Association between use of benzodiazepines and risk of fractures: a meta-analysis

Chronic benzodiazepine usage among older people: prevalence, indications, and treatment modifications in patients admitted to an acute geriatric unit

AIM

To investigate the prevalence and indications of benzodiazepines (BZD) usage among patients admitted to an acute geriatric unit and assess changes in prescriptions.

METHODS

BZD indications were documented reviewing clinical records, with appropriateness assessed based on the STOPP-START criteria. Changes in BZD prescriptions were recorded at discharge and 3 months later.

RESULTS

Among the 366 patients included (mean age: 92.8 years, 68% females), 91 (24.9%) were on BZD upon admission, being inappropriate in 93.4%. At discharge, BZD discontinuation was observed in 40.7% and dose reduction initiated in 57.4%. Among patients discharged without prescriptions, 10.8% resumed their use at 3 months. Of those discharged with BZD tapering, 74.1% were still on them 3 months later.

CONCLUSIONS

The majority of patients employing BZD lacked a medical indication. Admission to a geriatric ward resulted in successful discontinuation or dose reduction for most patients but was not maintained in the outpatient setting.

Prevalence, country-specific prescribing patterns and determinants of benzodiazepine use in community-residing older adults in 7 European countries

BACKGROUND

The use of benzodiazepines (BZDs) in older population is often accompanied by drug-related complications. Inappropriate BZD use significantly alters older adults' clinical and functional status. This study compares the prevalence, prescribing patterns and factors associated with BZD use in community-dwelling older patients in 7 European countries.

METHODS

International, cross-sectional study was conducted in community-dwelling older adults (65 +) in the Czech Republic, Serbia, Estonia, Bulgaria, Croatia, Turkey, and Spain between Feb2019 and Mar2020. Structured and standardized questionnaire based on interRAI assessment scales was applied. Logistic regression was used to evaluate factors associated with BZD use.

RESULTS

Out of 2,865 older patients (mean age 73.2 years ± 6.8, 61.2% women) 14.9% were BZD users. The highest prevalence of BZD use was identified in Croatia (35.5%), Spain (33.5%) and Serbia (31.3%). The most frequently prescribed BZDs were diazepam (27.9% of 426 BZD users), alprazolam (23.7%), bromazepam (22.8%) and lorazepam (16.7%). Independent factors associated with BZD use were female gender (OR 1.58, 95%CI 1.19-2.10), hyperpolypharmacy (OR 1.97, 95%CI 1.22-3.16), anxiety (OR 4.26, 95%CI 2.86-6.38), sleeping problems (OR 4.47, 95%CI 3.38-5.92), depression (OR 1.95, 95%CI 1.29-2.95), repetitive anxious complaints (OR 1.77, 95%CI 1.29-2.42), problems with syncope (OR 1.78, 95%CI 1.03-3.06), and loss of appetite (OR 0.60, 95%CI 0.38-0.94). In comparison to Croatia, residing in other countries was associated with lower odds of BZD use (ORs varied from 0.49 (95%CI 0.32-0.75) in Spain to 0.01 (95%CI 0.00-0.03) in Turkey), excluding Serbia (OR 1.11, 95%CI 0.79-1.56).

CONCLUSIONS

Despite well-known negative effects, BZDs are still frequently prescribed in older outpatient population in European countries. Principles of safer geriatric prescribing and effective deprescribing strategies should be individually applied in older BZD users.

Insomnia in Postmenopausal Women: How to Approach and Treat It?

Insomnia is one of the major complaints of menopausal women with advancing age and may be complexly related to a variety of causes. However, there is still a lack of standards on the general approach and treatment for insomnia in menopausal women. The aim of this review is to summarize recent pathogenic theories of sleep disturbance in the menopausal period and discuss the approach and management of insomnia in postmenopausal women. Sleep disturbances in menopausal women may be associated with physical and psychiatric factors and other comorbid diseases. Careful history taking and multidisciplinary physical and psychosocial evaluation are necessary and, in particular, comorbidities related to sleep disorders, such as obstructive sleep apnea, must be taken into consideration. A unique aspect of insomnia in postmenopausal women is that menopausal symptoms due to hormonal decline can be closely related to sleep disturbances. Therefore, menopausal hormone therapy (MHT) should be considered as the treatment of choice among pharmacological treatments following cognitive behavioral therapy, which is suggested as the first-line treatment in the general population insomnia treatment guidelines. Additionally, melatonin and 5HT-based drugs, which have fewer side effects, along with MHT should be preferentially recommended in menopausal women.

Potentially Inappropriate Medication Dispensing in Outpatients: Comparison of Different Measurement Approaches

Purpose of the Research

This paper aims at comparing different approaches to measure potentially inappropriate medication (PIM) with routinely collected data on prescriptions, patient age institutionalization status (ie in nursing home or in the community). A secondary objective is to measure the rate and prevalence of PIM dispensing and to identify problematic practices in Switzerland.

Material and Methods

The studied population includes about 90,000 insured over 17 years old from a Swiss health maintenance organization in 2019 and 2020. We computed and compared the number of PIM per patient for Beers criteria, Priscus list, Laroche, NORGEP and Prescrire approaches. We also created a composite indicator that accounts for the specificities of the Swiss context (adaptation to the Swiss drugs' market, recommendations in force related to sleeping pills, anxiolytics and NSAIDs). We also stratified the analysis per physician, including initiation and cessation of PIM prescription.

Results

Our comparison revealed similarities between the approaches, but also that each of them had specific gaps that provides further motivation for the development of a composite approach. PIM rate was particularly high for sleeping pills, anxiolytics, NSAIDs, even when analyses were limited to chronic use. Drugs with anticholinergic effect were also frequently prescribed. Based on our composite indicator, 27% of insured over 64 years old received at least one PIM in 2020, and 8% received more than one. Our analyses also reveal that for sleeping pills and anxiolytics, half of the volume (or prevalence?) occurs in the <65 population. We observed strong variations between physicians and a significant proportion of new users among patients with PIM.

Conclusion

Our results show that PIMs prescribing is very frequent in Switzerland and is driven mostly by a few drug categories. There is important physician variation in PIM prescribing that warrants the development of intervention targeted at high PIM-prescribers.

Influence of non-osteoporotic treatments in patients on active anti-osteoporotic therapy: evidence from the OSTEOMED registry

PURPOSE

To evaluate the effect of different non-osteoporotic drugs on the increase or decrease in the risk of incident fragility fractures (vertebral, humerus or hip) in a cohort of patients diagnosed with osteoporosis on active anti-osteoporotic therapy.

METHODS

For this retrospective longitudinal study, baseline and follow-up data on prescribed non-osteoporotic treatments and the occurrence of vertebral, humerus or hip fractures in 993 patients from the OSTEOMED registry were analyzed using logistic regression models. The drugs evaluated with a possible beneficial effect were thiazides and statins, while the drugs evaluated with a possible harmful effect were antiandrogens, aromatase inhibitors, proton pump inhibitors, selective serotonin reuptake inhibitors, benzodiazepines, GnRH agonists, thyroid hormones, and oral and inhaled corticosteroids.

RESULTS

Logistic regression analyses indicated that no treatment significantly improved fracture risk, with the only treatments that significantly worsened fracture risk being letrozole (OR = 0.18, p-value = 0.03) and oral corticosteroids at doses ≤ 5 mg/day (OR = 0.16, p-value = 0.03) and > 5 mg/day (OR = 0.27, p-value = 0.04).

CONCLUSION

The potential beneficial or detrimental effects of the different drugs evaluated on fracture risk are masked by treatment with anabolic or antiresorptive drugs that have a more potent action on bone metabolism, with two exceptions: letrozole and oral corticosteroids. These findings may have important clinical implications, as patients receiving these treatments are not fully protected by bisphosphonates, which may imply the need for more potent anti-osteoporotic drugs such as denosumab or teriparatide.

Therapeutic dilemmas with benzodiazepines and Z-drugs: insomnia and anxiety disorders versus increased fall risk: a clinical review

PURPOSE

The aim of this clinical review was to summarise the existing knowledge on fall risk associated with benzodiazepines (BZDs) and Z-drugs in older people with focus on appropriate prescribing, including deprescribing.

METHODS

We conducted a literature search in June 2021 in PubMed and Embase with citation and reference checking. Personal reference libraries and international websites were also used. Keywords for the searches included "benzodiazepines", "Z-drugs", "falls", "deprescribing", "fall-risk-increasing-drugs", "inappropriate prescribing", "older people" and matching synonyms. We discuss use of BZDs and Z-drugs, potential fall-related adverse reactions, alternatives for and deprescribing of BZDs and Z-drugs in older persons.

RESULTS

BZDs and Z-drugs differ in fall-related adverse effect profile. They contribute to fall risk through orthostatic hypotension, dizziness and/or imbalance, sedation, muscular weakness, ataxia, etc. Fall incidents contribute significantly to mortality and morbidity. Therefore, there is a need for appropriate prescribing and use of BZDs and Z-drugs in older people. In practice, this means pertaining to a strict indication, strongly consider to non-pharmacological alternatives, limit use to the lowest dose and the shortest duration possible. Judicious deprescribing should be considered and encouraged as well. Practical resources, tools and algorithms are available to guide and assist clinicians in deprescribing BZDs and Z-drugs.

CONCLUSIONS

Prescribing BZDs and Z-drugs should be done in a well-considered way in fall-prone older people. A good overview and insight in the fall-related adverse effects of these drugs, as well as the availability of different strategies to increase the appropriate use, including deprescribing initiatives, can assist clinicians in clinical decision-making.

Development and acceptability of a decision aid for anxiety disorder considering discontinuation of benzodiazepine anxiolytic

Aim

We aimed to develop a decision aid (DA) for individuals with anxiety disorders who consider tapering benzodiazepine (BZD) anxiolytics, and if tapering, tapering BZD anxiolytics with or without cognitive behavioral therapy (CBT) for anxiety. We also assessed its acceptability among stakeholders.

Methods

First, we conducted a literature review regarding anxiety disorders to determine treatment options. We cited the results of the systematic review and meta-analysis, which we conducted previously, to describe the related outcomes of two options: tapering BZD anxiolytics with CBT and tapering BZD anxiolytics without CBT. Second, we developed a DA prototype in accordance with the International Patient Decision Aid Standards. We carried out a mixed methods survey to assess the acceptability among stakeholders including those with anxiety disorders and healthcare providers.

Results

Our DA provided information such as explanation of anxiety disorders, options of tapering or not tapering BZD anxiolytics (if tapering, the options of tapering BZD anxiolytics with or without CBT) for anxiety disorder, benefits and risks of each option, and a worksheet for value clarification. For patients (n = 21), the DA appeared to be acceptable language (86%), adequate information (81%), and well-balanced presentation (86%). The developed DA was also acceptable for healthcare providers (n = 10).

Conclusion

We successfully created a DA for individuals with anxiety disorders who consider tapering BZD anxiolytics, which was acceptable for both patients and healthcare providers. Our DA was designed to assist patients and healthcare providers to involve decision-making about whether to taper BZD anxiolytics or not.

Association between the Use of Suvorexant and Hip Fracture in Older Adults in Japan Using a Nationwide Administrative Claims Database: A Matched Case-Control Study

BACKGROUND AND OBJECTIVE

The use of benzodiazepines and nonbenzodiazepines increases the risk for hip fracture, but the effect of suvorexant, an orexin receptor antagonist, is not clear. The objective of this study was to investigate the association between suvorexant use and hip fractures in older adults.

METHODS

A case-control study was conducted using real-world data (RWD) from Medical Data Vision Co., Ltd. with patients hospitalized between January 2019 and December 2020. Patients were aged 65-84 years and had been prescribed suvorexant at least once. Patients with hip fracture (cases) and those without (controls) were identified by matching up to 1:4 for sex, age (± 2 years), and hospital size category. Suvorexant exposure was identified the day before hospitalization. Hip fracture risk associated with suvorexant was presented as adjusted odds ratios (aOR) with 95% confidence intervals (CI) using conditional logistic regression analysis.

RESULTS

Matching identified 389 cases and 1509 controls. The risk of hip fracture was not increased in patients treated with suvorexant [aOR: 0.86, 95% confidence interval (CI) 0.61-1.20]. Additionally, concomitant use of suvorexant with other hypnotics did not increase the risk. Benzodiazepines (1.01, 0.46-2.22), nonbenzodiazepines (1.16, 0.57-2.34), and melatonin (1.80, 0.82-3.94) were combined with suvorexant. The risk was increased for the use of benzodiazepine without suvorexant (1.88, 1.10-3.21).

CONCLUSIONS

Using RWD in Japanese older adults, we showed that sleep therapy with suvorexant was not associated with an increased risk of hip fracture. The results provide evidence-based drug safety information for the selection of hypnotics for sleep disorders, which increase with age.

A Comparison between Perceptions of Psychiatric Outpatients and Psychiatrists Regarding Benzodiazepine Use and Decision Making for Its Discontinuation: A Cross-Sectional Survey in Japan

BACKGROUND

Although long-term use of benzodiazepines and z-drugs (BZDs) is not recommended, little is known about the stakeholders' perceptions. This study aimed to assess and compare the perceptions of BZD use and decision making regarding its discontinuation between psychiatric outpatients and psychiatrists.

METHODS

A cross-sectional survey was conducted.

RESULTS

Of 104 outpatients, 92% were taking hypnotics and 96% were taking anxiolytics for ≥a year, while 49% were willing to taper hypnotic/anxiolytics within a year of starting. Most psychiatrists felt that "patient and psychiatrist make the decision together on an equal basis" compared to patients (p < 0.001), while more patients felt that "the decision is (was) made considering the psychiatrists' opinion" compared to psychiatrists (p < 0.001). Of 543 psychiatrists, 79% reported "patients were not willing to discontinue hypnotic/anxiolytic" whereas a certain number of patients conveyed "psychiatrists did not explain in enough detail about hypnotic/anxiolytic discontinuation such as procedure (18.3%), timing (19.2%), and appropriate condition (14.4%)".

CONCLUSION

The results suggest that the majority of psychiatric outpatients were taking hypnotic/anxiolytics for a long time against their will. There might be a difference in perceptions toward hypnotic/anxiolytic use and decision making for its discontinuation between psychiatric outpatients and psychiatrists. Further research is necessary to fill this gap.

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

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Implementing a Multifaceted Intervention among Internal Medicine Residents with Audit and Educative Data Feedback Significantly Reduces Low-Value Care in Hospitalized Patients

Background: The dissemination of recommendations on low-value care alone may not lead to physicians’ behavioral changes. The aim of this study was to evaluate whether a multifaceted behavioral intervention among internal medicine residents could reduce low-value care in hospitalized patients. Methods: A pre–post quality improvement intervention was conducted at the Internal Medicine Division of La Tour hospital (Geneva, Switzerland) from May 2020 to October 2021. The intervention period (3 months) consisted of a multifaceted informational intervention with audits and educative feedback about low-value care. The pre- and post-intervention periods including the same six calendar months were compared in terms of number of blood samples per patient day, prescription rates of benzodiazepines (BZDs) and proton pump inhibitors (PPIs), as well as safety indicators including potentially avoidable readmissions, premature deaths and complications. results: A total of 3400 patients were included in this study; 1095 (32.2%) and 1155 (34.0%) were, respectively, hospitalized during the pre- and post-intervention periods. Patient characteristics were comparable between the two periods. Only the number of blood tests per patient day and the BZD prescription rate at discharge were significantly reduced in the post-intervention phase (pre: 0.54 ± 0.43 vs. post: 0.49 ± 0.60, p ≤ 0.001; pre: 4.2% vs. post: 1.7%, p = 0.003, respectively). PPI prescription rates remained comparable. Safety indicators analyses revealed no significant differences between the two periods of interest. Conclusions: Our results demonstrate a modest but statistically significant effect of a multifaceted educative intervention in reducing the number of blood tests and the BZD prescription rate at discharge in hospitalized patients. Limiting low-value services is very challenging and additional long-term interventions are necessary for wider implementation.

Psychotropics use and occurrence of falls in hospitalized patients: A matched case-control study

AIM

Several studies have suggested the use of psychotropics as a possible risk factor for falling. However, there were several limitations to these previous studies, such as the use of data obtained from administrative databases and the lack of information about the time interval between psychotropics use and falling. Therefore, in this study, we aimed to assess the association between psychotropics use and falling in hospitalized patients, using reliable data collected from medical records.

METHODS

A matched (age, sex, and inpatient department) case-control study of patients hospitalized at Tokyo Medical University Hospital was performed using the new-user design, based on data extracted from medical records. The outcome was the occurrence of falls. The use of four classes of psychotropics (antipsychotics, antidepressants, anxiolytics, and hypnotics) was compared between 254 cases (patients who experienced falls) and 254 controls (patients without falls). Multivariable logistic regression analysis was performed to clarify the associations between falling and the use of these psychotropics.

RESULTS

Univariable analyses demonstrated that the use of every class of psychotropic was statistically significantly associated with falling. Moreover, the association of the use of hypnotics with falls remained significant in the multivariable logistic regression model built including potential confounding factors, such as age, sex, inpatient department, body mass index, fall risk score measured by a fall risk assessment sheet completed on hospital admission, and the use of other classes of psychotropics.

CONCLUSIONS

Our findings suggest that the use of hypnotics may be a risk factor for falling in hospitalized patients.

Deprescribing clonazepam in primary care older patients: a feasibility study

Background Inappropriate use of clonazepam by older adults is associated with cognitive impairment, delirium, and falls. Strategies to optimize its use are important to increase patient safety. Objective To evaluate the feasibility of a clonazepam deprescription protocol in the elderly. Methods This is a quasi-experimental study. Elderly people with chronic use of clonazepam and attended in primary care units in two Brazilian municipalities were selected. A deprescription protocol was used, which included five fortnightly meetings between the older adults and the research team, to reduce the dose by 25%. Patients received instructions on sleep hygiene behaviors and the advantages of clonazepam deprescription; family physicians followed a flowchart for gradual dose reduction. In the 1st and 5th meetings, there were medical appointments for anamnesis and discharge. The monitoring of patients and the application of tests were carried out by the research team. Results Of the 35 elderly people included in the study, 27 reached the end; 81.5% achieved deprescription: 22.2% stopped completely and 59.3% decreased the dose. At the last meeting, 20% of elderly patients reported an increase in blood pressure. Conclusion The high rate of deprescription and the little relevance of clonazepam withdrawal reactions, showed that the use of the protocol was effective. However, the increase in blood pressure and the worsening of sleep quality in the last meeting show the need for adjustment in the last stage of the deprescription process.

Risk of fracture in antidepressant users with concurrent use of benzodiazepines: A self-controlled case-series analysis

OBJECTIVE

Despite the fracture risk associated with both antidepressant (AD) medication and benzodiazepines (BDZs), they are commonly prescribed simultaneously. However, studies elucidating the effects of concurrent use of BDZs and ADs on the risk fracture are scant. The objective of this study was to evaluate the risk of fracture associated with concurrent use of BDZs in AD users, using a self-controlled case-series analysis.

METHODS

A self-controlled case-series analysis, in which the participants act as their own control, was conducted using the Korean National Health Insurance Service-National Sample Cohort database (2002-2015). We studied AD users who were prescribed BDZs and diagnosed with a fracture. The risk periods were subdivided into consecutive periods (1-30, 31-60, and > 60 days) after receiving a BDZ. A 2-week pre-exposure period and a 2-week post-exposure period were also included. The incidence rate ratio (IRR) was estimated after adjusting for age and use of co-medications.

RESULTS

A total of 3020 patients were identified during the study period. There was an increased fracture risk in the first 30 days following BDZ use (IRR: 1.88, 95% confidence interval [CI] 1.66-2.12), in the 31-60-day period (1.73, 95% CI 1.48-2.02), and beyond the 60-day period (IRR: 1.68, 95% CI 1.47-1.91). The risks of fracture were greater in men and older patients.

CONCLUSION

The concomitant use of BDZs and ADs was related to a significant increase in fracture risk. AD users should be aware of the fracture risk with concomitant BDZ use, especially for first-time BDZ users and for elderly patients.

Risk of long-term benzodiazepine and Z-drug use following the first prescription among community-dwelling adults with anxiety/mood and sleep disorders: a retrospective cohort study

OBJECTIVE

To measure the incidence of long-term benzodiazepine receptor agonist (BZRA) use among individuals with anxiety, mood and/or sleep disorders. To identify factors associated with long-term use following the first prescription.

METHODS

This was a population-based retrospective cohort study using administrative databases in Manitoba, Canada. Individuals with anxiety/mood or sleep disorder who received their first BZRA between 1 April 2001 and 31 March 2015 were included. Long-term use was defined as ≥180 days. Logistic regression modelling was used to examine predictors of long-term use.

RESULTS

Among 206 933 individuals included, long-term BZRA use in the first episode of use was 4.5% (≥180 days) following their first prescription. Factors associated with ≥180 days of use included male sex (adjusted OR (aOR) 1.33, 95% CI 1.27 to 1.39), age ≥65 (aOR 5.15, 95% CI 4.81 to 5.52), income assistance (aOR 1.68, 95% CI 1.55 to 1.81), previous non-BZRA psychotropic (aOR 1.93, 95% CI 1.83 to 2.02) or opioid use (aOR 1.16, 95% CI 1.11 to 1.22), high comorbidity (aOR 1.43, 95% CI 1.32 to 1.55), high healthcare use (aOR 1.46, 95% CI 1.33 to 1.60) and psychiatrist prescriber (aOR 2.11, 95% CI 1.93 to 2.32).

CONCLUSIONS

Less than 1 in 20 patients use BZRAs ≥180 days in their first treatment episode. Several factors were associated with long-term use following the first prescription and further investigation into whether these factors need to be considered at the point of prescribing is warranted. In light of these findings, future research should examine the predictors of cumulative repeat episodes of BZRA exposure.

A meta-analysis of observational studies on anticholinergic burden and fracture risk: evaluation of conventional burden scales

Background

Anticholinergic burden potentially increases the risk of fracture. Although there are various anticholinergic burden scales, little is known about the inter-scale compatibility regarding the relationship of anticholinergic burden with fracture risk. We performed meta-analysis to examine the association of fracture risk with anticholinergic burden measured using various scales.

Methods

Primary literature was retrieved from PubMed (1966 to March, 2021), the Cochrane Library (1974 to March, 2021), Scopus (1970 to March, 2021), and Ichushi-web (1983 to March, 2021). Cohort and case-control studies that evaluated the association between any fracture and anticholinergic drugs were included. Additionally, we included studies in which patients were administered anticholinergic drugs included on the anticholinergic risk scale (ARS), anticholinergic cognitive burden (ACB), anticholinergic drug scale, or drug burden index-anticholinergic component. Random effects models were used to calculate pooled relative risk (RR) and 95% confidence interval (CI) due to heterogeneity among the studies. Publication bias was examined by funnel plots and the Begg’s test.

Results

A total of 49 datasets from 10 studies were included in the meta-analysis. Six of the 10 studies included only patients aged over 65 years, who accounted for 93% of the total study population (453,186/487,247). Meta-analysis indicated a positive relationship between use of anticholinergic drugs and fracture risk, regardless of the anticholinergic burden scale used. However, the relationship between anticholinergic burden and fracture risk varied depending on the scale used. Fracture risk increased linearly with increasing anticholinergic burden measured using ARS. ARS 1 point was associated with 28% increase in fracture risk, ARS 1–2 point(s) with 39%, ARS 2 points with 54%, ARS 3 points with 66%, and ARS ≥ 4 points with 77%. On the other hand, ACB 1 point and ACB 2 points were associated with similar fracture risk (pooled RR [95% CI]: overall; 1.28 [1.18–1.39], 1 point; 1.12 [1.06–1.18], 2 points; 1.15 [1.08–1.23]).

Conclusions

This result suggests that the relationship between anticholinergic drug burden and fracture risk may differ depending on the anticholinergic burden scale used.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40780-021-00213-y.

Refractory catatonia in old age: a case report

BACKGROUND

Catatonia is a clinical syndrome characterized by psychomotor disruption, which often goes undiagnosed. Most reports have focused on interventions and outcomes for catatonia in younger people and those with schizophrenia. The clinical characteristics and course of catatonia in old age are poorly understood. We present a report of an older person whose catatonia was refractory to extensive treatment, and we identify important implications for the management of catatonia in old age.

CASE PRESENTATION

We describe a 73-year-old white man with longstanding autistic spectrum disorder who presented with symptoms of depression. Following a period of diagnostic uncertainty and failure to improve with antidepressant medication, a lorazepam challenge yielded an abrupt improvement in presentation. The patient was treated extensively with lorazepam, zolpidem, and electroconvulsive therapy during his 16-month hospital admission, but his catatonia ultimately proved refractory to treatment.

CONCLUSIONS

Catatonia should be considered promptly as a differential diagnosis in older people presenting with atypical features of functional mental illness. Although partial improvement of catatonic features was achieved using benzodiazepines and electroconvulsive therapy, these were not sustained in our patient. We identified comorbid autistic spectrum disorder, prolonged duration of catatonia, and sensitivity to benzodiazepines as important factors in prognostication in old age.

Use of serotonin reuptake inhibitors and risk of subsequent bone loss in a nationwide population-based cohort study

This study examined whether the use of SRIs is associated with an increased risk of bone loss using a nested case-control design with a nationwide population-based cohort in Korea. Using the Korean National Health Screening Cohort, subjects newly diagnosed with osteoporosis or osteopenia (n = 55,799) were matched with controls (n = 278,995) at a ratio of 1:5. We stratified the participants by their time-dependent use of SRIs and sex and controlled for various confounders, including lifestyle habits, laboratory data, and comorbidities. Conditional logistic regression showed that both recent and former users of SRIs had an increased risk of subsequent bone loss compared with non-users: men [recent users: odds ratio (OR) 1.35, 95% confidential interval (CI) 1.20, 1.53; former-users: OR 1.10, 95% CI 1.01, 1.20]; women (recent users: OR 1.38, 95% CI 1.28-1.48; former-users: OR 1.07, 95% CI 1.02, 1.21). The use of SRIs was associated with an increased risk of bone loss in both men and women. In particular, the association was stronger in recent users. These findings provide population-level evidence for the risk of bone loss associated with SRI exposure and highlight the importance of monitoring the bone health of SRI users.

Comparative efficacy and safety of hypnotics for insomnia in older adults: a systematic review and network meta-analysis

STUDY OBJECTIVES

To compare the efficacy and safety of various hypnotics for identifying the best treatments for insomnia in older adults.

METHODS

We searched the EMBASE, PubMed, ClinicalTrials.gov, and ProQuest Dissertations and Theses A&I databases from the inception to September 12, 2020. Only randomized controlled trials comparing hypnotics with either another hypnotic or placebo for insomnia treatment in elderly people were included. Sleep outcomes, including total sleep time, sleep onset latency, wake after sleep onset, sleep efficiency, were derived from polysomnography, valid questionnaires, or sleep diaries.

RESULTS

We identified 24 articles with 5917 older adults. Eszopiclone and low-dose doxepin were ranked the optimal therapy for prolonging objective and subjective total sleep time (26.69 and 28.19 min), respectively, compared to placebo. Zaleplon was the most effective therapy in reducing objective and subjective sleep onset latency (-21.63 and -15.86 min) compared with control. Temazepam was the best treatment for objective and subjective wake after sleep onset (-25.29 and -22.25 min) compared with control. Low-dose doxepin appeared to be the effective treatment for increasing objective sleep efficiency (6.08%) Triazolam showed the higher risk of overall adverse events (odds ratio, 1.96, 95% confidence interval 1.03-3.74) when compared to zaleplon.

CONCLUSIONS

Considering study quality and the potential adverse effects of benzodiazepines and nonbenzodiazepines, low-dose doxepin seems to be the optimal pharmacotherapy for the improvements in total sleep time and sleep efficiency. Future RCTs investigating the treatment effects of hypnotics, particularly low-dose doxepin, on insomnia in older adults are warranted. PROSPERO Registration number: CRD42016046301.

Are Patients Taking Benzodiazepines at Increased Risk for Complications Following Primary Total Knee Arthroplasty?

BACKGROUND

Benzodiazepines are commonly taken by patients who are undergoing total knee arthroplasty (TKA), but there is a paucity of studies evaluating any associations. Therefore, we hoped to study if patients taking preoperative benzodiazepines would have increased complications following TKA.

METHODS

Using a nationwide database, from 2010 to 2019, we evaluated patients undergoing primary TKA who either did or did not have a preoperative record of benzodiazepine prescription. We performed a multivariable logistic regression analysis, adjusting for multiple variables (age, gender, obesity, and Charlson comorbidity index), to determine the association of preoperative benzodiazepine use and adverse events in a matched cohort. Furthermore, we stratified patients by one vs multiple preoperative benzodiazepine prescription(s). We evaluated 90-day and 2-year rates of revision, resection, femur fracture fixation, manipulation under anesthesia (MUA), and delirium.

RESULTS

Patients filling more than one preoperative benzodiazepine prescription had increased adjusted odds of 90-day (odds ratio [OR] = 1.198, confidence interval [CI] = 1.086-1.320) and 2-year (OR = 1.188, CI = 1.125-1.254) revision; 90-day resection (OR = 1.430, CI = 1.125-1.817); 90-day (OR = 1.639, CI = 1.255-2.141) and 2-year (OR = 1.646, CI = 1.412-1.919) femur fracture fixation; and 2-year delirium (OR = 2.288, CI = 1.564-3.382). Preoperative benzodiazepine users had decreased adjusted odds of 90-day (OR = 0.670, CI = 0.639-0.702) and 2-year (OR = 0.702, CI = 0.671-0.734) MUA.

CONCLUSION

After controlling for multiple variables, benzodiazepine use was associated with increased rates of revision, resection, femur fracture fixation, and delirium. Furthermore, benzodiazepine use was also associated with a decreased rate of MUA. Orthopaedic professionals can counsel patients taking this group of medications about the associated adverse events. Future studies should assess the use of other muscle relaxants in the prevention of knee stiffness and MUA.

Modifiable factors associated with postoperative delirium after hip fracture repair: An age-stratified retrospective cohort study

BACKGROUND

Postoperative delirium in hip fracture patients is common and is associated with substantial morbidity and consumption of resources.

OBJECTIVE

Using data from the USA, we aimed to examine the relationship between postoperative delirium and (modifiable) peri-operative factors mentioned in the American Geriatrics Society Best Practice Statement on Postoperative Delirium in Older Adults, stratified by 'young old' (<80 years) and 'old-old' (≥80 years) categories.

DESIGN

Retrospective cohort study from 2006 to 2016.

SETTING

Population-based claims data from the USA.

PARTICIPANTS

Patients undergoing 505 152 hip fracture repairs between 2006 and 2016 as recorded in the Premier Healthcare Database.

MAIN OUTCOMES AND MEASURES

The main outcome was postoperative delirium; modifiable factors of interest were peri-operative opioid use (high, medium or low; <25th, 25 to 75th or >75th percentile of oral morphine equivalents), anaesthesia type (general, neuraxial, both), use of benzodiazepines (long acting, short acting, both), pethidine, nonbenzodiazepine hypnotics, ketamine, corticosteroids and gabapentinoids. Multilevel models assessed associations between these factors and postoperative delirium, in the full cohort, and separately in those aged less than 80 and at least 80 years. Odds ratios (ORs) and Bonferroni-adjusted 95% confidence intervals (95% CIs) are reported.

RESULTS

Overall, postoperative delirium incidence was 15.7% (n = 79 547). After adjustment for relevant covariates, the use of long-acting (OR 1.82, CI 1.74 to 1.89) and combined short and long-acting benzodiazepines (OR 1.56, CI 1.48 to 1.63) and ketamine (OR 1.09, CI 1.03 to 1.15), in particular, was associated with increased odds for postoperative delirium, while neuraxial anaesthesia (OR 0.91 CI 0.85 to 0.98) and opioid use (OR 0.95, CI 0.92 to 0.98 and OR 0.88, CI 0.84 to 0.92 for medium and high dose compared with low dose) were associated with lower odds; all P < 0.05. When analysing data separately by age group, effects of benzodiazepines persisted, while opioid use was only relevant in those aged less than 80 years.

CONCLUSION

We identified modifiable factors associated with postoperative delirium incidence among patients undergoing hip fracture repair surgery.

Does cognitive behavioral therapy for anxiety disorders assist the discontinuation of benzodiazepines among patients with anxiety disorders? A systematic review and meta-analysis

Long-term use of benzodiazepines (BZD) is not recommended for the treatment of anxiety disorders. Cognitive behavioral therapy (CBT) is an effective treatment option for discontinuation of BZD in patients with anxiety disorders. This systematic review and meta-analysis sought to clarify whether CBT is effective for discontinuing BZD anxiolytics in patients with anxiety disorders. This study was preregistered with PROSPERO (registration number: CRD42019125263). A literature search of major electronic databases was conducted in December 2018. Three randomized controlled trials were included in this review, and meta-analyses were performed. The proportion of discontinuing BZD anxiolytics was significantly higher in the CBT plus gradual tapering group than in the gradual tapering alone group, both in the short term (3 months after allocation; number needed to treat: 3.2, 95% confidence interval [CI]: 2.1 to 7.1; risk ratio: 1.96, 95%CI: 1.29 to 2.98, P = 0.002, three studies) and long term (6 to 12 months after allocation; number needed to treat: 2.8, 95%CI: 1.9 to 5.3; risk ratio: 2.16, 95%CI: 1.41 to 3.32, P = 0.0004, three studies). CBT may be effective for discontinuing BZD anxiolytics, both in the short term and in the long term after the allocation. Further studies with larger sample sizes are necessary to draw definitive conclusions regarding the efficacy and safety of CBT for discontinuing BZD anxiolytics in patients with anxiety disorders.

Benzodiazepines: Thinking outside the black box

WHAT IS KNOWN AND OBJECTIVE

The United States Food and Drug Administration (FDA) recently issued a Drug Safety Communication requiring Boxed Warning updating and other changes in order to improve the safe use of the benzodiazepine drug class. These changes were prompted because 'The current prescribing information for benzodiazepines does not provide adequate warnings about [the] serious risks and harms associated with these medicines so they may be prescribed and used inappropriately'.

COMMENT

The FDA Communication points out that benzodiazepines can be an important option for treating disorders for which these drugs are indicated. However, the acknowledged problems of these drugs, which historically were considered an acceptable trade-off against their benefits, need to be reassessed in light of their widespread (over?) prescribing (for example, in 2019 an estimated 92 million benzodiazepine prescriptions were dispensed from US retail and mail-order pharmacies).

WHAT IS NEW AND CONCLUSION

The FDA Communication can be viewed as an important step in reminding healthcare providers of the 'serious risks and harms associated with these medicines', and validation of such reports by patients. Importantly, the FDA Communication includes an often-neglected aspect of benzodiazepine prescribing, namely how to discontinue use, and the perplexing protracted withdrawal syndrome experienced by some patients. The Communication advises to providers: 'No standard benzodiazepine tapering schedule is suitable for all patients; therefore, create a patient-specific plan to gradually reduce the dosage, and ensure ongoing monitoring and support as needed to avoid serious withdrawal symptoms or worsening of the patient's medical condition'.

Drug safety profiles in geriatric patients with Parkinson's disease using the FORTA (Fit fOR The Aged) classification: results from a mono-centric retrospective analysis

To reduce potentially inappropriate medications, the FORTA (Fit fOR The Aged) concept classifies drugs in terms of their suitability for geriatric patients with different labels, namely A (indispensable), B (beneficial), C (questionable), and D (avoid). The aims of our study were to assess the medication appropriateness in PD inpatients applying the FORTA list and drug-drug interaction software, further to assess the adequacy of FORTA list for patients with PD. We retrospectively collected demographic data, comorbidities, laboratory values, and the medication from the discharge letters of 123 geriatric inpatients with PD at the university hospital of Hannover Medical School. Patients suffered on average from 8.2 comorbidities. The majority of the medication was labeled A (60.6% of PD-specific and 40.9% of other medication) or B (22.3% of PD-specific and 26.9% of other medication). Administered drugs labeled with D were amantadine, clozapine, oxazepam, lorazepam, amitriptyline, and clonidine. Overall, 545 interactions were identified, thereof 11.9% severe interactions, and 1.7% contraindicated combinations. 81.3% of patients had at least one moderate or severe interaction. The FORTA list gives rational recommendations for PD-specific and other medication, especially for general practitioners. Considering the demographic characteristics and the common multimorbidity of geriatric PD patients, this study underlines the importance of awareness, education, and preventive interventions to increase drug safety.

Effect of pharmacological treatment prior to admission on the outcome of older hip fracture patients

PURPOSE

We aim to relate the pharmacological treatment at admission of hip fracture patients with their prognosis.

METHODS

We designed a prospective study including 436 hip fracture patients. We classified all the pharmacological treatment prior to admission of each patient into 25 groups according to their active agent and indications. We followed-up patients for one year for survival, emergency department visits (EDV), and in-hospital re-admissions (RAD). Differential analysis was performed by chi-square test, U-Mann Whitney test, and logistic regression. In all cases, p ≤ 0.05 was considered statistically significant.

RESULTS

At 30-day follow-up, 14.9% patients noted EDV, 9.2% RAD, and 3.2% dead. Patients taking beta-blockers (p = 0.046), loop diuretics (p = 0.018) or antiparkinsonian (p = 0.009) showed an increased 30-day EDV; patients taking benzodiazepines (p = 0.014), loop diuretics (p = 0.009) or antiparkinsonian (p = 0.009), an increased 30-day RAD. At one-year follow-up, 50.7% patients noted EDV, 30.7% RAD, and 22.7% dead. Patients taking oral antidiabetics (p = 0.006) noted a greater one-year EDV; patients taking major opioids (p = 0.001), benzodiazepines (p = 0.016), cardiac agents (p = 0.046), loop diuretics (p = 0.042), beta-blockers (p = 0.018), oral anticoagulants (p = 0.013) or gastric prophylaxis (p = 0.020), greater RAD; patients taking cardiac agents (p = 0.024), loop diuretics (p = 0.006) or oral anticoagulants (p = 0.015), increased 1-year mortality rate.

CONCLUSIONS

The pharmacological treatment noted at admission for hip fracture patients is related to the outcome, in a dose-independent way. The pharmacological treatment could be an additional parameter that could help us to improve the decision-making process and the resource assignation of hip fracture patients. A proper medication review upon admission because of a hip fracture is warranted.

Incidence of and Characteristics Associated With Long-term Benzodiazepine Use in Finland

IMPORTANCE

The proportion of patients who develop long-term benzodiazepine use remains controversial, as do the length of time before long-term use develops and the factors associated with long-term use.

OBJECTIVE

To investigate the incidence of long-term benzodiazepine and related drug (BZDR) use and factors associated with the development of long-term use implementing a follow-up design with new BZDR users.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used a nationwide cohort of 129 732 new BZDR users in Finland. New users of BZDRs aged 18 years or older were identified from the prescription register maintained by the Social Insurance Institution of Finland as individuals who initiated BZDR use during 2006 and had not used BZDRs from 2004 to 2005. The follow-up continued until death, long-term hospitalization, a gap of 2 years in BZDR use, or December 31, 2015. The population was analyzed according to age at treatment initiation, categorized into younger (<65 years) and older (≥65 years) subcohorts. Analyses were conducted from May 2019 to February 2020.

EXPOSURES

Use of BZDRs, modeled from register-based data using the PRE2DUP (from prescriptions to drug use periods) method.

MAIN OUTCOMES AND MEASURES

Long-term BZDR use, defined as continuous use of 180 days or longer, and factors associated with long-term vs short-term use, compared using Cox proportional hazards models.

RESULTS

Among the 129 732 incident BZDR users, the mean (SD) age was 52.6 (17.7) years, and 78 017 (60.1%) individuals were women. During the follow-up period, 51 099 BZDR users (39.4%) became long-term users. Long-term treatment was more common in the older subcohort (19 103 individuals [54.5%]) than the younger subcohort (31 996 individuals [33.8%]). At 6 months, 28 586 individuals (22.0%) had become long-term users: 11 805 (33.7%) in the older subcohort and 16 781 (17.7%) in the younger subcohort. The largest proportions of initiators who became long-term users were those persons who initiated treatment with nitrazepam (76.4%; 95% CI, 73.6%-79.1%), temazepam (63.9%; 95% CI, 62.9%-65.0%), lorazepam (62.4%; 95% CI, 59.7%-65.1%), or clonazepam (57.5%; 95% CI, 55.9%-59.2%). Factors associated with the development of long-term use included male sex, older age, receipt of social benefits, psychiatric comorbidities, and substance abuse.

CONCLUSIONS AND RELEVANCE

The findings of this population-based cohort study conducted in Finland suggest that the incidence of subsequent long-term BZDR use in individuals who initiate use of BZDRs is high, especially among older persons, and that the specific BZDR used initially is associated with the development of long-term BZDR use and should be carefully considered when prescribing BZDRs. The observed factors that appear to be associated with development of long-term BZDR use also should be considered in clinical decision-making when starting and monitoring BZDR treatment.

Insomnia and menopause: a narrative review on mechanisms and treatments

The menopausal transition is associated with an increased frequency of sleep disturbances. Insomnia represents one of the most reported symptoms by menopausal women. According to its pathogenetic model (3-P Model), different predisposing factors (i.e. a persistent condition of past insomnia and aging per se) increase the risk of insomnia during menopause. Moreover, multiple precipitating and perpetuating factors should favor its occurrence across menopause, including hormonal changes, menopausal transition stage symptoms (i.e. hot flashes, night sweats), mood disorders, poor health and pain, other sleep disorders and circadian modifications. Thus, insomnia management implies a careful evaluation of the psychological and somatic symptoms of the individual menopausal woman by a multidisciplinary team. Therapeutic strategies encompass different drugs but also behavioral interventions. Indeed, cognitive behavioral therapy represents the first-line treatment of insomnia in the general population, regardless of the presence of mood disorders and/or vasomotor symptoms (VMS). Different antidepressants seem to improve sleep disturbances. However, when VMS are present, menopausal hormone therapy should be considered in the treatment of related insomnia taking into account the risk-benefit profile. Finally, given its good tolerability, safety, and efficacy on multiple sleep and daytime parameters, prolonged-released melatonin should represent a first-line drug in women aged ≥ 55 years.

[Association Suvorexant and Ramelteon Use with the Risk of Falling: A Retrospective Case-control Study]

Sedative hypnotics are among the classes of drugs reported to influence falls. However, the effects of the sedative hypnotic drugs, suvorexant and ramelteon, on falls are not well known. Therefore, we conducted this retrospective case-control study to examine the association of the use of these two sedative hypnotics with the risk of falls. Conducted at the Sapporo Medical University Hospital in Japan, our study included 360 patients with fall incidents and 819 randomly selected control patients. Patients in the fall group were significantly older with a lower body mass index, and had a history of falls, disabilities in activities of daily living, cognitive impairment, and delirium. Monovariate analysis revealed that patients in the fall group frequently used ramelteon [odds ratio (OR) 2.38, 95% confidence interval (CI): 1.49-3.81, p<0.001], but rarely used suvorexant (OR 0.66, 95% CI: 0.29-1.39, p=0.317), compared with control patients. Furthermore, multivariate analysis revealed that ramelteon use did not increase the risk of falls (adjusted OR 1.43, 95% CI: 0.82-2.48, p=0.207), whereas suvorexant use significantly decreased the risk of falls (adjusted OR 0.32, 95% CI: 0.13-0.76, p=0.009). Although ramelteon tends to be used in patients at a high risk of falls, it may not increase the risk of falls. In contrast, the use of suvorexant may reduce the risk of falls.

Use of benzodiazepines, z-hypnotics and antidepressants among hip fracture patients in Finland. Consistency between recorded and detected benzodiazepines

PURPOSE

We described the use of benzodiazepines (BZDs), z-hypnotics, and antidepressants; analyzed the consistency between recorded and detected BZDs among hip fracture patients admitted to two Finnish hospitals during one year; and compared the results with corresponding results from 12 years earlier.

METHODS

Current use of medication was obtained from the National Prescription Register. Urine and blood samples used to detect BZD were taken during admission. The following Anatomical Therapeutic Chemical (ATC) classes were included: BZDs: N05BA, N05CD; z-hypnotics: N05CF; and antidepressants: N06A.The presence of BZDs in urine was analyzed using immunoassay. Positive BZDs were confirmed by gas chromatography mass spectrometry. BZDs in serum were analyzed using liquid chromatography. Concordance between recorded and detected BZDs was calculated with kappa (κ) and described using a Venn diagram.

RESULTS

A total of 245 patients were enrolled in the study. BZD was detected in 18 %. Kappa was 0.39 (95 % CI 0.25-0.53). Overlap of detected and recorded BZDs was 59 %. According to the prescription register, 18 % used z-hypnotics, and according to both the detection of BZDs and register, 49 % used BZDs and/or z-hypnotics. 22 % used antidepressants and 15 % used combinations of the studied drugs concomitantly.

CONCLUSION

Use rate of BZDs and/or z-hypnotics was similar to that 12 years ago. No difference in the consistency between our previous and present study was found either. All studied drugs and their concomitant use increase the risk for fractures. In the elderly, point prevalence of medication and appropriateness should be regularly assessed.

Benzodiazepine Treatment and Fracture Risk in Young Persons With Anxiety Disorders

BACKGROUND

Benzodiazepines are commonly prescribed to treat anxiety disorders and have been associated with falls and fractures in older adults. It is unknown whether benzodiazepines increase fracture risk in youth. We examined whether youth with anxiety disorders initiating benzodiazepine treatment have an increased risk of fractures compared with youth initiating selective serotonin reuptake inhibitors (SSRIs).

METHODS

We used claims from commercially insured children (6-17 years) and young adults (18-24) with a recent anxiety disorder diagnosis, initiating benzodiazepines or SSRIs (2008-2016). Youth were followed until fracture, treatment discontinuation or switching, disenrollment, 3 months, or December 31, 2016. The primary end point was diagnostic codes for upper and lower limb fractures. Incident fracture rates, incident rate ratios (IRRs), and incident rate differences (IRDs) were estimated with propensity score inverse probability of treatment weighting.

RESULTS

The cohort included 120 715 children and 179 768 young adults. In children, crude fracture rates during treatment were 33.1 per 1000 person-years (PYs) for benzodiazepine initiators and 25.1 per 1000 PYs for SSRI initiators. Adjusted IRR and IRD were 1.53 (95% confidence interval [CI]: 0.94-2.50) and 13.4 per 1000 PYs. Risk was heightened in children initiating long-acting benzodiazepines versus SSRIs (adjusted IRR = 2.30 [95% CI: 1.08-4.91]). Fracture rates were lower in young adults, with minimal differences between treatments (adjusted IRR = 0.85 [95% CI: 0.57-1.27]; adjusted IRD = -1.3 per 1000 PYs).

CONCLUSIONS

An increased rate of fractures in children, but not young adults, with anxiety disorders initiating benzodiazepine treatment compared to SSRI treatment suggests a need for increased caution in the weeks after benzodiazepine initiation in children.

Association of benzodiazepines, opioids and tricyclic antidepressants use and falls in trauma patients: Conditional effect of age

Introduction

The relationship between benzodiazepines, opioids and tricyclic antidepressants and trauma is of great importance because of increased consumption and the growing evidence of a positive association among older adults. The objective of this study was to determine the effect size of the association between the consumption of psychotropic medications /opioids and falls in patients who have suffered trauma by studying the role of other variables in this relationship.

Method

From 2011 to 2016, the presence of benzodiazepines, opioids and tricyclic antidepressants and other drugs in 1060 patients admitted for trauma at a level I trauma hospital was analysed. Multivariate models were used to measure the adjusted effect size of the association between consumption of benzodiazepines, opioids and tricyclic antidepressants and falls, and the effect of age on this association was studied.

Results

A total of 192 patients tested positive for benzodiazepines, opioids and tricyclic antidepressants, with same-level falls being the most frequent mechanism of injury in this group (40.1%), with an odds ratio of 1.96 (1.40–2.75), p < 0.001. Once other covariates were introduced, this association was not observed, leaving only age, gender (woman) and, to a lesser extent, sensory conditions as variables associated with falls. Age acted as an effect modifier between benzodiazepines, opioids and tricyclic antidepressants and falls, with significant effect sizes starting at 51.9 years of age.

Conclusions

The association between the consumption of benzodiazepines, opioids and tricyclic antidepressants and falls in patients admitted for trauma is conditioned by other confounding variables, with age being the most influential confounding variable.

Impact of pre-exposure time bias in self-controlled case series when the event conditions the exposure: Hip/femur fracture and use of benzodiazepines as a case study

BACKGROUND

In self-controlled case series (SCCS), the event should not condition the probability of subsequent exposure. If this assumption is not met, an important bias could take place. The association of hip/femur fracture (HFF) and use of benzodiazepines (BDZ) has a bidirectional causal relationship and can serve as case study to investigate the impact of this methodological issue.

OBJECTIVES

To assess the magnitude of bias introduced in a SCCS when HFF conditions the posterior exposure to BDZ and explore ways to correct it.

METHODS

Four thousand four hundred fifty cases of HFF who had at least one BZD prescription were selected from the primary care health record database BIFAP. Exposure to BZD was divided into non-use, current, recent, and past use. Conditional Poisson regression was used to estimate incidence rate ratios (IRRs) of HFF among current vs non-use/past, adjusted for age. To investigate possible event-exposure dependence, a pre-exposure time of different lengths (15, 30, and 60 days) was excluded from the reference category to evaluate the IRR.

RESULTS

IRR of HHF for current use was 0.79 (0.72-0.86); removing 30 days, IRR was 1.43 (1.31-1.57). Removing 15 days, IRR was 1.29 (1.18-1.41), and removing 60 days, IRR was 1.56 (1.42-1.72). A pre-exposure period up to 182 days was necessary to remove such effect giving an IRR of 1.64 (1.48-1.81).

CONCLUSIONS

HFF remarkably conditioned the use of BDZs resulting in seriously biased IRRs when this association was studied through a SCCS design. The use of pre-exposure periods of different lengths helped to correct this error.

Psychotropic medications and proton pump inhibitors and the risk of fractures in the teriparatide versus risedronate VERO clinical trial

BACKGROUND

VERO is a fracture endpoint study in women with established osteoporosis that showed reduction in the risks of new vertebral fractures (VFx) and clinical fractures in women randomized to teriparatide compared with risedronate. Patients on psychotropic drugs (hypnotics, benzodiazepines and antidepressants [selective serotonin- and norepinephrine-reuptake inhibitors: SSRIs and SNRIs]) and proton pump inhibitors (PPIs) may be at a higher risk of fractures. We studied the association of exposure to these medications with the risk of fractures in the VERO study cohort, including an assessment of their potential interactions with the assigned clinical trial drugs.

METHODS

A total of 1360 postmenopausal women with at least 2 moderate or 1 severe VFx and bone mineral density T-score ≤-1.50 were randomized to subcutaneous daily teriparatide (20μg) or oral weekly risedronate (35mg) in a double-blind, double-dummy, 2-year trial. In thispost-hoc analysis, multivariable log-binomial and Cox proportional hazards regression models were used to estimate adjusted risk ratios (RR) or hazard ratios (HR) for the exposure to these concomitant medications with the occurrence of incident fractures. We also assessed treatment effect modifications on anti-fracture efficacy driven by the use of these medications.

RESULTS

There were 406 (29.9 %), 347 (25.5 %) and 176 (12.9 %) subjects taking PPIs, benzodiazepines/hypnotics, and SSRIs/SNRIs during the study, respectively. For all fracture endpoints, the greater risk reduction of teriparatide versus risedronate did not significantly differ within the categories of psychotropic drugs and PPIs. Multivariable analysis showed that the risk of pooled new and worsened VFx was higher in PPI users than in non-PPI users (RR: 1.57; p=0.032), regardless of the study treatment. Benzodiazepine/hypnotic drug users showed an increased risk of clinical fractures (HR: 1.71; p=0.026) and non-vertebral fragility fractures (NVFFx, HR: 1.89; p=0.017), regardless of the study treatment. Increases in the risk of clinical fractures (HR: 1.93; p=0.018) and NVFFx (HR: 2.16; p=0.011) were also observed in SSRI/SNRI users, regardless of the study treatment.

CONCLUSION

In postmenopausal women with severe osteoporosis, the superior anti-fracture efficacy of teriparatide compared with risedronate was consistent regardless of psychotropic or PPI drugs use. Patients taking psychotropic drugs and PPIs showed a higher risk for NVFFx and VFx respectively, compared to those not on these medications.

Prescription Benzodiazepine Use in Privately Insured U.S. Children and Adolescents

INTRODUCTION

Benzodiazepines are commonly prescribed in the U.S. but entail safety concerns, including dependency. In pediatrics, many indications lack trial data. Authors aimed to describe youth initiating prescription benzodiazepine treatment, identify potential indications and prescribing concerns, estimate the duration of treatment by potential indication, and identify factors that predict long-term use.

METHODS

The study cohort included children (aged 3-12 years) and adolescents (aged 13-17 years) initiating prescription benzodiazepine treatment (≥3 days' supply) from January 2010 to September 2015 in a U.S. commercial claims database. Potential indications included selected ICD-9-CM diagnoses (≤30 days prior). Long-term (≥6 months) benzodiazepine treatment was estimated with Kaplan-Meier estimation and modified Poisson regression identified independent predictors of long-term benzodiazepine treatment (analysis completed in 2018).

RESULTS

Of 24,504 children and 61,046 adolescents initiating benzodiazepines, 62% of the children and 68% of the adolescents had a potential indication. Anxiety disorders were the most common indication, with mental health indications more common among adolescents (45%) than children (23%) and epilepsy and movement disorders higher in children. Recent opioid prescriptions were common before benzodiazepine initiation (children, 22%; adolescents, 21%). Six percent of the initiators became long-term benzodiazepine users. Potential indication, provider contact, psychotropic medication, and chronic conditions independently predicted long-term benzodiazepine treatment in adolescents and children.

CONCLUSIONS

U.S. children and adolescents are prescribed benzodiazepines for various mental health and other medical conditions, many lacking evidence of pediatric efficacy. Long-term benzodiazepine treatment, concurrent opioid prescriptions, psychotropic use, and prior substance use disorder diagnoses suggest safety risks among some youth prescribed benzodiazepines.

Medical use, non-medical use and use disorders of benzodiazepines and prescription opioids in adults: Differences by insurance status

OBJECTIVES

To report and analyze prevalence's of Benzodiazepines (BZDs) and Prescription Opioids (POs) use by insurance status and to investigate associations between insurance status and BZDs, POs and concurrent medical/non-medical use and use disorders.

METHODS

This study included 81,133 adults ages 18 and older from 2015 and 2016 National Survey on Drug Use and Health. Participants' self-reported past- year medical use, non-medical use and use disorders of BZDs and POs were assessed, along with their insurance status (Private/Military, Medicare, Medicaid, and Uninsured) and demographic characteristics.

RESULTS

In 2015-2016, 12.6% of adults reported using BZDs and 36.9% reported using POs in the past year. Among adults, 8.3% reported past-year use of both BZDs and POs; also, 1.9% and 3.8% reported non-medical use of BZDs and POs, respectively, and 0.9% reported non-medical use of both BZDs and POs. Medicaid-covered respondents had higher risk of BZDs (aRRR = 1.59, 95%CI = [1.45, 1.74]), POs (aRRR = 1.66, 95%CI = [1.54, 1.79]) and concurrent past-year medical use (aRRR = 2.11, 95%CI = [1.87, 2.38]), higher risk of BZDs non-medical use (aRRR = 1.40, 95%CI = [1.17, 1.68]) and BZD Use Disorders (aRRR = 2.60, 95%CI = [1.82, 3.72]), POs non-medical use (aRRR = 1.67, 95%CI = [1.45, 1.92]), PO use Disorders (aRRR = 4.12, 95%CI = [3.33, 5.11]) and concurrent non-medical use (aRRR = 1.52, 95%CI = [1.20, 1.92]) and Use Disorders (aRRR = 3.68, 95%CI = [1.93, 6.78]), compared to those with private insurance.

CONCLUSIONS

Future health policies should focus on reducing individual and co-prescription of BZDs and POs and providing different strategies of pain management.

Predictors of Hip Fracture Despite Treatment with Bisphosphonates among Frail Older Adults

OBJECTIVES

Bisphosphonates are effective at preventing hip fractures among older adults, yet many patients still fracture while on treatment and may benefit from additional preventive interventions. Little data are specifically available to target such efforts among bisphosphonate users. We aimed to identify predictors of hip fracture unique to frail older adults initiating pharmacologic treatment for osteoporosis.

DESIGN

Retrospective cohort using 2008-2013 linked national Minimum Data Set assessments, Medicare claims, and nursing home (NH) facility data.

SETTING

NHs in the United States.

PARTICIPANTS

Long-stay NH residents 65 years or older who initiated treatment with a bisphosphonate (N = 17 753). Estimates for bisphosphonate initiators were contrasted with those for calcitonin initiators (control group; N = 5348).

MEASUREMENTS

Hospitalized hip fracture outcomes were measured using Part A claims. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated for 36 a priori selected potential predictors.

RESULTS

The mean (SD) age of the study population was 84 (8) years, 85% were women, and 51% had moderate to severe cognitive impairment. Predictors associated with a higher risk of hip fracture despite bisphosphonate use included age 75 years or older to 85 years (vs ≥65 to <75 y; HR = 1.25; 95% CI = 1.02-1.55), female sex (HR = 1.33; 95% CI = 1.06-1.67), white race (vs black race (HR = 1.87; 95% CI = 1.36-2.58), and body mass index = 18.5-24.9 (vs ≥30; HR = 1.93; 95% CI = 1.53-2.42). Independent ability to transfer (vs total dependence; HR = 3.11; 95% CI = 1.83-5.30) and occasional urinary incontinence (vs frequent; HR = 1.45; 95% CI = 1.18-1.78) were also important predictors. Dementia, diabetes, psychoactive drug use, and other characteristics were not associated with post-prescribing hip fracture. Predictors did not differ between bisphosphonate and calcitonin users.

CONCLUSION

Predictors of hip fracture among frail older adults did not differ between those who were new users of bisphosphonates vs calcitonin. Given the absence of risk factors unique to bisphosphonate users, targeting of fracture prevention efforts should extend beyond pharmacologic therapy to include existing nonpharmacologic therapies, particularly fall prevention strategies. J Am Geriatr Soc 68:256-260, 2020.

Effect of reimbursement restriction policy on the use of benzodiazepines in the Netherlands: an interrupted time series analysis

OBJECTIVES

Use of benzodiazepines has health risks. Reimbursement was restricted in the Netherlands from January 2009 onwards with the goal to reduce chronic use and healthcare expenditures. The aim of this study is to assess the initial and long-term effects of this policy on benzodiazepine use.

DESIGN

Interrupted time series analysis, segmented regression models, Kaplan-Meier survival analysis and Cox proportional hazards analysis.

SETTING

A 10% random sample of benzodiazepine dispensings by outpatient pharmacies between January 2002 and August 2015 were obtained from the PHARMO database. This database covered a catchment area representing about 3.6 million residents in 2015.

PARTICIPANTS

2 500 800 benzodiazepine prescriptions from 128 603 patients were included.

INTERVENTION

Reimbursement restriction policy from January 2009 onwards.

OUTCOME MEASURES

Changes in: the volume of dispensed prescriptions and doses, the incidence, prevalence of incidental, regular and chronic use and discontinuation rates of benzodiazepines.

RESULTS

The volume of dispensed prescriptions and doses decreased by 12.5% (95% CI 9.0% to 15.9%) and 15.1% (95% CI 11.4% to 17.3%) respectively in January 2009 compared with December 2008. A clear initial effect on the overall incidence (-14.7%; 95% CI -19.8% to 9.6%) and the prevalence of incidental (-17.8%; 95% CI -23.9% to 11.7%), regular (-20.0%; 95% CI -26.1% to 13.9%) and chronic (-16.0%; 95% CI -23.1% to 8.9%) use was observed. A statistically significant reduction in the monthly trend per 1000 medication users was observed for the overall incidence (-0.017; 95% CI -0.031 to 0.003) and the prevalence of incidental (-3.624; 95% CI -4.996 to 2.252) but not for regular (-0.304; 95% CI -1.204 to 0.596) and chronic (0.136; 95% CI -0.858 to 1.130) use. Patients who started treatment before policy had a slightly higher probability of discontinuation (HR=1.013; 95% CI 1.004 to 1.022).

CONCLUSIONS

The reimbursement policy had a significant initial effect on the volume, incidence and prevalence of benzodiazepine use. In addition, there is a statistically significant reduction in the monthly trend of overall incidence and of the prevalence of incidental use. No statistically significant reduction in the monthly trend of chronic use, the main purpose of the reimbursement restriction, could be demonstrated.

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.

Use of Central Nervous System (CNS) Medicines in Aged Care Homes: A Systematic Review and Meta-Analysis

BACKGROUND

Both old age and institutionalization in aged care homes come with a significant risk of developing several long-term mental and neurological disorders, but there has been no definitive meta-analysis of data from studies to determine the pooled estimate of central nervous system (CNS) medicines use in aged care homes. We conducted this systematic review to summarize the use of CNS drugs among aged care homes residents.

METHODS

MEDLINE, EMBASE, CINAHL, Scopus, and International Pharmaceutical Abstracts (IPA) databases were searched (between 1 January 2000 and 31 December 2018) to identify population-based studies that reported the use of CNS medicines in aged care homes. Pooled proportions (with 95% confidence interval), according to study location were calculated.

RESULTS

A total of 89 studies reported the use of CNS medicines use in aged care. The pooled estimate of CNS drugs use varied according to country (from 20.3% in Ireland to 49.0% in Belgium) and region (from 31.7% in North America to 42.5% in Scandinavia). The overall pooled estimate of psychotropic medicines use was highest in Europe (72.2%, 95% CI, 67.1-77.1%) and lowest in ANZ region (56.9%, 95% CI, 52.2-61.4%). The pooled estimate of benzodiazepines use varied widely from 18.9% in North America to 44.8% in Europe. The pooled estimate of antidepressants use from 47 studies was 38.3% (95% CI 35.1% to 41.6%) with highest proportion in North America (44.9%, 95% CI, 35.3-54.5%).

CONCLUSION

The overall use of CNS drugs varied among countries, with studies from Australia-New Zealand reported the lowest use of CNS drugs. The criteria for prescribing CNS drugs in clinical practice should be evidence-based. The criteria should be used not to prohibit the use of the listed medications but to support the clinical judgement as well as patient safety.

Benzodiazepines or related drugs and risk of pneumonia: A systematic review and meta-analysis

OBJECTIVE

Benzodiazepines and benzodiazepine-related drugs (BZRDs) are used to treat various psychiatric diseases. However, there are concerns that BZRDs increase the risk of pneumonia.

METHODS

We performed a systematic review and meta-analysis of observational studies to determine whether BZRD use affects the risk of pneumonia. Our analysis included all observational studies that compared pneumonia development among patients receiving BZRD vs those with no treatment.

RESULTS

In total, 12 citations of 10 studies involving more than 120,000 pneumonia cases were included in our meta-analysis. After pooling the estimates, the odds for developing pneumonia were 1.25-fold higher (odd ratio, OR = 1.25; 95% confidence interval (CI), 1.09-1.44) in BZRD users compared with individuals who had not taken BZRD. On the basis of exposure window, we found an increased risk of pneumonia among current (OR = 1.4; 95%CI, 1.22-1.6) and recent (OR = 1.38; 95%CI, 1.06-1.8) users, but not with the past users (OR = 1.11; 95%CI, 0.96-1.27).

CONCLUSION

Current or recent exposure to BZRD is associated with an increased pneumonia risk. Clinicians need to weight the benefit-risk balance of BZRD use, especially those with other risk factors for pneumonia.

Fracture status in middle-aged individuals with early CKD: cross-sectional analysis of the CARTaGENE survey

Whether early chronic kidney disease (CKD) is associated with fracture in middle-aged adults is unclear. In a cross-sectional analysis of the CARTaGENE survey, we observed that early CKD was not associated with increased fracture, did not modify the association between calcaneal QUS and fracture, but modified the association between clinical, pharmacological parameters and fracture.

INTRODUCTION

The association between advanced CKD and increased fracture risk is well described. However, whether early CKD is associated with increased fractures, especially in middle-aged adults, is unclear. We aimed to assess if early CKD is associated with increased fracture status and whether early CKD status modifies the association between calcaneal quantitative ultrasound parameters, clinical, pharmacological parameters, and fractures.

METHODS

Cross-sectional analysis of CARTaGENE, a population-based survey of 40- to 69-year-old individuals. Individuals with CKD (stage 2, estimated glomerular filtration rate [eGFR] 60-89 ml/min/1.73 m²; stage 3, eGFR 30-59) were compared to non-CKD individuals (eGFR > 90). Fracture status (excluding face, toe, hand, and patella) was identified through a questionnaire at baseline. Calcaneal quantitative ultrasound (QUS) was measured in each participant.

RESULTS

A total of 17,608 individuals (656 CKD stage 3; 8227 stage 2; 8725 non-CKD) were included. CKD stage 2 and 3 individuals (mean eGFR 78 and 53 ml/min/1.73 m²) were older and had more diabetes, cardiovascular disease, and hypertension. Fracture status prevalence was 14.9% in CKD stage 3, 10.8% in CKD stage 2, and 9.0% in non-CKD individuals. Fracture status prevalence was similar between CKD and non-CKD individuals when stratified by age or after adjustment for demographic and clinical parameters. QUS stiffness index was associated with fracture status in both CKD stage 3 (standardized odds ratio [sOR] = 1.525 [1.200 to 1.939] per 1 SD decrease), stage 2 (sOR = 1.415 [1.310 to 1.530]), and non-CKD individuals (sOR = 1.477 [1.361 to 1.602]). The associations between blood pressure, antihypertensive, and fracture status followed a U-shape throughout the progression of CKD.

CONCLUSIONS

CKD stage 3 was not associated with an increase in fracture status. QUS parameters were similarly associated with fracture status in patients with and without CKD.

Impacts of Psychological Stress on Osteoporosis: Clinical Implications and Treatment Interactions

The significant biochemical and physiological effects of psychological stress are beginning to be recognized as exacerbating common diseases, including osteoporosis. This review discusses the current evidence for psychological stress-associated mental health disorders as risk factors for osteoporosis, the mechanisms that may link these conditions, and potential implications for treatment. Traditional, alternative, and adjunctive therapies are discussed. This review is not intended to provide therapeutic recommendations, but, rather, the goal of this review is to delineate potential interactions of psychological stress and osteoporosis and to highlight potential multi-system implications of pharmacological interventions. Review of the current literature identifies several potentially overlapping mechanistic pathways that may be of interest (e.g., glucocorticoid signaling, insulin-like growth factor signaling, serotonin signaling) for further basic and clinical research. Current literature also supports the potential for cross-effects of therapeutics for osteoporosis and mental health disorders. While studies examining a direct link between osteoporosis and chronic psychological stress are limited, the studies reviewed herein suggest that a multi-factorial, personalized approach should be considered for improved patient outcomes in populations experiencing psychological stress, particularly those at high-risk for development of osteoporosis.

Benzodiazepines and risk of pneumonia in schizophrenia: a nationwide case-control study

OBJECTIVES

To investigate the relationship between benzodiazepine and risk of developing pneumonia in patients with schizophrenia, whose benzodiazepine dosage and usage frequency was higher than that of the general population.

METHODS

We conducted a nested case-control study to assess the association between benzodiazepine use and pneumonia among patients with schizophrenia. By using the Taiwan National Health Insurance Research Database, we identified a schizophrenia cohort comprising 34,929 patients during 2000-2010. Within the schizophrenia cohort, 2501 cases of pneumonia and 9961 matched control patients (1:4 ratio) were identified. Benzodiazepine exposure was categorized by drug, treatment duration, and daily dose. Conditional logistic regression models were used to examine the association between benzodiazepine exposure and the risk of pneumonia.

RESULTS

The current use (within 30 days) of midazolam led to the highest pneumonia risk (adjusted risk ratio = 6.56, P < 0.001), followed by diazepam (3.43, P < 0.001), lorazepam (2.16, P < 0.001), and triazolam (1.80, P = 0.019). Furthermore, nearly all the benzodiazepines under current use had a dose-dependent effect on pneumonia risk. The risk of pneumonia was correlated with the affinities of γ-aminobutyric acid A α1, α2, and α3 receptors.

CONCLUSIONS

Benzodiazepines had a dose-dependent relationship with pneumonia in patients with schizophrenia. The differences in risk and mechanism of action of the individual drugs require further investigation. Clinicians should be aware of the early signs of pneumonia in patients with schizophrenia receiving benzodiazepines.

Association between use of antidepressants or benzodiazepines and the risk of subsequent fracture among those aged 65+ in the Netherlands

This is the first study to examine the association between antidepressant and benzodiazepine use following a MOF and risk of subsequent fracture in those 65+. Using national data, drug use following MOF showed that the 1-year fully adjusted risk of subsequent MOF in those on antidepressants was more than doubled.

INTRODUCTION

We evaluated the association between the use of antidepressants or benzodiazepines and the risk of a subsequent major osteoporotic fracture.

METHODS

A cohort study was performed using the Dutch PHARMO Database Network. Between 2002 and 2011, a total of 4854 patients sustained a first major osteoporotic fracture after the age of 65 years, of which 1766 sustained a hip fracture. Incidence rates and adjusted hazard ratios were calculated using Cox proportional hazards models.

RESULTS

Within 1 year following a major osteoporotic fracture, 15% (95% CI 13.7-15.7) and 31% (95% CI 30.1-32.8) of patients were dispensed an antidepressant or benzodiazepine, respectively. Current use of antidepressants in the first year following a major osteoporotic fracture was associated with subsequent fracture (adjusted HR 2.17 (95% CI 1.37-3.43)). Recent and past use of antidepressants were also associated with an increased risk of subsequent fracture. When the complete follow-up period was included, only the current use of antidepressants was associated with subsequent fracture following a major osteoporotic fracture (adjusted HR 1.48; 95% CI 1.06-2.06). Current benzodiazepine use was not associated with an increased risk of fracture within 1 year following a major osteoporotic fracture (adjusted HR 1.18; 95% CI 0.76-1.81) or during the complete follow-up period (adjusted HR 1.18; 95% CI 0.90-1.55).

CONCLUSION

This study provides evidence that antidepressants should be used with caution following a major osteoporotic fracture. It provides needed insights that can be used to inform clinicians when assessing subsequent fracture risk in patients.