risk = 0.83; 95% confidence interval, 0.58-1.19). Women were less likely than men to receive a benzodiazepine at discharge from an ED (relative risk = 0.53; 95% confidence interval, 0.32-0.88).

IMPLICATIONS

In a large, multicenter study of ED patients treated for MVC, there were gender differences in the acute psychological response to MVC with women reporting more psychological and somatic symptoms. Women and men were equally likely to receive opioid prescriptions at discharge. Future research should investigate potential gender-specific interventions to reduce both posttraumatic distress and the risk of developing negative long-term outcomes like chronic pain.

Older adults and high-risk medication administration in the emergency department

BACKGROUND

Older adults are susceptible to adverse effects from opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and benzodiazepines (BZDs). We investigated factors associated with the administration of elevated doses of these medications of interest to older adults (≥65 years old) in the emergency department (ED).

PATIENTS AND METHODS

ED records were queried for the administration of medications of interest to older adults at two academic medical center EDs over a 6-month period. Frequency of recommended versus elevated ("High doses" were defined as doses that ranged between 1.5 and 3 times higher than the recommended starting doses; "very high doses" were defined as higher than high doses) starting doses of medications, as determined by geriatric pharmacy/medicine guidelines and expert consensus, was compared by age groups (65-69, 70-74, 75-79, 80-84, and ≥85 years), gender, and hospital.

RESULTS

There were 17896 visits representing 11374 unique patients >65 years of age (55.3% men, 44.7% women). A total of 3394 doses of medications of interest including 1678 high doses and 684 very high doses were administered to 1364 different patients. Administration of elevated doses of medications was more common than that of recommended doses. Focusing on opioids and BZDs, the 65-69-year age group was much more likely to receive very high doses (1481 and 412 doses, respectively) than the ≥85-year age groups (relative risk [RR] 5.52, 95% CI 2.56-11.90), mainly reflecting elevated opioid dosing (RR 8.28, 95% CI 3.69-18.57). Men were more likely than women to receive very high doses (RR 1.47, 95% CI 1.26-1.72), primarily due to BZDs (RR 2.12, 95% CI 2.07-2.16).

CONCLUSION

Administration of elevated doses of opioids and BZDs in the older population occurs frequently in the ED, especially to the 65-69-year age group and men. Further attention to potentially unsafe dosing of high-risk medications to older adults in the ED is warranted.

National Trends in Antidepressant, Benzodiazepine, and Other Sedative-Hypnotic Treatment of Older Adults in Psychiatric and Primary Care

OBJECTIVE

To describe how use of antidepressants, benzodiazepines, and other anxiolytic/sedative-hypnotics among older adults (age ≥ 65 years) has changed over time among visits to primary care providers and psychiatrists.

METHODS

Data were from the National Ambulatory Medical Care Survey (years 2003-2005 and 2010-2012), a nationally representative cross-section of outpatient physician visits. Analysis focused on visits to primary care providers (n = 14,282) and psychiatrists (n = 1,095) at which an antidepressant, benzodiazepine, or other anxiolytic/sedative-hypnotic was prescribed, which were stratified by demographic and clinical characteristic (including ICD-9-CM diagnosis) and compared across study intervals. Odds of medication use were calculated for each stratum, adjusting for demographic and clinical characteristics.

RESULTS

The visit rate by older adults to primary care providers where any of the medications were prescribed rose from 16.4% to 21.8% (adjusted odds ratio [AOR] = 1.43, P < .001) while remaining steady among psychiatrists (75.4% vs 68.5%; AOR = 0.69, P = .11). Primary care visits rose for antidepressants (9.9% to 12.3%; AOR = 1.28, P = .01) and other anxiolytic/sedative-hypnotics (3.4% to 4.7%; AOR = 1.39, P = .01), but the largest growth was among benzodiazepines (5.6% to 8.7%; AOR = 1.62, P < .001). Among patients in primary care, increases primarily occurred among men, non-Hispanic white patients, and those with pain diagnoses as well as those with no mental health or pain diagnoses.

CONCLUSIONS

From 2003 to 2012, use of the most common psychotropic medications among older adults seen in primary care increased, with concentration among patients with no mental health or pain diagnosis. As the population of older adults grows and receives mental health treatment in primary care, it is critical to examine the appropriateness of psychotropic use.

Benzodiazepine Use in Older Adults: Dangers, Management, and Alternative Therapies

Several major medical and psychiatric organizations, including the American Geriatrics Society, advise against using benzodiazepines or nonbenzodiazepine hypnotics in older adults. Despite these recommendations, benzodiazepines continue to be massively prescribed to a group with the highest risk of serious adverse effects from these medications. This article summarizes legitimate reasons for prescribing benzodiazepines in the elderly, serious associated risks of prescribing them, particularly when not indicated, barriers physicians encounter in changing their prescription patterns, and evidence-based strategies on how to discontinue benzodiazepines in older patients. Although more research is needed, we propose several alternatives for treating insomnia and anxiety in older adults in primary care settings. These include nonpharmacological approaches such as sleep restriction-sleep compression therapy and cognitive behavioral therapy for anxiety or insomnia, and as well as alternative pharmacological agents.

Differences in Benzodiazepine Receptor Agonist Use in Rural and Urban Older Adults

BACKGROUND

Older adults are especially susceptible to adverse consequences of potentially inappropriate medications (PIMs), such as benzodiazepine receptor agonists (BZDRAs), due to age-related pharmacokinetic and pharmacodynamic changes. Although some risk factors for BZDRA use in older adults have been identified, the role of rural versus urban residence is less clear.

OBJECTIVE

To describe BZDRA use in rural versus urban older adults using pharmaceutical claims from Pennsylvania's Pharmaceutical Assistance Contract for the Elderly (PACE) program.

METHODS

The sample consisted of older adults enrolled in Pennsylvania's Healthy Steps for Older Adults and participated in Pennsylvania's PACE program. Independent sample t tests and contingency tables were used to examine residence differences. Multivariate binary logistic modeling was performed.

RESULTS

The total sample (N = 426) was 305 (71.6 %) urban-dwelling adults and 121 (28.4 %) rural-dwelling adults. Rural participants were more likely to be male, white, married, and have less than a high school education compared with urban participants (p <.01). Specifically, 25 % of rural-dwelling adults received a BZDRA compared with 15 % of urban-dwelling adults (p = 0.02). Three variables reached statistical significance for predicting BZDRA use in a multivariate model: rural residence (OR 2.58, 95 % CI 1.39-4.79), history of anxiety/depression (OR 4.20, 95 % CI 2.39-7.46), and number of medications (OR 1.11, 95 % CI 1.02-1.21).

CONCLUSIONS

BZDRA prescription differences in older, rural-dwelling adults further highlights the need for geriatric and mental health specialists to provide specialized care to this population. Rural healthcare professionals may be less aware of PIMs for older adults, and initiatives to support geriatric services and provide education for existing providers may be beneficial.

Discontinuing benzodiazepines: best practices

In July 2015, the Canadian Agency for Drugs and Technologies in Health (CADTH) released a Rapid Response report summary, with a critical appraisal, on discontinuation strategies for patients with long-term benzodiazepines (BDZ) use. The CADTH document is a review of the literature. It includes studies whose intervention is BDZ discontinuation. Also, clinical guidelines, systematic reviews and meta-analyses are included. What emerges from the CADTH guidelines is that the best strategy remains gradual tapering of BDZ with little evidence for the use of adjunctive medications. The results show that simple interventions such as discontinuation letters from clinicians, self-help information and support in general, added to gradual tapering may be associated with a two- to three-fold higher chance of successful withdrawal, compared with treatment as usual. We suggest possible implications for day-to-day clinical practice.

[Depression, anxiety, stress, and mortality]

The analytical paper summarizes the main results of recent investigations of the relationships of depression, anxiety, and stress with overall and cardiovascular mortality. It shows that depression and stress are associated with an increased risk of death mainly from cardiovascular diseases, and depression treatment and stress control can increase life expectancy.