Specialist prescribing of psychotropic drugs to older persons in Sweden--a register-based study of 188,024 older persons

Benzodiazepine-Receptor Agonist Utilization in Outpatients with Anxiety Disorder: A Retrospective Study Based on Electronic Healthcare Data from a Large General Tertiary Hospital

Benzodiazepine-receptor agonists (BZRAs), including benzodiazepines (BZDs) and drugs related to BZDs (Z-drugs), are commonly used for anxiety, but often have side effects. We retrospectively investigated the utilization and prescription characteristics of BZRAs for patients with anxiety disorders in a large tertiary care general hospital between 2018 and 2021, based on electronic healthcare records. We also examined the pattern of simultaneous consumption of multiple BZRA drugs, and the diseases coexisting with anxiety that are associated with this. The numbers of patients and BZRA prescriptions increased over the 4 years. Moreover, 7195 prescriptions from 694 patients contained two or more BZRAs, of which 78.08% contained both BZDs and Z-drugs, 19.78% contained multiple BZDs, and 2.14% contained multiple Z-drugs. For anxiety patients with concomitant Alzheimer's disease or Parkinson's disease, and dyslipidemia, they were more likely to consume multiple BZRAs simultaneously, whereas patients with concomitant insomnia, depression, hypertension, diabetes, or tumors were less likely to consume multiple BZRAs (all p < 0.05). Furthermore, older patients who consume multiple BZRAs simultaneously may have higher probabilities of long-term drug use. Better interventions supporting standardized BZD utilization may be needed to minimize the side effects of inappropriate BZRA administration.

Process of Deinstitutionalization of Aging Individuals With Severe and Disabling Mental Disorders: A Review

BACKGROUND

For more than 60 years, psychiatric services has gradually gone from an asylum model to a community model. This change has led to the emergence of a deinstitutionalization movement. This movement seems to have left behind long-term hospitalized aging individuals with severe and disabling mental disorders. The objective of this article is to conduct a review on the challenges and issues associated with the process of deinstitutionalization among hospitalized aging individuals with severe and disabling mental disorders.

METHODS

Using PRISMA statement, the research methodology was carried out in English and French in 16 databases with a combination of 3 lists of keywords. The selection process was then followed by a thematic analysis which aimed at categorizing by theme and classifying the writings selected.

RESULTS

A total of 83 articles published between 1978 and 2019 were selected and organized into six categories: (a) a forgotten population in research and health policies, (b) an economic presentation of the deinstitutionalization process, (c) an improvement in quality of life and global functioning for deinstitutionalized patients (d) from stigmatization to the rejection of elderly psychiatric inpatients from deinstutionalization process, (e) a difficult community-based care offer and a difficult epistemological identification, (f) from the lack of community services to the phenomenon of transinstitutionalization. The current state of scientific research, institutional policies and clinical practices associated with the deinstitutionalization process of SVPTSIH are then commented.

CONCLUSIONS

Recommendations are proposed to researchers and professionals concerned with the support of long-term hospitalized aging individuals with severe and disabling mental disorders.

Benzodiazepine Use and Risk of Acute Angle-Closure Glaucoma: A Population-Based Case-Crossover Study

INTRODUCTION

Theoretically, benzodiazepines (BZDs) can narrow the iridocorneal angle and induce acute angle-closure glaucoma (AACG). However, little evidence exists regarding this association.

OBJECTIVE

The objective of this study was to assess whether the use of BZDs is associated with the risk of AACG.

METHODS

We conducted a population-based case-crossover study using the nationwide claims database of the National Health Insurance Service in Korea. Patients with newly diagnosed AACG-between 1 January 2013 and 31 December 2016-who had received at least one BZD prescription prior to AACG diagnosis were enrolled. The date of AACG diagnosis was set as the index date. We assessed BZD use by each patient during a 30-day case period prior to the index date and three consecutive control periods that preceded this date. We used conditional logistic regression that adjusted for concomitant medications to determine the odds ratio for the use of BZDs in the case period compared with that in the control period in patients with incident AACG.

RESULTS

Of the 11,093 patients with incident AACG, 6709 received a prescription for BZD prior to diagnosis. BZD use was associated with an increased risk of AACG [adjusted odds ratio (aOR) = 1.40; 95% confidence interval (CI) 1.27-1.54]. AACG risk was similar for short-acting (aOR = 1.40, 95% CI 1.24-1.57) and long-acting BZDs (aOR = 1.33, 95% CI 1.18-1.50).

CONCLUSION

We found that BZD use was associated with AACG risk in the Korean population. Clinicians should carefully monitor the occurrence of visual disturbance in BZD-treated patients.

Variation and appropriateness of antipsychotic use in long-term care facilities across Newfoundland and Labrador

Objective:

The use of antipsychotics to treat seniors in long-term care facilities (LTCFs) has raised concern because of health consequences (i.e., increased risk of falls, stroke, death) in this vulnerable population. This study measured geographic patterns of antipsychotic utilization among seniors living in LTCFs in Newfoundland and Labrador (NL) and assessed potential inappropriateness.

Method:

We analyzed prescription records among adults 66 years and older with provincial prescription drug coverage admitted to LTCFs in NL between April 1, 2011, and March 31, 2014. Patterns of use were analyzed across the 4 regional health authorities (RHAs) in NL and LTCFs. Logistic, Poisson and linear regression models were used to test variations in prevalence, rate and volume of antipsychotic utilization. To assess potential inappropriateness of antipsychotic use, we analyzed data from Resident Assessment Instrument–Minimum Data Set (RAI-MDS) 2.0 forms from NL LTCFs between January 1, 2016, and December 31, 2018. Pearson chi-squared analysis was performed at the RHA and LTCF levels to determine changes in percentage of total prescriptions or antipsychotic prescriptions without psychosis.

Results:

Between 2011 and 2014, 2843 seniors were admitted to LTCFs across NL; of these, 1323 residents were prescribed 1 or more antipsychotics. Within the 3-year period, the percentage of antipsychotic use across facilities ranged from 35% to 78%. Using data from 27,260 RAI-MDS 2.0 assessments between 2016 and 2018, 71% (6995/9851) of antipsychotic prescriptions were potentially inappropriate.

Discussion:

There is substantial variation across NL regions concerning the utilization of antipsychotics for senior in LTCFs. Facility size and management styles may be reasons for this.

Conclusion:

With nearly three-quarters of antipsychotic prescriptions shown to be potentially inappropriate, systematic interventions to assess indications for antipsychotic use are warranted. Can Pharm J (Ott) 2021;154:xx-xx.

Problematic Medication With Benzodiazepines, "Z-drugs", and Opioid Analgesics

BACKGROUND

An estimated 1.4 to 2.6 million people in German suffer from drug dependence. Most of them are long-term users of benzodiazepines (BZD), Z drugs (ZD), or opioid analgesics (OA).

METHODS

This analysis is based on prescription data from patients of the national statutory health insurance system in the German federal states of Schleswig-Holstein, Hamburg, Bremen, and Lower Saxony. Drug-taking trends, duration, dosage, and long-term use of BZD, ZD, and OA in the years 2006 to 2015 are analyzed; prevalences are estimated for the years 2006 to 2016.

RESULTS

In 2006, 7.7% of patients received at least one prescription for a BZD, ZD, or OA; in 2016, 7.0% did. Over the period of analysis, a marked drop was seen in prescriptions of BZD and a slight fall in prescriptions of ZD (2006: BZD 3.5%, ZS 1.1%; 2016: BZD 2.0%, ZS 0.8%), but there was also an increase in prescriptions of OA, from 4.2% to 4.9%. The number of defined daily doses (DDD) prescribed per year fell for both BZD and ZD. For OA, the number of DDD prescribed per year rose from 2006 to 2009 and decreased by a small amount in subsequent years. The proportions of BZD and ZD patients who had long-term prescriptions fell over time, while the corresponding percentage of OA patients rose.

CONCLUSION

Nearly one-fifth of all prescriptions for BZD were long-term prescriptions for an entire year, in violation of the relevant guidelines. The rising prevalence of OA use was in the expected range in view of the aging population, but the number of prescriptions rose among younger patients as well. This trend toward more common treatment with opioid analgesics should be critically examined.

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.

Home care assistants' perspectives on detecting mental health problems and promoting mental health among community-dwelling seniors with multimorbidity

INTRODUCTION

Elderly people with multiple chronic conditions, or multimorbidity, are at risk of developing poor mental health. These seniors often remain in their homes with support from home care assistants (HCAs). Mental health promotion by HCAs needs to be studied further because they may be among the first to observe changes in clients' mental health status.

AIM

To describe HCAs' perspectives on detecting mental health problems and promoting mental health among homebound seniors with multimorbidity.

METHODS

We applied a descriptive qualitative study design using semi-structured interviews. Content analyses were performed on five focus group interviews conducted in 2014 with 26 HCAs.

RESULTS

Most HCAs stated that they were experienced in caring for clients with mental health problems such as anxiety, depression, sleep problems, and high alcohol consumption. The HCAs mentioned as causes, or risk factors, multiple chronic conditions, feelings of loneliness, and social isolation. The findings reveal that continuity of care and seniors' own thoughts and perceptions were essential to detecting mental health problems. Observation, collaboration, and social support emerged as important means of detecting mental health problems and promoting mental health.

CONCLUSION

The HCAs had knowledge of risk factors, but they seemed insecure about which health professionals had the primary responsibility for mental health. They also seemed to have detected early signs of mental health problems, even though good personal knowledge of the client and continuity in home visits were crucial to do so. When it came to mental health promotion, the suggestions related to the aim of ending social isolation, decreasing feelings of loneliness, and increasing physical activity. The results indicate that the HCAs seemed dependent on supervision by district nurses and on care managers' decisions to support the needed care, to schedule assignments related to the detection of mental health problems, and to promote mental health.

Benzodiazepine use and associated factors in elderly in the city of Dourados, MS, Brazil

ABSTRACT Objective The use of benzodiazepines (BZD) and associated factors in the elderly of Dourados, MS, Brazil was investigated. Methods This is a cross-sectional population-based study using a multistage sampling design. Participants were 1,022 individuals aged ≥ 60 years. Measurements socioeconomic status, schooling, demographic aspects, marital status, physical activity, hospitalizations, self-rated health, use of alcohol beverages and smoking were assessed by standard questionnaire. The drugs used were obtained by checking the prescription or package and classified according to the Anatomical Therapeutic Chemical Index. Chi-square test, Chi-square for linear tendency, Fisher's exact test and Poisson regression were used to assess association between variables. Results The prevalence of use of BZD was 6.5% (CI95%: 5.1-8.2%). The oldest group (PR: 1.60 for 70-79 years and PR: 1.79 for ≥ 80 years), non-use of alcohol (PR: 4.14) and use of antidepressants (PR: 8.73) were the statistically associated characteristics. Conclusions The prevalence of use of BZD in the study population was low, similar to findings of more recent Brazilian studies and lower than those obtained in international studies. The prevalence of use of BZD increased with aging and use of antidepressants.

Loneliness in the elderly is associated with the use of psychotropic drugs

OBJECTIVE

The aim of this study was to evaluate the association between loneliness in elderly people with the use of psychotropic drugs.

METHODS

A subsample of 3111 participants (ages 55-85) of the large population-based German ESTHER study was included in the study. Loneliness was measured by using a three-item questionnaire. Two subgroups were defined according to their degrees of loneliness. Psychotropic drugs were categorized by study doctors. Logistic regression analyses were conducted to determine the association between loneliness subgroups and the use of psychotropic drugs adjusted for psychosocial variables, multimorbidity, depression, anxiety, and somatic symptom severity.

RESULTS

Of the participants 14.1% (95%-CI = [12.9; 15.4]) were estimated to have a high degree of loneliness (women > men); 19% (95%-CI = [17.6; 20.4]) of the participants used psychotropic drugs, 8.4% (95%-CI = [7.5; 9.5]) antidepressants. Logistic regression analysis showed that more lonely participants had significantly higher odds for using psychotropic drugs (OR: 1.495; 95%-CI = [1.121; 1.993]). Depression severity, somatic symptom severity, and female gender were also positively associated with the use of psychotropic drugs.

CONCLUSION

A high degree of subjective loneliness in the elderly is associated with the use of psychotropic drugs, even after adjustment for somatic and psychological comorbidities and psychosocial variables.

Deprescribing benzodiazepines and Z-drugs in community-dwelling adults: a scoping review

BACKGROUND

Long-term sedative use is prevalent and associated with significant morbidity, including adverse events such as falls, cognitive impairment, and sedation. The development of dependence can pose significant challenges when discontinuation is attempted as withdrawal symptoms often develop. We conducted a scoping review to map and characterize the literature and determine opportunities for future research regarding deprescribing strategies for long-term benzodiazepine and Z-drug (zopiclone, zolpidem, and zaleplon) use in community-dwelling adults.

METHODS

We searched PubMed, Cochrane Central Register of Controlled Trials, EMBASE, PsycINFO, CINAHL, TRIP, and JBI Ovid databases and conducted a grey literature search. Articles discussing methods for deprescribing benzodiazepines or Z-drugs in community-dwelling adults were selected.

RESULTS

Following removal of duplicates, 2797 articles were reviewed for eligibility. Of these, 367 were retrieved for full-text assessment and 139 were subsequently included for review. Seventy-four (53%) articles were original research, predominantly randomized controlled trials (n = 52 [37%]), whereas 58 (42%) were narrative reviews and seven (5%) were guidelines. Amongst original studies, pharmacologic strategies were the most commonly studied intervention (n = 42 [57%]). Additional deprescribing strategies included psychological therapies (n = 10 [14%]), mixed interventions (n = 12 [16%]), and others (n = 10 [14%]). Behaviour change interventions were commonly combined and included enablement (n = 56 [76%]), education (n = 36 [47%]), and training (n = 29 [39%]). Gradual dose reduction was frequently a component of studies, reviews, and guidelines, but methods varied widely.

CONCLUSIONS

Approaches proposed for deprescribing benzodiazepines and Z-drugs are numerous and heterogeneous. Current research in this area using methods such as randomized trials and meta-analyses may too narrowly encompass potential strategies available to target this phenomenon. Realist synthesis methods would be well suited to understand the mechanisms by which deprescribing interventions work and why they fail.

Evolution of First-generation and Second-generation Antipsychotic Prescribing Patterns in Belgium Between 1997 and 2012: A Population-based Study

INTRODUCTION

In recent decades, a substantial increase in prescriptions of antipsychotics has been reported in several countries. This increase in antipsychotic sales has been attributed to the success of second-generation antipsychotics.

METHODS

This national register-based study investigated the evolution of outpatient antipsychotic sales in Belgium between 1997 and 2012. The impact of the specialization of the prescriber and the demographic characteristics of both prescribing doctors and patients were examined. The study used data obtained from the Belgian National Institute for Health and Disability Insurance and IMS Health Belgium.

RESULTS

Over this 15-year period, antipsychotic sales increased by 122% in Belgium. This growth was mainly explained by a 3-fold increase in antipsychotic prescriptions by psychiatrists and neurologists. Overall, only 29.5% of prescriptions for antipsychotics were for psychotic disorders and only 26.2% of prescriptions for antipsychotics were for mood disorders, suggesting a large amount of off-label use. A significant shift toward second-generation agents was found in prescriptions by both psychiatrists and general practitioners, although there may have been a small delay in moving toward second-generation agents in the latter group. This increase in second-generation antipsychotic prescribing was mainly due to the steep rise in sales of quetiapine, followed by olanzapine and risperidone. The shift toward the newer products was also mainly seen in younger prescribers.

CONCLUSIONS

The results of this study suggest that there has been an increase in adequate management of patients in need of antipsychotic treatment. Nevertheless, very few of the patients received continued treatment throughout the year, which implies that few outpatients with schizophrenia are receiving adequate treatment.

Socioeconomic inequalities in access to specialized psychotropic prescribing among older Swedes: a register-based study

Background: Mental disorders among older adults are mainly treated with psychotropic drugs. Few of these drugs are, however, prescribed by specialized geriatricians or psychiatrists, but rather from general practitioners (GPs). Socioeconomic inequalities in access to specialist prescribing have been found in younger age groups. Hence, we aimed to investigate whether there are socioeconomic differences in access to geriatrician and psychiatrist prescribing of psychotropic drugs among older adults. Methods: By record-linkage of The Swedish Prescribed Drug Register and The Swedish Education Register, we obtained information for persons aged 75–89 years who had filled a prescription for psychotropic drugs (antipsychotics, anxiolytics, hypnotic/sedatives or antidepressants) with information on prescriber specialty from July to October 2005 (n = 221 579). Multinomial regression analysis was used to investigate whether education was associated with geriatrician and psychiatrist prescribing of psychotropic drugs. Results: The vast majority of the psychotropic drugs were prescribed by ‘GPs and other specialists’ (∼95% GPs). Older adults with higher educational level were more likely to be prescribed psychotropic drugs from psychiatrists and geriatricians. However, after adjustment for place of residence, the association between patient’s education and prescription by a geriatrician disappeared, whereas the association with seeing a psychiatrist was only attenuated. Conclusion: Access to specialized prescribing of psychotropics is unequally distributed between socioeconomic groups of older adults in Sweden. This finding was partially confounded by place of residence for geriatrician but not for psychiatrist prescribing. Further research should examine if inequalities in specialized psychotropic prescribing translate into worse outcomes for socioeconomically deprived and non-metropolitan-living older individuals.

Benzodiazepine (BZD) use in community-dwelling older adults: Longitudinal associations with mobility, functioning, and pain

The aim of the study was to determine the prospective association between baseline BZD use and mobility, functioning, and pain among urban and rural African-American and non-Hispanic white community-dwelling older adults. From 1999 to 2001, a cohort of 1000 community-dwelling adults, aged ≥ 65 years, representing a random sample of Medicare beneficiaries, stratified by ethnicity, sex, and urban/rural residence were recruited. BZD use was assessed at an in-home visit. Every six months thereafter, study outcomes were assessed via telephone for 8.5-years. Mobility was assessed with the Life-Space Assessment (LSA). Functioning was quantified with level of difficulty in five basic activities of daily living (ADL: bathing, dressing, transferring, toileting, eating), and six instrumental activities of daily living (IADL: shopping, managing money, preparing meals, light and heavy housework, telephone use). Pain was measured by frequency per week and the magnitude of interference with daily tasks. All analytic models were adjusted for relevant covariates and mental health symptoms. After multivariable adjustment, baseline BZD use was significantly associated with greater difficulty with basic ADL (Estimate=0.39, 95% confidence interval (CI): 0.04-0.74), and more frequent pain (Estimate=0.41, 95%CI: 0.09-0.74) in the total sample and declines in mobility among rural residents (Estimate=-0.67, t(5,902)=-1.98, p=0.048), over 8.5 years. BZD use was prospectively associated with greater risk for basic ADL difficulties and frequent pain among African-American and non-Hispanic white community-dwelling older adults, and life-space mobility declines among rural-dwellers, independently of relevant covariates. These findings highlight the potential long-term negative impact of BZD use among community-dwelling older adults.

Interventions for reducing benzodiazepine use in older people: meta-analysis of randomised controlled trials

BACKGROUND

The use of benzodiazepines has been advised against in older people, but prevalence rates remain high.

AIMS

To review the evidence for interventions aimed at reducing benzodiazepine use in older people.

METHOD

We conducted a systematic review, assessment of risk of bias and meta-analyses of randomised controlled trials of benzodiazepine withdrawal and prescribing interventions.

RESULTS

Ten withdrawal and eight prescribing studies met the inclusion criteria. At post-intervention, significantly higher odds of not using benzodiazepines were found with supervised withdrawal with psychotherapy (odds ratio (OR) = 5.06, 95% CI 2.68-9.57, P<0.00001) and withdrawal with prescribing interventions (OR = 1.43, 95% CI 1.02-2.02, P = 0.04) in comparison with the control interventions treatment as usual (TAU), education placebo, withdrawal with or without drug placebo, or psychotherapy alone. Significantly higher odds of not using benzodiazepines were also found for multifaceted prescribing interventions (OR = 1.37, 95% CI 1.10-1.72, P = 0.006) in comparison with control interventions (TAU and prescribing placebo).

CONCLUSIONS

Supervised benzodiazepine withdrawal augmented with psychotherapy should be considered in older people, although pragmatic reasons may necessitate consideration of other strategies such as medication review.