Association between risk factors for injurious falls and new benzodiazepine prescribing in elderly persons

Prescription of benzodiazepines and Z-drugs among older patients in primary care: a French, national, cohort study

BACKGROUND

In France, general practitioners (GPs) prescribe benzodiazepines and Z-drugs (BZD/ZDs) widely, and especially to older adults. Several characteristics of patients and/or GPs linked to BZD/ZD overprescription have been described in the general population but not among older patients in primary care.

OBJECTIVES

To estimate the proportion of GP consultations by patients aged 65 and over that resulted in a BZD/ZD prescription, and determine whether any GP-related factors predicted BZD/ZD overprescription in this setting.

METHODS

We analyzed sociodemographic and practice-related GP characteristics, and aggregated data on consultations recorded prospectively by 117 GPs in a database between 2000 and 2010. Next, we used logistic regression models to look for factors potentially associated with BZD/ZD overprescription (defined as an above-median prescription rate).

RESULTS

The GPs' mean age at inclusion was 47.4 (7.1), and 87.9% were male. During the study period, the median (95% confidence interval) proportion of consultations with patients aged 65 and over resulting in a BZD/ZD prescription was 21.8% (18.1-26.1) (range per GP: 5-34.1%). In a multivariable analysis, a greater number of chronic disease (OR [95% CI] = 2.10 [1.22-3.64]), a greater number of drugs prescribed per consultation (5.29 [2.72-10.28]), and shorter study participation were independently associated with BZD/ZD overprescription.

CONCLUSIONS

BZD/ZD overprescription was associated with a greater chronic disease burden and the number of drugs prescribed per consultation but not with any sociodemographic or practice-related GP characteristics. Targeted actions are needed to help GPs limit their prescription of BZD/ZDs to older patients with multiple comorbidities and polypharmacy.

The Impact of an Educational Intervention on Enhancing Clinical Knowledge of Physicians and Pharmacists Regarding Statins and Monitoring Parameters: The Experience of a Tertiary Teaching Hospital

Introduction

Understanding the latest guideline recommendations is crucial for healthcare professionals to apply statin therapy effectively. Thus, the purpose of this study was to evaluate the efficacy of an educational intervention in enhancing the awareness and understanding of physicians and pharmacists concerning risk assessment of Atherosclerotic cardiovascular disease (ASCVD) and the role of statin therapy.

Methods

This pre- and post-intervention study was conducted in Sana'a, Yemen's capital city, at the University of Science and Technology Hospital. The study was done between 11/2021-12/2021, and two separate educational sessions were ‎held. The McNemar's test and Wilcoxon signed-rank test were employed as necessary.

Results

Participants' awareness of the Framingham CVD risk calculator improved significantly from 40.4% pre-intervention to 78.7% post-intervention. Similarly, understanding of the parameters used in the 10-year ASCVD Risk calculator rose from 46.8% pre-intervention to 76.6% post-intervention. The ability to identify high, moderate, and low-intensity statin therapy, for instance, increased from 34% to 63.8% post-intervention. Regarding statins' contraindications, safety, and efficacy monitoring parameters, pre-intervention knowledge was unsatisfactory, and the educational intervention improved it significantly (p <0.05). For physicians, the median ASCVD risk assessment knowledge score was significantly improved from ‎‎4 (IQR = 3-5) pre-intervention to 7 (6.25-8) immediately post-intervention, while the statin therapy clinical knowledge median score ‎significantly improved from 3 (1.25-6.5) to 9 (7.25-14.75) post-education intervention, p-values were 0.002 and 0.003; respectively. For pharmacists, a similar significant improvement (p <0.05) in the overall knowledge scores for both ASCVD risk ‎assessment and statin therapy was noted.

Conclusion

The educational intervention improved participants' knowledge of statin therapy and ASCVD risk assessment. Therefore, further education lectures and training programs through continuing ‎medical ‎education on the up-to-date guidelines' recommendations should be regularly implemented to raise ‎awareness and improve ‎the clinical knowledge and appropriateness of statins use in clinical settings.‎.

The effectiveness of exercise interventions targeting sleep in older adults with cognitive impairment or Alzheimer's disease and related dementias (AD/ADRD): A systematic review and meta-analysis

Sleep loss is associated with reduced health and quality of life, and increased risk of Alzheimer's disease and related dementias. Up to 66% of persons with Alzheimer's disease and related dementias experience poor sleep, which can predict or accelerate the progression of cognitive decline. Exercise is a widely accessible intervention for poor sleep that can protect against functional and cognitive decline. No previous systematic reviews have investigated the effectiveness of exercise for sleep in older adults with mild cognitive impairment or Alzheimer's disease and related dementias. We systematically reviewed controlled interventional studies of exercise targeting subjectively or objectively (polysomnography/actigraphy) assessed sleep in persons with mild cognitive impairment or Alzheimer's disease and related dementias. We conducted searches in PubMed, Embase, Scopus and Cochrane-Library (n = 6745). Nineteen randomised and one non-randomised controlled interventional trials were included, representing the experiences of 3278 persons with mild cognitive impairment or Alzheimer's disease and related dementias. Ten had low-risk, nine moderate-risk, and one high-risk of bias. Six studies with subjective and eight with objective sleep outcomes were meta-analysed (random-effects model). We found moderate- to high-quality evidence for the beneficial effects of exercise on self-reported and objectively-measured sleep outcomes in persons with mild cognitive impairment or Alzheimer's disease and related dementias. However, no studies examined key potential moderators of these effects, such as sex, napping or medication use. Our results have important implications for clinical practice. Sleep may be one of the most important modifiable risk factors for a range of health conditions, including cognitive decline and the progression of Alzheimer's disease and related dementias. Given our findings, clinicians may consider adding exercise as an effective intervention or adjuvant strategy for improving sleep in older persons with mild cognitive impairment or Alzheimer's disease and related dementias.

Hermeneutic Phenomenological Approach to the Experiences of the Individuals Living with Schizophrenia: A Qualitative Study

Background

Schizophrenia affects various spheres of life causing so many difficulties and burden, but the studies focusing on the experience of individuals living with schizophrenia with reference to the Tamil Nadu context are sparse.

Material and Methods

A qualitative interview based on a hermeneutic phenomenological approach was conducted with 10 individuals living with Schizophrenia and was recorded. The responses were transcribed and coded. Based on codes, domains and subdomains were identified.

Results

Six themes were identified, under which the participant's burden was described. Participants expressed a deep longing for love and care. They were deprived of family's affection. Participants felt economically insecured, which was owing to their unemployment. Participants had many physical complaints including sleep disturbance and fatigue. Participants expressed that they had failing memory, concentration issues, and difficulty in planning. Most of the participants felt isolated by family and kin. They did not participate in much social activities due to the fear of judgment and stigmatization.

Conclusion

The experience of individuals living with Schizophrenia revealed that they experienced a series of burdens owing to their illness and its impacts that were categorized into various themes including physical, vocational, cognitive, psychological, personal, and social factors.

Psychotropic medication use and future unexplained and injurious falls and fracture amongst community-dwelling older people: data from TILDA

PURPOSE

Psychotropic medications (antidepressants, anticholinergics, benzodiazepines, 'Z'-drugs and antipsychotics) are frequently identified as Falls Risk Increasing Drugs. The aim of this study is to clarify the association of psychotropic medication use with future falls/fracture amongst community-dwelling older people.

METHODS

Participants ≥ 65 years from TILDA were included and followed from Waves 1 to 5 (8-year follow-up). Incidence of falls (total falls/unexplained/injurious) and fracture was by self-report; unexplained falls were falls not caused by a slip/trip, with no apparent cause. Poisson regression models reporting incidence rate ratios (IRR) assessed the association between medications and future falls/fracture, adjusted for relevant covariates.

RESULTS

Of 2809 participants (mean age 73 years), 15% were taking ≥ 1 psychotropic medication. During follow-up, over half of participants fell, with 1/3 reporting injurious falls, over 1/5 reporting unexplained falls and almost 1/5 reporting fracture. Psychotropic medications were independently associated with falls [IRR 1.15 (95% CI 1.00-1.31)] and unexplained falls [IRR 1.46 (95% CI 1.20-1.78)]. Taking ≥ 2 psychotropic medications was further associated with future fracture (IRR 1.47 (95% CI 1.06-2.05)]. Antidepressants were independently associated with falls [IRR 1.20 (1.00-1.42)] and unexplained falls [IRR 2.12 (95% CI 1.69-2.65)]. Anticholinergics were associated with unexplained falls [IRR 1.53 (95% CI 1.14-2.05)]. 'Z'-drug and benzodiazepine use were not associated with falls or fractures.

CONCLUSION

Psychotropic medications, particularly antidepressants and anticholinergic medications, are independently associated with falls and fractures. Regular review of ongoing need for these medications should therefore be central to the comprehensive geriatric assessment.

The Safety and Efficacy of Psychedelic-Assisted Therapies for Older Adults: Knowns and Unknowns

Psychedelics and related compounds have shown efficacy for the treatment of a variety of conditions that are prevalent among older adults, including mood disorders, the psychological distress associated with a serious medical illness, post-traumatic stress disorder (PTSD), and prolonged grief disorder. Psychedelics also have properties that could help provide therapeutic benefits for patients with dementing disorders, as well as promoting personal growth among healthy older adults. This article focuses on psilocybin, a classic psychedelic, and MDMA, a substituted amphetamine with properties similar to classic psychedelics. Both act on the 5HT_2A receptor. Psychedelics can be safely administered to healthy adults in controlled conditions. However, both psilocybin and MDMA can increase blood pressure and heart rate, which could be a concern if used in older adults with cardiovascular disease. Very few older adults or patients with serious comorbidities have been included in clinical trials of psychedelics to date, raising the question of how generalizable study results are for the patients that most geropsychiatrists will be treating. Research on the neurophysiologic and mechanistic effects of psychedelics in older adults could also provide insights into the aging brain that could have clinical applications in the future. Given the potential of psychedelic compounds to benefit older adults, more research is needed to establish safety and efficacy among older adults, particularly those with multi-morbidity.

GPs' views on the implementation of combined lifestyle interventions in primary care in the Netherlands: a qualitative study

OBJECTIVES

Prevention and lifestyle support are emerging topics in general practice. Healthcare insurance companies reimburse combined lifestyle interventions (CLIs) in the Netherlands since January 2019. CLIs support people with overweight (body mass index, BMI 25-30) or obesity (BMI >30) to reduce weight in peer groups. General practitioners (GPs) are key in the successful implementation of lifestyle interventions in primary care. This study explored GPs' experiences and views on the implementation of CLIs to identify barriers and facilitators to the successful implementation in primary care.

DESIGN

Qualitative study using semistructured interviews. Content analysis consisted of thematic coding and mapping a first stage of predefined and second stage of iterative evolving set of themes.

SETTING

GPs were interviewed in a variety of primary care practices between February and April 2019.

PARTICIPANTS

Fifteen GPs were purposively recruited for semi-structured interviews through snowballing.

RESULTS

Experiences with lifestyle support among GPs ranged from referring patients to other healthcare professionals to taking a proactive role in lifestyle support themselves. Whether or not GPs took an active role in lifestyle support was related to their belief in the effect of lifestyle interventions. Overall, GPs had little experience with CLI in every day practice. Perceived barriers were a lack of availability of CLIs in the region and the potential lack of added value of CLIs on top of existing lifestyle support. Perceived facilitators were coordination of care provision by GP cooperatives and monitoring of the CLI implementation and their results. Reimbursement of CLIs without any costs for participants enabled application.

CONCLUSION

The importance of lifestyle interventions in primary care was acknowledged by all GPs, but they differed in their level of experience with providing lifestyle support and awareness of CLIs. Successful integration of CLIs with primary care requires a solid promotion, a well-coordinated implementation strategy and structural evaluation of long-term effectiveness.

Role of primary care physician factors on diagnostic testing and referral decisions for symptoms of possible cancer: a systematic review

BACKGROUND

Missed opportunities for diagnosing cancer cause patients harm and have been attributed to suboptimal use of tests and referral pathways in primary care. Primary care physician (PCP) factors have been suggested to affect decisions to investigate cancer, but their influence is poorly understood.

OBJECTIVE

To synthesise evidence evaluating the influence of PCP factors on decisions to investigate symptoms of possible cancer.

METHODS

We searched MEDLINE, Embase, Scopus, CINAHL and PsycINFO between January 1990 and March 2021 for relevant citations. Studies examining the effect or perceptions and experiences of PCP factors on use of tests and referrals for symptomatic patients with any cancer were included. PCP factors comprised personal characteristics and attributes of physicians in clinical practice.

DATA EXTRACTION AND SYNTHESIS

Critical appraisal and data extraction were undertaken independently by two authors. Due to study heterogeneity, data could not be statistically pooled. We, therefore, performed a narrative synthesis.

RESULTS

29 studies were included. Most studies were conducted in European countries. A total of 11 PCP factors were identified comprising modifiable and non-modifiable factors. Clinical judgement of symptoms as suspicious or 'alarm' prompted more investigations than non-alarm symptoms. 'Gut feeling' predicted a subsequent cancer diagnosis and was perceived to facilitate decisions to investigate non-specific symptoms as PCP experience increased. Female PCPs investigated cancer more than male PCPs. The effect of PCP age and years of experience on testing and referral decisions was inconclusive.

CONCLUSIONS

PCP interpretation of symptoms as higher risk facilitated testing and referral decisions for possible cancer. However, in the absence of 'alarm' symptoms or 'gut feeling', PCPs may not investigate cancer. PCPs require strategies for identifying patients with non-alarm and non-specific symptoms who need testing or referral.

PROSPERO REGISTRATION NUMBER

CRD420191560515.

Integrating Clinical Signs at Presentation and Clinician's Non-analytical Reasoning in Prediction Models for Serious Bacterial Infection in Febrile Children Presenting to Emergency Department

OBJECTIVE

Development and validation of clinical prediction model (CPM) for serious bacterial infections (SBIs) in children presenting to the emergency department (ED) with febrile illness, based on clinical variables, clinician's "gut feeling," and "sense of reassurance.

MATERIALS AND METHODS

Febrile children presenting to the ED of Children's Clinical University Hospital (CCUH) between April 1, 2017 and December 31, 2018 were enrolled in a prospective observational study. Data on clinical signs and symptoms at presentation, together with clinician's "gut feeling" of something wrong and "sense of reassurance" were collected as candidate variables for CPM. Variable selection for the CPM was performed using stepwise logistic regression (forward, backward, and bidirectional); Akaike information criterion was used to limit the number of parameters and simplify the model. Bootstrapping was applied for internal validation. For external validation, the model was tested in a separate dataset of patients presenting to six regional hospitals between January 1 and March 31, 2019.

RESULTS

The derivation cohort consisted of 517; 54% (n = 279) were boys, and the median age was 58 months. SBI was diagnosed in 26.7% (n = 138). Validation cohort included 188 patients; the median age was 28 months, and 26.6% (n = 50) developed SBI. Two CPMs were created, namely, CPM1 consisting of six clinical variables and CPM2 with four clinical variables plus "gut feeling" and "sense of reassurance." The area under the curve (AUC) for receiver operating characteristics (ROC) curve of CPM1 was 0.744 (95% CI, 0.683-0.805) in the derivation cohort and 0.692 (95% CI, 0.604-0.780) in the validation cohort. AUC for CPM2 was 0.783 (0.727-0.839) and 0.752 (0.674-0.830) in derivation and validation cohorts, respectively. AUC of CPM2 in validation population was significantly higher than that of CPM1 [p = 0.037, 95% CI (-0.129; -0.004)]. A clinical evaluation score was derived from CPM2 to stratify patients in "low risk," "gray area," and "high risk" for SBI.

CONCLUSION

Both CPMs had moderate ability to predict SBI and acceptable performance in the validation cohort. Adding variables "gut feeling" and "sense of reassurance" in CPM2 improved its ability to predict SBI. More validation studies are needed for the assessment of applicability to all febrile patients presenting to ED.

The role of trust and hope in antipsychotic medication reviews between GPs and service users a realist review

BACKGROUND

Increasing number of service users diagnosed with schizophrenia and psychosis are being discharged from specialist secondary care services to primary care, many of whom are prescribed long-term antipsychotics. It is unclear if General Practitioners (GPs) have the confidence and experience to appropriately review and adjust doses of antipsychotic medication without secondary care support.

AIM

To explore barriers and facilitators of conducting antipsychotic medication reviews in primary care for individuals with no specialist mental health input.

DESIGN & SETTING

Realist review in general practice settings.

METHOD

A realist review has been conducted to synthesise evidence on antipsychotic medication reviews conducted in primary care with service users diagnosed with schizophrenia or psychosis. Following initial scoping searches and discussions with stakeholders, a systematic search and iterative secondary searches were conducted. Articles were systematically screened and analysed to develop a realist programme theory explaining the contexts (C) and mechanisms (M) which facilitate or prevent antipsychotic medication reviews (O) in primary care settings, and the potential outcomes of medication reviews.

RESULTS

Meaningful Antipsychotic medication reviews may not occur for individuals with only primary care medical input. Several, often mutually reinforcing, mechanisms have been identified as potential barriers to conducting such reviews, including low expectations of recovery for people with severe mental illness, a perceived lack of capability to understand and participate in medication reviews, linked with a lack of information shared in appointments between GPs and Service Users, perceived risk and uncertainty regarding antipsychotic medication and illness trajectory.

CONCLUSIONS

The review identified reciprocal and reinforcing stereotypes affecting both GPs and service users. Possible mechanisms to counteract these barriers are discussed, including realistic expectations of medication, and the need for increased information sharing and trust between GPs and service users.

Risk of fall-related injury and all-cause hospitalization of select concomitant central nervous system medication prescribing in older adult persistent opioid users: A case-time-control analysis

BACKGROUND

Concomitant use of central nervous system (CNS) medications frequently occurs in older adults with persistent opioid use. The risks of adverse outcomes associated with combinations of opioids, sedative hypnotics, or skeletal muscle relaxants have not been sufficiently described in this population.

OBJECTIVE

To compare the overall and incremental risk of (1) fall-related injury and (2) all-cause hospitalization associated with sedative hypnotics and skeletal muscle relaxants among older persistent opioid users.

METHODS

A case-time-control study was conducted using administrative claims of adults ages ≥66 years with a history of persistent (≥90 days) opioid use. Cases included those with first (1) emergency department, hospital, or outpatient visit for a fall-related injury, or (2) all-cause hospitalization. Exposure to CNS medications prior to the case event versus earlier periods, and the risk associated with CNS drug class combinations and sequence of use, was estimated using conditional logistic regression, adjusted for time trends and time-varying covariates.

RESULTS

Among 140,101 older persistent opioid users, 20,723 experienced fall-related injury and 39,444 were hospitalized during follow-up. Skeletal muscle relaxant use was associated with an increased risk of fall-related injury (Odds ratio [OR] 1.28) and all-cause hospitalization (OR 1.11). Statistically significant associations were observed for the joint effects of interactions involving skeletal muscle relaxants on fall-related injury (with opioid: OR 1.25; with sedative hypnotic: OR 1.24), and interactions involving opioids on all-cause hospitalization (with sedative hypnotic: OR 1.10; with skeletal muscle relaxant: OR 1.17). The addition of a skeletal muscle relaxant to an opioid regimen was associated with a 25% increased risk of fall-related injury. Additions of other CNS medications did not have apparent incremental effects on the risk of all-cause hospitalization.

CONCLUSION

The excess risks of fall-related injury and hospitalization associated with various combinations of CNS medications among older persistent opioid users should be considered in therapeutic decision making. Further research is needed to confirm these findings.

Parents and carers' experiences of seeking health information and support online for long-term physical childhood conditions: a systematic review and thematic synthesis of qualitative research

OBJECTIVE

To systematically review and synthesise qualitative research exploring parents/carers' experiences of seeking online information and support for long-term physical childhood conditions.

DESIGN

Systematic review and thematic synthesis of qualitative research.

DATA SOURCES

Medline, CINAHL, Embase, PsycINFO and the International Bibliography of the Social Sciences were searched from inception to September 2019. We used thematic synthesis to analyse findings.

ELIGIBILITY CRITERIA

Primary research papers presenting qualitative data collection and analysis, focusing on parents/carers' experiences of seeking health information and support from online resources for long-term physical childhood health conditions. No language restrictions were placed.

RESULTS

23 studies from seven countries met inclusion criteria and were included in the synthesis. Included studies presented data collected through interviews/focus groups with 559 parents/carers; free-text surveys and essays with 26 parents/carers and 2407 messages from online support groups. Parents/carers developed a variety of strategies to obtain information and support online, based on personal preferences, appraisal of trustworthiness, perceived needs and previous experiences online. Many parents sought the benefits of online information and support, which included reassurance and validation from online communities, and feeling they had greater knowledge about their children's conditions. Some concerns and perceived risks were discussed, which often stemmed from prior unsatisfactory experiences of seeking information and support online, consultations with health professionals and seeing distressing stories online.

CONCLUSION

Most parents/carers were successful in obtaining information and support online. Many continued to share experiences with other parents/carers online. The need for information was particularly apparent early after diagnosis of the condition, whereas the need for peer support continued. The potential concerns and perceived risks with information and support online were especially apparent among parents/carers of children with life-limiting long-term conditions. Findings may be useful for health professionals to facilitate discussions regarding use of online resources, and researchers designing online health resources for parents/carers.

PROSPERO REGISTRATION NUMBER

CRD42018096009.

Parenting Science Gang: radical co-creation of research projects led by parents of young children

BACKGROUND

Parents are increasingly searching online for information supported by research but can find it difficult to identify results relevant to their own experiences. More troublingly, a number of studies indicate that parenting information found online often can be misleading or wrong. The goal of the Parenting Science Gang (PSG) project was to use the power of the Internet to help parents ask questions they wanted to have answered by scientific research and to feel confident in assessing research evidence.

METHODS

By using Facebook to recruit groups and facilitate interactions, PSG was able to engage fully the target public of parents of young children in the radical co-production of scientific studies, while not creating an undue burden on time or restricting participants due to disability, financial status or location. By giving parents true partnership and control of creation of projects, PSG ensured that the chosen questions were ones that were of most relevance and interest to them.

RESULTS

This paper presents a summary of eight projects, with three in more detail, designed and implemented by PSG Facebook groups in collaboration with experts. Most projects had health related themes, often prompted by dissatisfaction with treatment of parents by health professionals or by feelings of being marginalised by pregnancy and motherhood, as well as by the lack of evidence for their questions and concerns. The PSG approach meant that these frustrations were channelled into actions. All eight of the PSG groups engaged in meaningful interactions with experts and co-produced studies with the groups defining the questions of interest.

CONCLUSIONS

This radically user-led design meant that the PSG staff and the collaborating experts had to live with a high degree of uncertainty. Nevertheless, PSG achieved its goal of academically productive, truly co-produced projects, but as important were the positive effects it had on many of the participants, both parents and experts. At the point of writing this paper, PSG projects have led to outputs including at least eight papers published, in press or in preparation, seven conference presentations, testimony to the Infant Feeding All-Party Parliamentary Group, and with more to come.

Insomnia, Benzodiazepine Use, and Falls among Residents in Long-term Care Facilities

Background: Falls are leading cause of injury among older people, especially for those living in long-term care facilities (LTCFs). Very few studies have assessed the effect of sleep quality and hypnotics use on falls, especially in Chinese LTCFs. The study aimed to examine the association between sleep quality, hypnotics use, and falls in institutionalized older people. Methods: We recruited 605 residents from 25 LTCFs in central Shanghai and conducted a baseline survey for sleep quality and hypnotics use, as well as a one-year follow-up survey for falls and injurious falls. Logistic regression models were applied in univariate and multivariate analysis. Results: Among the 605 participants (70.41% women, mean age 84.33 ± 6.90 years), the one-year incidence of falls and injurious falls was 21.82% and 15.21%, respectively. Insomnia (19.83%) and hypnotics use (14.21%) were prevalent. After adjusting for potential confounders, we found that insomnia was significantly associated with an increased risk of falls (adjusted risk ratio (RR): 1.787, 95% CI, 1.106–2.877) and the use of benzodiazepines significantly increased the risk of injurious falls (RR: 3.128, 95% CI, 1.541–6.350). Conclusion: In elderly LTCF residents, both insomnia and benzodiazepine use are associated with an increased risk of falls and injuries. Adopting non-pharmacological approaches to improve sleep quality, taking safer hypnotics, or strengthening supervision on benzodiazepine users may be useful in fall prevention.

Utilization of somatic healthcare in Croatian patients with schizophrenia spectrum disorder, major depression, PTSD and the general population

BACKGROUND

Utilization of somatic healthcare services is highly predictive of the development of chronic physical illnesses and increased mortality risks. The objective of this study was to assess the differences in healthcare utilization among patients with schizophrenia spectrum disorders (SSD), major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) and the general population in Croatia.

METHODS

We enrolled 566 Croatian participants from the general population, 282 with SSD, 178 with MDD, and 86 with PTSD. The primary outcome was a self-reported specialist consultation for non-psychiatric (e.g., somatic) causes within the previous 12 months.

RESULTS

Although SSD patients with chronic physical illnesses were significantly more often hospitalized for physical illness than the general population, the proportion of patients who had a specialist consultation were equal in SSD and the general population. MDD and PTSD patients had significantly higher adjusted odds for specialist consultation than the general population and SSD patients (MDD compared to SSD: OR = 2.14; 95% CI 1.27-3.59; PTSD compared to SSD: OR = 2.03; 95% CI 1.00-4.10).

CONCLUSIONS

SSD patients' utilization of somatic healthcare is equal to the general population, despite their increased healthcare needs. However, their utilization is lower than in MDD and PTSD patients and, therefore, probably not adequate.

TRIAL REGISTRATION

The study protocol was registered at ClinicalTrials.gov ( NCT02773108 ) on May 16, 2016.

Characterisation of Benzodiazepine Use in an Older Population Registered in Family Health Units in the Region of Minho, Portugal

Benzodiazepines are the most frequently consumed psychotropic drugs among older persons. This pharmacological class has been advised against in this group, due to the various risks associated with its use in an older population. This study seeks to determine the prevalence of benzodiazepine use in a non-institutionalized older population over the age of 75 that is registered in Family Health Units (USF) in the region of Minho, Portugal, as well as to characterize these patients and understand the link between benzodiazepine use and chronic medication use, risk of falls, and level of physical and functional dependence. The data extracted from the clinical records registered in the SAM^® were analyzed using the Statistical Package for the Social Sciences (SPSS). A sample of 700 patients was obtained. These patients presented a mean age of 82.3 years, 62.7% were female, 95.3% were physically independent, and 38.0% were functionally independent. Almost half of the elder persons presented a moderate (36.9%) or high (11.4%) risk of falls. 37.9% of the patients were chronic benzodiazepines users, using between 1 and 3 active substances belonging to this pharmacological class, with a higher rate of use among women (p < 0.001) and elder persons. There was a statistically significant association among the use of benzodiazepines, a functional independence, and a higher risk of falls. These pioneering findings in Portugal reveal a high prevalence of benzodiazepine use in the population studied and warn about the specific characteristics of said population and the importance in reducing the risks associated with the inappropriate prescription of these drugs.

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.

The association between depressive symptoms and fall accidents among middle-aged and elderly people in China

Background

Depressive symptoms are a worldwide health problem. However, the research about the effect of depressive symptoms on the fall among the Chinese mid-aged and elderly people is lacking. Therefore, this study aims to investigate the association between depressive symptoms and fall accidents among middle-aged and elderly people in China.

Methods

This study was conducted based on 12,527 sets of data from China Health and Retirement Longitudinal Survey (CHARLS). The 2011 depressive symptoms data and the 2013 fall data were chosen for this study. The depressive symptom-related data was assessed by the Chinese version of Center for Epidemiologic Studies Depression scales (CES-D). Individuals were divided into subgroups according to gender (male or female), age (45–59, middle-aged or ≥ 60, elderly people), and residence (rural or urban). The odds ratios (ORs) were compared between subgroups using multivariable logistic regression analysis method.

Results

The adjusted OR value (OR = 1.19 [95% CI 1.07–1.33]) shows there is a significant association between depressive symptoms and subsequent fall accidents. The ORs of the female, elderly people, rural, and urban subgroups are 1.31 (95% CI 1.11–1.55), 1.24 (95% CI 1.08–1.43), 1.17 (95% CI 1.02–1.33), and 1.25 (95% CI 1.04–1.49), respectively, which reveals that this association is also statistically significant in these subgroups.

Conclusions

This study shows that there is a significant association between depressive symptoms and their subsequent fall accidents among the Chinese middle-aged and elderly people.

Chronic benzodiazepine suppresses translocator protein and elevates amyloid β in mice

Benzodiazepine (BZD) is a commonly prescribed anxiolytic and sedation aid medication, especially in elderly women. However, long-term use of BZD provokes adverse nontherapeutic effects that include movement deficit. Here, we investigated motoric deficit and molecular changes in cerebellum associated with the chronic use of BZD (cBZD) in female mice. We measured neuroprotective translocator protein (TSPO), neurotoxic amyloid β (Aβ), Aβ-producing presenilin-1 (PS1), and Aβ-degrading neprilysin. We also tested whether cBZD treatment damages mitochondrial membranes by measuring mitochondrial membrane swelling and mitochondrial respiration. Young and old mice received BZD (lorazepam) for 20 days, were tested for motoric function using Rotarod, and then euthanized to collect cerebellum. The major methods were immunoblot and RT-PCR for TSPO, PS1, and neprilysin expressions; ELISA for Aβ level; spectrometry for mitochondrial membrane swelling; XF-respirometry for mitochondrial respiration. cBZD-treated old mice showed poorer motoric function than old control or young cBZD-treated mice. Old mice treated with cBZD showed a decrease in TSPO and neprilysin and an increase in Aβ and PS1 production compared to old control mice. Old cBZD-mice also showed an increase in mitochondrial membrane swelling and a decrease in mitochondrial respiration. These data suggest that cBZD exacerbates motoric aging in a manner that involves diminished TSPO, elevated Aβ, and mitochondrial damage.

Benzodiazepines and Z-Drugs: An Updated Review of Major Adverse Outcomes Reported on in Epidemiologic Research

Various adverse events resulting from, or associated with, benzodiazepine and/or Z-drug use have been extensively reported on and discussed in great detail within the biomedical literature. It is widely accepted that motor vehicle accidents and falls leading to fractures in older adults are major adverse events that have been shown to occur more frequently in users of sedative-hypnotic medication, especially of the benzodiazepine and related Z-drug variety. However, the last few years have seen increasing reports in the literature raising the issue of benzodiazepine and Z-drug exposure in the development of other serious medical issues including dementia, infections, respiratory disease exacerbation, pancreatitis, and cancer. This article provides an overview and interpretation on the current state of evidence regarding each of these associations and proposes what gaps in the evidence for drug-exposure–harm associations need to be addressed in the future for the purpose of evaluating causality of harm as it relates to these drugs.

Does initial use of benzodiazepines delay an adequate pharmacological treatment? A multicentre analysis in patients with psychotic and affective disorders

It is established that delayed effective pharmacotherapy plays a significant role in the overall burden of psychiatric disorders, which are often treated with symptomatic drugs, that is benzodiazepines (BZDs), in relation to their rapid onset of action and safety, despite long-term side effects. We aimed to assess the influence of initial treatment with BZDs on the duration of untreated illness (DUI) and whether specific sociodemographic and clinical factors could influence the choice of BZDs as first treatment in 545 patients affected by schizophrenia, mood and anxiety spectrum disorders. Statistical analyses (one-way analysis of variance and χ) were carried out to compare patients who used BZDs as first treatment (BZD w/) and those who did not (BZD w/o). The overall DUI, irrespective of diagnosis, resulted in significantly longer in BZD w/ versus w/o patients, who also experienced more frequently anxious/depressive symptoms at onset. Furthermore, BZD w/ patients more frequently autonomously decided to look for treatment (mainly refering to psychologists or general practitioners) and experimented more frequently phobias, than BZD w/o ones. The present findings suggest that initial BZDs treatment may prolong the overall DUI, although their prescription seems to be influenced by specific sociodemographic and clinical factors. Further studies are needed to confirm the present findings.

Molecular spectroscopic studies examining the interactions between phenobarbital and human serum albumin in alcohol consumption

BACKGROUND

Alcohol dependence is associated with a wide range of serious mental, physical, and social consequences and is one of the most common chronic diseases worldwide. Barbiturates, which are a first-line treatment in the clinic for alcohol withdrawal, may result in combined barbiturate and alcohol use. Their co-use abuse may promote synergistic effects between barbiturates and alcohol in vivo.

OBJECTIVE

To investigate the effects of different alcohol concentrations on the synergistic effects of phenobarbital and alcohol.

METHODS

The interactions between phenobarbital and human serum albumin (HSA) and the effects of different alcohol concentrations on the binding behaviors of the phenobarbital-HSA system were investigated by molecular docking and spectroscopic methods, including fluorescence spectroscopy and UV-visible absorption spectroscopy.

RESULTS

Experimental results revealed that phenobarbital can be stored and carried by HSA. The presence of alcohol (≤1.96 × 10^-2 M) can increase the proportion of free phenobarbital and shorten the half-life and storage time of phenobarbital in the blood, thereby enhancing its bioactive efficacy. The binding constants (K_b) of the phenobarbital-HSA system decrease in the presence of alcohol (≥2.61 × 10^-2 M), which suggests that phenobarbital should be quickly cleared from blood, thereby decreasing the activity of phenobarbital.

CONCLUSIONS

The effects of alcohol on the transposition of phenobarbital by HSA at the beginning of the barbiturate metabolic process play an important role in the synergistic effects of phenobarbital and alcohol. This mechanism may be significant for the clinical dosage of patients with alcohol dependence.

Using Multiple Pharmacovigilance Models Improves the Timeliness of Signal Detection in Simulated Prospective Surveillance

INTRODUCTION

Prospective pharmacovigilance aims to rapidly detect safety concerns related to medical products. The exposure model selected for pharmacovigilance impacts the timeliness of signal detection. However, in most real-life pharmacovigilance studies, little is known about which model correctly represents the association and there is no evidence to guide the selection of an exposure model. Different exposure models reflect different aspects of exposure history, and their relevance varies across studies. Therefore, one potential solution is to apply several alternative exposure models simultaneously, with each model assuming a different exposure-risk association, and then combine the model results.

METHODS

We simulated alternative clinically plausible associations between time-varying drug exposure and the hazard of an adverse event. Prospective surveillance was conducted on the simulated data by estimating parametric and semi-parametric exposure-risk models at multiple times during follow-up. For each model separately, and using combined evidence from different subsets of models, we compared the time to signal detection.

RESULTS

Timely detection across the simulated associations was obtained by fitting a set of pharmacovigilance models. This set included alternative parametric models that assumed different exposure-risk associations and flexible models that made no assumptions regarding the form/shape of the association. Times to detection generated using a simple combination of evidence from multiple models were comparable to those observed under the ideal, but unrealistic, scenario where pharmacovigilance relied on the single 'true' model used for data generation.

CONCLUSIONS

Simulation results indicate that, if the true model is not known, an association can be detected in a more timely manner by first fitting a carefully selected set of exposure-risk models and then generating a signal as soon as any of the models considered yields a test statistic value below a predetermined testing threshold.

Does accreditation improve pro re nata benzodiazepines administration in psychiatric inpatients? Pre-post accreditation medical record comparison

Background

In psychiatric inpatients, administration of pro re nata benzodiazepines is a common practice. Benzodiazepine use is associated with potential complications of risk of abuse, cognitive impairment, and falls. An interest in accreditation is growing rapidly among many countries to enhance the quality of health care services. We aimed to investigate whether hospital accreditation drives improvements for administered pro re nata benzodiazepines in psychiatric inpatients.

Methods

The study reviewed medical records of consecutive hospital admissions for pre- and post-accreditation comparisons of PRN benzodiazepine medications in two acute mental health wards at a teaching general hospital. Data obtained from the 12-month-post-accreditation period (July 2011–June 2012) were compared with those from the 12-month-pre-accreditation period (July 2009–June 2010). The adoption of accreditation standards occurred over a 12-month period in the middle of the study (July 2010–June 2011). Compiled information included demographics, diagnosis, assessment, and LOS. All identified charts were reviewed; there were no exclusion criteria. Patients were not contacted.

Results

There was a statistically significant (P < 0.002) reduction of approximately 22% in the number of administered PRN benzodiazepines. Post-accreditation, the average number of PRN benzodiazepines administrations per patient, was 4.83 ± 2.1 compared to 6.19 ± 3.4 pre-accreditation. There was no significant difference between the two genders. The highest average quantity of PRN benzodiazepines administered was during the time interval of 18–24 h.

Conclusion

Accreditation may have a positive impact on the process of administering PRN benzodiazepine medications in psychiatric inpatients.

Falls among the elderly: risk factors in a population-based study

PURPOSE

The aim of the present study was to identify factors associated with the occurrence of falls among elderly adults in a population-based study (ISACamp 2008).

METHODS

A population-based cross-sectional study was carried out with two-stage cluster sampling. The sample was composed of 1,520 elderly adults living in the urban area of the city of Campinas, São Paulo, Brazil. The occurrence of falls was analyzed based on reports of the main accident occurred in the previous 12 months. Data on socioeconomic/demographic factors and adverse health conditions were tested for possible associations with the outcome. Prevalence ratios (PR) were estimated and adjusted for gender and age using the Poisson multiple regression analysis.

RESULTS

Falls were more frequent, after adjustment for gender and age, among female elderly participants (PR = 2.39; 95% confidence interval (95% CI) 1.47 - 3.87), elderly adults (80 years old and older) (PR = 2.50; 95% CI 1.61 - 3.88), widowed (PR = 1.74; 95% CI 1.04 - 2.89) and among elderly adults who had rheumatism/arthritis/arthrosis (PR = 1.58; 95% CI 1.00 - 2.48), osteoporosis (PR = 1.71; 95% CI 1.18 - 2.49), asthma/bronchitis/emphysema (PR = 1,73; 95% CI 1.09 - 2.74), headache (PR = 1.59; 95% CI 1.07 - 2.38), mental common disorder (PR = 1.72; 95% CI 1.12 - 2.64), dizziness (PR = 2.82; 95% CI 1.98 - 4.02), insomnia (PR = 1.75; 95% CI 1.16 - 2.65), use of multiple medications (five or more) (PR = 2.50; 95% CI 1.12 - 5.56) and use of cane/walker (PR = 2.16; 95% CI 1.19 - 3,93).

CONCLUSION

The present study shows segments of the elderly population who are more prone to falls through the identification of factors associated with this outcome. The findings can contribute to the planning of public health policies and programs addressed to the prevention of falls.

Shame Experiences Underlying Depression of Adult Turkish Women

Shame is a major component of many mental health problems and affects symptoms, coping styles, remission, and therapeutic ruptures. There are few qualitative studies aimed at understanding shame and its role for patients diagnosed with depression. In this research, we explored the origins of shame, and the coping strategies that patients diagnosed with depression employ to cope with shame. This qualitative research aimed at an in-depth analysis of shame experiences of adult women who had been diagnosed with depression and treated with cognitive behavioral psychotherapy in a Women Health Center in Turkey. Purposive sampling yielded nine high shame prone adult women who were married and had children. Four semi-structured interviews were conducted with each of the nine participants, and 36 semi-structured interviews were analyzed by Interpretative Phenomenological Analysis. According to the results of the analysis, four themes emerged. These were "substitution of rage for the feeling of shame and unworthiness," "perfection struggle to overcompensate the belief of being inadequate," "feeling shame for their own body and sexual acts," and "need for individuation." The results were interpreted by considering the social context and culture of Turkey, and the clinical implications were discussed.

[Factors associated with the danger of accidental falls among institutionalized elderly individuals: an integrative review]

The scope of this research is to identify the major risk factors associated with accidental falls among the elderly. It involves an integrative review of the literature between 2002 and 2012 in English and Portuguese. The selection of articles was based on the following key words in the Lilacs, Medline and BDENF databases: accidental falls, homes for the elderly and health services. In the final sample 19 articles were selected, of which 11 were national and 8 were international. They indicate that the major factors related to the risk of accidental falls in Homes for the Elderly are: being female, being diagnosed with chronic disease, treatment with benzodiazepine, earlier cases of accident falls, and mobility restriction. The research reveals that architectonic and furniture inadequacies in Homes for the Elderly may be predisposing factors for accidental falls. Analysis of the articles reveals the need for further longitudinal studies and, consequently, enhanced monitoring of the conditions of the functional capacity of the elderly, especially the risks related to falls, considered one of the leading causes of death among institutionalized elderly individuals.

Antiresorptive treatment, when initiated after a first hip fracture, may not protect of a second contralateral episode in elderly population: A study with 685 patients

INTRODUCTION

Osteoporosis predisposes for a higher risk of hip fracture and its treatment is frequently underprescribed. Our purpose was to assess the relation between having a second hip fracture and receiving osteoporosis treatment. Also to assess the relation between this second fracture and using central nervous system drugs or being institutionalised.

PATIENTS AND METHODS

We reviewed all the patients that were admitted to our hospital with an osteoporotic proximal femoral fracture between September 2009 and February 2011. We identified 685 patients, 74 of which presented a contralateral fracture. We evaluated if they were receiving osteoporosis treatment or taking any medication that could affect the central nervous system and if they were institutionalised.

RESULTS

A 10.8% of patients had a second fracture and the mean time between the two of them was 20 months (1-122). There was a clear female predominance (76.35%). The mean age at occurrence of the primary fracture was 83.02 years and 85 for the second. A 90.8% did not follow any type of osteoporosis medication before the first fracture. A 50.9% did not receive central nervous system drugs and 79.1% lived at home at the time of the first fracture. 12.8% of the patients that did not follow the osteoporosis treatment, had a contralateral fracture, 3% more than those that did follow some kind of treatment, but this difference was not significant (p=0.2).

DISCUSSION

We identified a similar number of patients undergoing osteoporotic treatment as registered in literature. There was no significant difference between suffering a second hip fracture and following osteoporosis treatment, using psychotropic drugs or being institutionalised.

Effects of a geriatric intervention aiming to improve quality care in nursing homes on benzodiazepine use and discontinuation

BACKGROUND

Benzodiazepines and "Z drugs" are often prescribed in residents of nursing homes (NH) despite their well-known deleterious effects. We aimed to investigate if a general intervention on quality of care led to discontinuation of benzodiazepine, and to examine which NH-related factors were associated in change of benzodiazepines use.

METHODS

IQUARE is a quasi-experimental study, investigating the impact of an intervention based on a geriatric education with NH staff on several quality indicators of care (including appropriate prescriptions). All participating NH received an initial and 18-month audit regarding drug prescriptions and other quality of care variables. The analysis included 3973 residents, 2151 subjects (mean age: 84.6 ± 8.5 years; 74.3% women) in the control group and 1822 (mean age: 85.5 ± 8.1 years; 77.4% women) in the intervention group. Outcomes at 18 months were benzodiazepines use, long-acting benzodiazepines use, new-use of benzodiazepines, and discontinuation. The effect of the intervention was investigated using mixed-effect logistic regression models, including NH variables and residents' health status as confounders.

RESULTS

Higher reductions in benzodiazepine use (-2.8% vs. -1.5%) and long-acting benzodiazepine (-3.7% vs. -3.5%) were observed in intervention group, but not statistically significant. None of the structural and organisational NH-related variables predicted either discontinuation or new-use of benzodiazepines; hospitalisations and initial use of meprobamate increased the likelihood of becoming a new-user of benzodiazepines. Multivariate analysis suggested that living in a particular NH could affect benzodiazepines discontinuation.

CONCLUSIONS

A general intervention designed to improve overall NH quality indicators did not succeed in reducing benzodiazepines use. External factors interfered with the intervention. Further studies are needed to examine which NH-related aspects could impact benzodiazepines discontinuation.

Update on managing generalized anxiety disorder in older adults

With the recent updates to the Diagnostic and Statistical Manual of Mental Disorders (5th edition; DSM-5), there are many questions on how to care for older adults with generalized anxiety disorder (GAD) and other psychiatric conditions. The current article reviews the new changes to the DSM-5 for diagnosis of GAD, discusses new anxiety assessment scales that are validated in older adults, evaluates pharmacological agents that have been studied in older adults for GAD treatment, and provides monitoring recommendations to help those who provide care to older adults experiencing GAD.

Psychosocial interventions for benzodiazepine harmful use, abuse or dependence

BACKGROUND

Benzodiazepines (BZDs) have a sedative and hypnotic effect upon people. Short term use can be beneficial but long term BZD use is common, with several risks in addition to the potential for dependence in both opiate and non-opiate dependent patients.

OBJECTIVES

To evaluate the effectiveness of psychosocial interventions for treating BZD harmful use, abuse or dependence compared to pharmacological interventions, no intervention, placebo or a different psychosocial intervention on reducing the use of BZDs in opiate dependent and non-opiate dependent groups.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL- the Cochrane Library issue 12, 2014) which includes the Cochrane Drugs and Alcohol Group Specialized Register; PubMed (from 1966 to December 2014); EMBASE (from 1988 to December 2014); CINAHL Cumulative Index to Nursing and AlliedHealth Literature (1982 to September 2013); PsychINFO (1872 to December 2014); ERIC (Education Resources Information Centre, (January 1966 to September 2013); All EBM Reviews (1991 to September 2013, Ovid Interface); AMED (Allied & Alternative Medicine) 1985 to September 2013); ASSIA (Applied Social Sciences Index & Abstracts (1960 to September 2013); LILACS (January 1982 to September 2013);Web of Science (1900 to December 2014);Electronic Grey Literature Databases: Dissertation Abstract; Index to Theses.

SELECTION CRITERIA

Randomised controlled trials examining the use of a psychosocial intervention to treat BZDs versus pharmacological interventions,no intervention, placebo or a different psychosocial intervention on reducing the use of BZDs in opiate dependent and non-opiate dependent groups.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures outlined in Cochrane Guidelines.

MAIN RESULTS

Twenty-five studies including 1666 people met the inclusion criteria. The studies tested many different psychosocial interventions including cognitive behavioural therapy (CBT) (some studies with taper, other studies with no taper), motivational interviewing (MI),letters to patients advising them to reduce or quit BZD use, relaxation studies, counselling delivered electronically and advice provided by a general practitioner (GP). Based on the data obtained, we performed two meta-analyses in this Cochrane review: one assessing the effectiveness of CBT plus taper versus taper only (575 participants), and one assessing MI versus treatment as usual (TAU) (80 participants).There was moderate quality of evidence that CBT plus taper was more likely to result in successful discontinuation of BZDs within four weeks post treatment compared to taper only (Risk ratio (RR) 1.40, 95% confidence interval (CI) 1.05 to 1.86; nine trials, 423 participants) and moderate quality of evidence at three month follow-up (RR 1.51, 95% CI 1.15 to 1.98) in favour of CBT (taper)for 575 participants. The effects were less certain at 6, 11, 12, 15 and 24 months follow-up. The effect of CBT on reducing BZDs by> 50% was uncertain for all time points examined due to the low quality evidence. There was very low quality evidence for the effect on drop-outs at any of the time intervals; post-treatment (RR 1.05, 95% CI 0.66 to 1.66), three month follow-up (RR 1.71, 95% CI0.16 to 17.98) and six month follow-up (RR 0.70, 95% CI 0.17 to 2.88).Based on the very low quality of evidence available, the effect of MI versus TAU for all the time intervals is unclear; post treatment(RR 4.43, 95% CI 0.16 to 125.35; two trials, 34 participants), at three month follow-up (RR 3.46, 95% CI 0.53 to 22.45; four trials,80 participants), six month follow-up (RR 0.14, 95% CI 0.01 to 1.89) and 12 month follow-up (RR 1.25, 95% CI 0.63 to 2.47).There was very low quality of evidence to determine the effect of MI on reducing BZDs by > 50% at three month follow-up (RR 1.52,95% CI 0.60 to 3.83) and 12 month follow-up (RR 0.87, 95% CI 0.52 to 1.47). The effects on drop-outs from treatment at any of e time intervals between the two groups were uncertain due to the wide CIs; post-treatment (RR 0.50, 95% CI 0.04 to 7.10), three month follow-up (RR 0.46, 95% CI 0.06 to 3.28), six month follow-up (RR 8.75, 95% CI 0.61 to 124.53) and 12 month follow-up(RR 0.42, 95% CI 0.02 to 7.71).The following interventions reduced BZD use - tailored GP letter versus generic GP letter at 12 month follow-up (RR 1.70, 95%CI 1.07 to 2.70; one trial, 322 participants), standardised interview versus TAU at six month follow-up (RR 13.11, 95% CI 3.25 to 52.83; one trial, 139 participants) and 12 month follow-up (RR 4.97, 95% CI 2.23 to 11.11), and relaxation versus TAU at three month follow-up (RR 2.20, 95% CI 1.23 to 3.94).There was insufficient supporting evidence for the remaining interventions.We performed a 'Risk of bias' assessment on all included studies. We assessed the quality of the evidence as high quality for random sequence generation, attrition bias and reporting bias; moderate quality for allocation concealment, performance bias for objective outcomes, and detection bias for objective outcomes; and low quality for performance bias for subjective outcomes and detection bias for subjective outcomes. Few studies had manualised sessions or independent tests of treatment fidelity; most follow-up periods were less than 12 months.Based on decisions made during the implementation of protocol methods to present a manageable summary of the evidence we did not collect data on quality of life, self-harm or adverse events.

AUTHORS' CONCLUSIONS

CBT plus taper is effective in the short term (three month time period) in reducing BZD use. However, this is not sustained at six months and subsequently. Currently there is insufficient evidence to support the use of MI to reduce BZD use. There is emerging evidence to suggest that a tailored GP letter versus a generic GP letter, a standardised interview versus TAU, and relaxation versus TAU could be effective for BZD reduction. There is currently insufficient evidence for other approaches to reduce BZD use.

General practitioners' perceptions of and involvement in health behaviour change: can computer-tailored interventions help?

AIM

To explore GPs' perceptions of their role in primary prevention, barriers experienced and willingness to accommodate an automated, computer-tailored intervention.

BACKGROUND

General practice is an attractive setting for primary prevention of chronic disease. Due to constraints in time and knowledge it is underutilised.

METHODS

Telephone interviews of 13 GPs in Brisbane, Australia, whose patients were previously involved in a lifestyle change research project. Qualitative responses were grouped into themes.

FINDINGS

GPs perceived their role in lifestyle change as 'educators', 'supporters' and 'prompters'. Smoking and physical activity were addressed more often than alcohol and salt intake. Longer lifestyle-focussed consultations and computer-generated reminders were suggested to overcome barriers. A computer-tailored approach was appreciated due to its minimal impact on practice routine. GPs understand their role in primary prevention but need help to overcome barriers. GP initiated consultations focusing on lifestyle and prevention along with computer support systems could improve capability for prevention in general practice.

Use of benzodiazepines and related drugs in Manitoba: a population-based study

BACKGROUND

Despite their favourable toxicology profile, benzodiazepines and the related Z-drugs (zopiclone, zolpidem and zaleplon) have been associated with physiological tolerance, dependence and addiction. Evidence of harm (e.g., falls, motor vehicle collisions and cognitive disturbances) has been reported in older populations. The aim of this study was to determine the relation between users' characteristics and the use of benzodiazepines and Z-drugs in Manitoba over a 16-year period.

METHODS

This time-series analysis was based on prescription data from Apr. 1, 1996, to Mar. 31, 2012, obtained from the Drug Product Information Network database of Manitoba. We obtained sociodemographic information on benzodiazepine and Z-drug users from the Population Registry and determined changes in utilization rates over time using generalized estimating equations.

RESULTS

Overall, the prevalence of benzodiazepine use remained stable at about 61.0 per 1000 population between 1996/97 and 2011/12; however, the prevalence of Z-drug use increased steadily from 10.9 to 37.0 per 1000 over the same period. In older people (≥ 65 years), the incidence of benzodiazepine use decreased from 55.5 to 30.3 users per 1000, whereas the incidence of Z-drug use increased from 7.3 to 20.3 users per 1000 over the study period. Among those 18-64 years of age, the incidence of benzodiazepine use decreased from 30.1 to 27.6 users per 1000, but the increase in incidence of Z-drug use was more than 2-fold. The youngest population (≤ 17 years) showed the lowest rates of use of these drugs. The highest rates of use were observed among older women and the low-income population.

INTERPRETATION

Over the study period, benzodiazepines have been prescribed less frequently to older patients in Manitoba; however, zopiclone prescribing has continued to increase for all age groups. The reasons for this increase remain to be determined.

Fighting insomnia and battling lethargy: the yin and yang of palliative care

There is an interdependent relationship between insomnia and fatigue in the medical literature, but both remain distinct entities. Insomnia entails problematic sleep initiation, maintenance, or restoration with an accompanying decrease in perceived daytime function. Lethargy is a symptom that has a wide differential diagnosis that heavily overlaps with cancer-related fatigue; however, insomnia may contribute to worsened fatigue and lethargy in cancer patients. Insomnia is a major risk factor for mood disturbances such as depression, which may also contribute to lethargy in this at-risk population. The pathophysiology of fatigue and insomnia is discussed in this review, including their differential diagnoses as well as the emerging understanding of the roles of neurotransmitters, branched-chain amino acids, and inflammatory cytokines. Treatment approaches for insomnia and fatigue are also discussed and reviewed, including the role of hypnotics, psychotropics, hormonal agents, and alternative therapies.

Why is your patient sedated?

PURPOSE

The purpose of this paper is to examine the recording of clinical indication for prescribed sedative/hypnotic (SH) medications in a large, acute tertiary referral hospital.

DESIGN/METHODOLOGY/APPROACH

All hospital inpatients' medications (n = 367) were audited for prescription details regarding SH medications. Medical notes were then examined for evidence of a recorded indication for such medications.

FINDINGS

SH medications were prescribed to many hospital inpatients (42.5 per cent) during admission. An indication was documented in the nursing or medical records for 24.4 per cent of patients who were prescribed such medications. Nurses rather than by doctors prescribed most SH medications (74 vs 26 per cent, respectively, p = 0.003). Some patients receiving SH medications were both over 65 and impaired in their mobility (19.2 per cent). The treatment indication was documented in 47 per cent.

PRACTICAL IMPLICATIONS

Most patients prescribed SH medications have nothing in their medical record explaining why these drugs are being used, including half of the elderly, less mobile patients. All health professionals dealing with SH medications and doctors in particular need to justify the use of such medications in the medical record. For the particularly high-risk groups where SH medications are potentially more dangerous, explicit guidance on why and how such medications are to be used must be provided by prescribers.

ORIGINALITY/VALUE

For the first time, data are presented on documentation rates for clinical indication of prescribed SH medications across a large acute hospital, and highlights significant shortcomings in practice. This study should inform other organisations of the need to be mindful of facilitating greater compliance with good prescribing practice.

Long-term benzodiazepine use in patients with major depressive disorder in China

PURPOSE

There have been no data about long-term benzodiazepine (BZD) use and its correlates in patients with major depressive disorder (MDD) in China. This study aimed to examine the prevalence of long-term BZD use (more than three months) and its demographic and clinical correlates in Chinese patients with MDD.

DESIGN AND METHODS

A total of 1,192 patients with MDD were examined in 10 mental health centers in China. Patients' socio-demographic and clinical characteristics and prescriptions for psychotropic drugs were recorded using a standardized form.

FINDINGS

A large portion of patients (36.2%) received long-term BZD treatment. Univariate analyses revealed that long-term BZD users were older, poorer, and had more impaired occupational functioning than patients not taking BZDs. Long-term BZD users had fewer psychotic symptoms and took less antipsychotic drugs. In multivariate analyses, long-term BZD use was independently associated with older age and more severe impaired occupational functioning; long-term BZD users were less likely to receive antipsychotic medications and traditional antidepressants (tricyclic antidepressants, tetracyclic antidepressant, and monoamine oxidase inhibitors).

PRACTICE IMPLICATIONS

Long-term BZD use was common in patients with MDD in China. A host of demographic and clinical factors were independently associated with long-term BZD use.

Socio-demographic, lifestyle and psychological predictors of benzodiazepine and z-hypnotic use patterns

AIMS

Risk and demographic factors for benzodiazepine and z-hypnotic use are incompletely understood. The aim of the paper was therefore to investigate socio-demographic, lifestyle and psychological factors predicting onset and differential pattern of prescribed benzodiazepine and z-hypnotic use in a Norwegian population sample.

METHODS

This retrospective cohort study obtained socio-demographic, psychological and lifestyle variables from the Nord-Trøndelag Health Study. Information about benzodiazepine prescriptions from the Norwegian prescription database were linked to epidemiological questionnaire data. Benzodiazepine use was classified into single-period, intermittent and chronic use, and high dose use was defined as being prescribed a yearly average above 180 daily defined doses.

RESULTS

Older age, sleep difficulties and smoking were positively associated with all patterns of benzodiazepine use. Male gender was related to a reduced risk of all patterns of use, whereas educational achievement was negatively associated with single-period use. Alcohol consumption, anxiety and tension were positively related to intermittent and chronic use, while exercise was negatively related to chronic use. Smoking, sleep difficulties and old age were positively associated with prescriptions of high benzodiazepine doses, while exercise was associated with lower doses.

CONCLUSIONS

Patterns of prescribed benzodiazepine use are linked to demographic, lifestyle and clinical variables. Non-pharmacological treatment for sleep difficulties and smoking cessation may reduce the risk of chronic benzodiazepine use.

The elimination half-life of benzodiazepines and fall risk: two prospective observational studies

BACKGROUND

the STOPP criteria advise against the use of long-acting benzodiazepines (LBs).

OBJECTIVE

to study whether LBs are associated with a higher fall risk than short-acting benzodiazepines (SBs) (elimination half-life ≤ 10 h).

METHODS

we used base-line data and prospective fall follow-up from the Longitudinal Aging Study Amsterdam, a longitudinal cohort study including 1,509 community-dwelling older persons (Study 1) and from a separate fall prevention study with 564 older persons after a fall (Study 2). Time to the first fall after inclusion and number of falls in the first year after inclusion were the primary endpoints.

RESULTS

both in Study 1 and Study 2 the use of SBs was associated with time to the first fall, hazard ratio (HR) 1.62 (95% CI: 1.03-2.56) and HR 1.64 (95% CI: 1.19-2.26),respectively. LBs were not significantly associated with time to first fall, HR 1.40 (0.85-2.31) and HR 1.08 (0.72-1.62). In both studies, the use of SBs was also associated with number of falls, odds ratio (OR) 1.28 (95% CI: 1.01-1.61) and OR 1.37 (95% CI: 1.10-1.70). LBs were not significantly associated with number of falls, OR 1.23 (0.96-1.57) and 1.10 (0.82-1.48).

CONCLUSIONS

the use of SBs is not associated with a lower fall risk compared with LBs. The use of both SBs and LBs by old persons should be strongly discouraged.

[Benzodiazepine prescription in the elderly in different health care levels: characteristics and related factors]

OBJECTIVES

To determine the prevalence of benzodiazepine (BZD) prescription and the factors related to prescribing them in the elderly in the community, in an acute general hospital (AH) and in a convalescence geriatric unit (CGU).

MATERIAL AND METHODS

Retrospective study of 334 CGU inpatients discharged from an AH. A comprehensive geriatric assessment included functional and cognitive evaluation before hospitalization, at admission and at discharge from CGU (Barthel index, Lawton index and Folstein Mini-Mental State Examination), as well as comorbidity (Charlson index), polypharmacy and social situation. The percentage of benzodiazepine prescriptions at the different healthcare levels was compared and their related factors were evaluated (Chi-squared test).

RESULTS

The prevalence of benzodiazepine prescriptions in the community was 23.6%, and being female and polypharmacy were related factors to prescribing at this level. During AH admission, this proportion increased up to 38.6%, and after CGU admission decreased to 21.,9%. Factors related to prescription in AH were, being female, polypharmacy and osteoarticular-fracture related diagnosis, and in CGU, being female and polypharmacy.

CONCLUSIONS

The prevalence of benzodiazepine prescribing was high among elderly people at every healthcare level (community, AH and CGU), and polypharmacy was one of the significant factors associated with prescribing. This prescribing was increased during AH admission due to a medical or surgical process.

Prescribing of psychotropic medications to the elderly population of a Canadian province: a retrospective study using administrative databases

Background. Psychotropic medications, in particular second-generation antipsychotics (SGAs) and benzodiazepines, have been associated with harm in elderly populations. Health agencies around the world have issued warnings about the risks of prescribing such medications to frail individuals affected by dementia and current guidelines recommend their use only in cases where the benefits clearly outweigh the risks. This study documents the use of psychotropic medications in the entire elderly population of a Canadian province in the context of current clinical guidelines for the treatment of behavioural disturbances.

Methods. Prevalent and incident utilization of antipsychotics, benzodiazepines and related medications (zopiclone and zaleplon) were determined in the population of Manitobans over age 65 in the time period 1997/98 to 2008/09 fiscal years. Comparisons between patients living in the community and those living in personal care (nursing) homes (PCH) were conducted. Influence of sociodemographic characteristics on prescribing was assessed by generalized estimating equations. Non-optimal use was defined as the prescribing of high dose of antipsychotic medications and the use of combination therapy of a benzodiazepine (or zopiclone/zaleplon) with an antipsychotic. A decrease in intensity of use over time and lower proportions of patients treated with antipsychotics at high dose or in combination with benzodiazepines (or zopiclone/zaleplon) was considered a trend toward better prescribing. Multiple regression analysis determined predictors of non-optimal use in the elderly population.

Results. A 20-fold greater prevalent utilization of SGAs was observed in PCH-dwelling elderly persons compared to those living in the community. In 2008/09, 27% of PCH-dwelling individuals received a prescription for an SGA. Patient characteristics, such as younger age, male gender, diagnoses of dementia (or use of an acetylcholinesterase inhibitor) or psychosis in the year prior the prescription, were predictors of non-optimal prescribing (e.g., high dose antipsychotics). During the period 2002/3 and 2007/8, amongst new users of SGAs, 10.2% received high doses. Those receiving high dose antipsychotics did not show high levels of polypharmacy.

Conclusions. Despite encouraging trends, the use of psychotropic medications remains high in elderly individuals, especially in residents of nursing homes. Clinicians caring for such patients need to carefully assess risks and benefits.

The effect of the Medicare Part D benzodiazepine exclusion on the utilization patterns of benzodiazepines and substitute medications

BACKGROUND

Although the benzodiazepine exclusion policy in the U.S. Medicare Part D drug coverage program has been studied, little information is available on individual use and switching patterns between benzodiazepines and substitute medications. Patients voluntarily were continuing or stopping benzodiazepines or switching to substitute medications. These individual-level outcomes can provide information beneficial to providers and policymakers to better understand the intended and unintended consequences of exclusion policies.

OBJECTIVE

The objective was to determine the effect of the Medicare Part D benzodiazepine exclusion on the utilization patterns of benzodiazepines and substitute medications by a select group of Medicare beneficiaries for a year following implementation of the exclusion. This research focused on the examination of the within-person patterns of benzodiazepine use and factors associated with these patterns.

METHODS

A quasi-experimental, comparative study was used to analyze prescription patterns and multinomial regression models were applied to investigate factors predicting different benzodiazepine use patterns. Pharmacy dispensing data for continuously eligible Medicare beneficiaries with at least one benzodiazepine fill in 2005 were reduced to a comparison group of 216 individuals with continual coverage and an intervention group of 250 individuals who lost coverage for benzodiazepines. Four individual patients' drug use patterns, continuation, switch, fluid movement, and cessation were identified by sorting and arraying pharmacy dispensing data to apply systematic drug file review. Multinomial regression models were used to examine the impact of coverage, demographic, medical, economic, and pharmaceutical factors.

RESULTS

Significantly more Medicare seniors who lost benzodiazepine coverage switched to potential substitute medications than those who continued to have coverage. Interestingly, 12 percent of affected seniors and 6 percent of unaffected seniors switched from and back to benzodiazepines (fluid movement). Zolpidem was the most popular substitute agent despite being an expensive brand-name drug. Regression models revealed that affected individuals had nearly two times the odds of engaging in switch-related patterns than those who had continuous coverage. Also, women were twice as likely to discontinue benzodiazepines as men.

CONCLUSIONS

More seniors who lost benzodiazepine coverage engaged in medication switching, and women were more likely to stop benzodiazepines after the implementation of the exclusion policy.

Dementia and hip fractures: development of a pathogenic framework for understanding and studying risk

Dementia and hip fractures are 2 conditions that are seen primarily in older adults, and both are associated with substantial morbidity and mortality. An individual with dementia is up to 3 times more likely than a cognitively intact older adult to sustain a hip fracture. This may occur via several mechanisms, including (1) risk factors that are common to both outcomes; (2) the presence of dementia increasing hip fracture incidence via intermediate risk factors, such as falls, osteoporosis, and vitamin D; and (3) treatment of dementia causing side effects that increase hip fracture risk. We describe a model that applies these 3 mechanisms to explain the relationship between dementia and hip fractures. Comprehensive understanding of these pathways and their relative influence on the outcome of hip fracture will guide the development of effective interventions and potentially improve prevention efforts.