Benzodiazepine prescription and length of hospital stay at a Japanese university hospital

Benzodiazepine Dependence After Cardiothoracic Intensive Care: A Nationwide Cohort Study

BACKGROUND

This study aimed to describe benzodiazepine use after cardiothoracic intensive care unit (ICU) care, including factors associated with new long-term high-potency benzodiazepine use after critical care, and to determine whether benzodiazepine use is associated with an increased risk of death.

METHODS

A nationwide retrospective cohort study was conducted of all cardiothoracic ICU patients in Sweden between 2010 and 2018. All patients older than 18 years who survived the first 3 months after admission to a cardiothoracic ICU were eligible for inclusion. A total of 36,135 patients were screened, and 4163 were ineligible.

RESULTS

In the final study cohort of 31,972 benzodiazepine-naive patients admitted to critical care, 578 patients had persistent high-potency benzodiazepine use. The proportion of new persistent benzodiazepine users was 5% in the first 3 months after ICU care, followed by a decline to a consistent level of 2% at 2 years of follow-up. Factors associated with persistent benzodiazepine use included higher age, female sex, psychiatric and somatic comorbidities, substance abuse, and preadmission opioid and low-potency benzodiazepine use. Adjusted hazard ratio for death 6 to 18 months after admission for new persistent benzodiazepine users was 2.2 (95% CI, 1.5-3.1; P < .001).

CONCLUSIONS

High-potency benzodiazepine consumption is increased 2 years after admission to cardiothoracic ICU care despite lack of support for long-term use of benzodiazepines. Being older and female, prior opioid use, and comorbid conditions were among risk factors for persistent benzodiazepine use. Persistent benzodiazepine users had an increased risk of death.

Benzodiazepine and Z-Drug Use in Switzerland: Prevalence, Prescription Patterns and Association with Adverse Healthcare Outcomes

PURPOSE

This study aimed to give a nationwide comprehensive picture of the prevalence and prescription patterns of benzodiazepines (BZ) and Z-drugs (ZD) in Switzerland and to analyze the association with adverse health care outcomes.

PATIENTS AND METHODS

A population-based, cross-sectional study was conducted, using a large health insurance database in Switzerland. Records from all adult patients with ≥1 prescription for a benzodiazepine and/or a Z-drug in 2018 were included. We calculated the prevalence of BZ and ZD user (extrapolated to the Swiss general population), the number of prescriptions and the type of provider (among each BZ and ZD only user). Multivariate logistic regression models were performed to estimate the association between drug prescription and the risk of hospitalization in different healthcare settings.

RESULTS

Of a total of 844'692 patients, 95'179 had ≥1 BZ and/or ZD prescription in 2018. The extrapolated one-year prevalence for the general Swiss population was 8.1% for a BZ prescription, 3.5% for a ZD prescription, and 10.5% for a BZ and/or ZD prescription, and continuously increased with age. The majority of the elderly (over 65 years) had ≥1 prescription (BZ: 51.9%; ZD: 56.9%; BZ and/or ZD: 53.5). The proportion of patients with ≥6 prescriptions per year was 23.1% for BZ only user and 35.2% for ZD only user. Most patients had ≥1 prescription from a general practitioner. Regression models showed a higher likelihood to be admitted to acute care, psychiatry, rehabilitation, or nursing home with ≥1 prescription for a benzodiazepine and/or a Z-drug.

CONCLUSION

This study is the first to give a nationwide overview of the current use of benzodiazepines and Z-drugs in Switzerland based on health insurance claims data. The results revealed a remarkably high prevalence among the general Swiss population, especially in older generations. The negative consequences of heavy BZ and ZD use are a crucial public health problem, that should be addressed.

An Implementation Guide to Promote Sleep and Reduce Sedative-Hypnotic Initiation for Noncritically Ill Inpatients

Sedative-hypnotic medications are frequently prescribed for hospitalized patients with insomnia, but they can result in preventable harm such as delirium, falls, hip fractures, and increased morbidity. Furthermore, sedative-hypnotic initiation while in the hospital carries a risk of chronic use after discharge. Disrupted sleep is a major contributor to sedative-hypnotic use among patients in the hospital and other institutional settings. Numerous multicomponent studies on improving sleep quality in these settings have been described, some demonstrating an associated reduction of sedative-hypnotic prescriptions. This selected review summarizes effective interventions aimed at promoting sleep and reducing inappropriate sedative-hypnotic initiation and proposes an implementation strategy to guide quality improvement teams.

Influence of lipopolysaccharide on diazepam-modified loss of righting reflex duration by pentobarbital treatment in mice

Benzodiazepine receptor agonists are widely prescribed therapeutic agents, alter gamma-aminobutyric acid (GABA)_A receptor function, and have hypnotic, anxiolytic, anticonvulsant, and antispastic effects. GABA_A receptor activity increases under systemic inflammatory conditions. We investigated the effect of benzodiazepine receptor agonists on pentobarbital-induced loss of righting reflex (LORR) duration using a mouse model of lipopolysaccharide (LPS)-induced inflammation. We assessed pentobarbital-induced LORR duration 24 h after LPS treatment in mice. Additionally, we examined the microglial response by immunohistochemistry and serum IL-6 and TNF-α concentrations in mice. LPS treatment significantly increased the duration of pentobarbital-induced LORR in mice treated with benzodiazepine receptor agonists (diazepam and brotizolam) and a GABA_A receptor agonist (muscimol) compared to that of mice treated with vehicle. These effects were blocked by bicuculline, a GABA_A receptor antagonist. LPS significantly increased the number of ionized calcium binding adapter molecule-1-positive hippocampal cells 2 and 24 h after treatment. The enhancing effect of diazepam in LPS-treated mice was significantly reduced by minocycline. These findings suggest that LPS enhances pentobarbital-induced LORR duration in mice treated with benzodiazepine via GABA_A receptor activity.

Cost-effectiveness analysis of suvorexant for the treatment of Japanese elderly patients with chronic insomnia in a virtual cohort

AIMS

This study assessed the cost-effectiveness of the orexin receptor antagonist suvorexant against zolpidem, the most widely used hypnotic benzodiazepine receptor agonist in Japan. To this end, a model was used that factored in insomnia and the risk for hip fractures, which have devastating effects on the elderly.

METHODS

Data were derived from published papers. The target population was a virtual cohort of elderly patients (≥65 years) with insomnia residing in Japan. Cost-effectiveness was evaluated using quality-adjusted life years (QALYs) and the incremental cost-effectiveness ratio as effectiveness measures. The investigators assumed the perspective of healthcare payers.

RESULTS

In the base-case analysis, suvorexant was cost-saving (suvorexant: $252.3, zolpidem: $328.7) and had higher QALYs gained (suvorexant: 0.0641, zolpidem: 0.0635) for elderly Japanese patients with insomnia compared with zolpidem, indicating that suvorexant was dominant. In the sensitivity analysis, the outcome changed from dominant to dominated due to the relative risk for hip fractures associated with suvorexant. However, when the other parameters were varied from the lower to the upper limits of their ranges, suvorexant remained dominant compared to zolpidem.

LIMITATIONS

The relative risk for hip fractures for suvorexant used in the model was based on data from pre-approval clinical trials. More precise data may be needed.

CONCLUSIONS

Suvorexant seemed to be more cost-effective than the alternative zolpidem. The findings suggested that suvorexant might be a viable alternative to zolpidem for elderly patients with insomnia. A sensitivity analysis showed that outcome varied depending on the relative risk for hip fractures associated with suvorexant. Further investigations may be needed for more precise results.

Prescribing practices in Southeastern Europe - focus on benzodiazepine prescription at discharge from nine university psychiatric hospitals

There is much concern about the widespread long-term use of benzodiazepines. Our manuscript addressed its use in the region of Southeastern Europe, which seems extensive, but insufficiently explored. At nine university psychiatric hospitals (Croatia, Macedonia and Serbia), we retrospectively analyzed discharge summary documents to find the prevalence of discharge benzodiazepine prescriptions and the prescribed benzodiazepine doses. This study included 1047 adult subjects and showed that 81.9% of them had benzodiazepines prescribed in the discharge summary document, with high mean daily dose of around 5mg lorazepam equivalents. Factors associated with the prescriptions were exclusively clinical factors (diagnosis of schizophrenia spectrum disorders, more lifetime hospitalizations, psychiatric comorbidity, co-prescription of antidepressant or mood stabilizer, shorter duration of the hospitalization), while socio-demographic factors were not found to influence benzodiazepine discharge prescriptions. Similarly, factors which influenced the prescription of higher daily benzodiazepine dose were more lifetime psychiatric hospitalizations and co-prescription of antidepressant or mood stabilizer, as well as the diagnosis of mental/behavioral disorders due to substance use and co-prescribed antipsychotic. Our data are emphasizing an urgent need for guidelines and improved education of both health care professionals and patients, in order to prevent long term benzodiazepine (mis)use and related side-effects.

Benzodiazepines are Prescribed More Frequently to Patients Already at Risk for Benzodiazepine-Related Adverse Events in Primary Care

BACKGROUND

Benzodiazepine use is associated with adverse drug events and higher mortality. Known risk factors for benzodiazepine-related adverse events include lung disease, substance use, and vulnerability to fracture.

OBJECTIVE

To determine whether benzodiazepine prescribing is associated with risk factors for adverse outcomes.

DESIGN

Longitudinal cohort study between July 1, 2011, and June 30, 2012.

PARTICIPANTS

Patients who visited hospital- and community-based practices in a primary care practice-based research network.

MAIN MEASURES

Odds ratio of having a target medical diagnosis for patients who received standard and high-dose benzodiazepine prescriptions; rates per 100 patients for outpatient and emergency department visits and hospitalizations.

KEY RESULTS

Among 65,912 patients, clinicians prescribed at least one benzodiazepine to 15 % (9821). Of benzodiazepine recipients, 5 % received high doses. Compared to non-recipients, benzodiazepine recipients were more likely to have diagnoses of depression (OR, 2.7; 95 % CI, 2.6-2.9), substance abuse (OR, 2.2; 95 % CI, 1.9-2.5), tobacco use (OR, 1.7; 95 % CI, 1.5-1.8), osteoporosis (OR, 1.6; 95 % CI, 1.5-1.7), chronic obstructive pulmonary disease (OR, 1.6; 95 % CI, 1.5-1.7), alcohol abuse (OR, 1.5; 95 % CI, 1.3-1.7), sleep apnea (OR, 1.5; 95 % CI, 1.3-1.6), and asthma (OR, 1.5; 95 % CI, 1.4-1.5). Compared to low-dose benzodiazepine recipients, high-dose benzodiazepine recipients were even more likely to have certain medical diagnoses: substance abuse (OR, 7.5; 95 % CI, 5.5-10.1), alcohol abuse (OR, 3.2; 95 % CI, 2.2-4.5), tobacco use (OR, 2.7; 95 % CI, 2.1-3.5), and chronic obstructive pulmonary disease (OR, 1.5; 95 % CI, 1.2-1.9). Benzodiazepine recipients had more primary care visits per 100 patients (408 vs. 323), specialist outpatient visits (815 vs. 578), emergency department visits (47 vs. 29), and hospitalizations (26 vs. 15; p < .001 for all comparisons).

CONCLUSIONS

Clinicians prescribed benzodiazepines and high-dose benzodiazepines more frequently to patients at higher risk for benzodiazepine-related adverse events. Benzodiazepine prescribing was associated with increased healthcare utilization.

Clinical risk factors associated with postoperative delirium and evaluation of delirium management and assessment team in lung and esophageal cancer patients

Background

Delirium is an acute change in cognition and concentration that complicates the postoperative course. Patients who suffer delirium after surgery have an increased risk of persistent cognitive impairment, functional decline, and death. Postoperative delirium is also associated with an increased length of hospital stay and higher costs. With the goal of preventing delirium in postoperative patients, we organized a medical team from the Delirium Management and Assessment Center (D-mac) at Okayama University Hospital in January 2012. The team members consisted of physicians, pharmacists, nurses, and clinical psychologists.

Methods

We retrospectively reviewed the medical records of patients with delirium to examine risk factors related to the patients’ background.

Results

Fifty-nine postoperative patients with lung or esophageal cancer were investigated; 25% exhibited delirium during hospitalization. Multiple logistic regression analysis showed significant associations between the presence of delirium and a past history of delirium (odds ratio, 4.22; 95% CI, 1.10-16.2; p = 0.09) and use of benzodiazepine receptor agonists (odds ratio, 3.97; 95% CI, 1.09-14.5; p = 0.03). Intervention by the D-mac significantly reduced the rate of delirium episodes in lung cancer patients (p =0.01). Notably, prior to intervention, the incidence of delirium was 100% when three high-risk factors for delirium were present. In contrast, the incidence of delirium in patients with three high-risk factors decreased following implementation of the D-mac intervention.

Conclusions

These findings suggest that active participation by various staff in the medical team managing delirium had a marked therapeutic impact.

[Remote consequences of the long-term uncontrolled use of anxiolytic and hypnotic drugs by elderly patients: cognitive disorders]

OBJECTIVE

Frequents cases (10-30% of the elderly population) of regular long-term use of anxiolytic and hypnotic drugs, in particular, benzodiazepines, without control of the physician is an urgent problem of medicine worldwide. Severe and irreversible cognitive impairment is a frequent and severe consequence of this use. Authors studied cognitive impairment in these cases.

MATERIAL AND METHODS

Patients were enrolled in the study from a psychiatric hospital. The study included 56 women, aged over 50 years, admitted to the hospital with the diagnosis of a mental disorder. Before admission, the patients regularly used benzodiazepines without a prescription for more than 2 months. Later on, anxiolytics were withdrawn during 1-5 days. The patients were studied during 4 weeks in the hospital. To assess the severity and dynamics of their condition, authors used MADRS, HAM-A, MMSE.

RESULTS AND CONCLUSION

Severe cognitive impairment, achieving the level of dementia, was found in 57.2% of the patients, mild or moderate of cognitive impairment was in 32.1% and only 10.7% had normal level of cognitive functioning. After 4 weeks of benzodiazepine withdrawal, the percentage of patients with dementia reduced to 21.4%, the severity of cognitive impairment was estimated as mild or moderate. A number of patients without cognitive impairment increased to 37.5%. The old age of patients was a significant negative predictor of the dynamics. An impact of the high anxiolytic dose was shown on trend level. The duration of a mental disorder and duration of uncontrollable consumption of anxiolytics and hypnotics did not exert an effect on the development and reversibility of cognitive impairment. A combination of anxiolytics with alcohol increased the risk of dementia and did not reverse the cognitive pathology.

[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.