Risk of falling and hypnotic drugs: retrospective study of inpatients

Post-surgical fall risk prediction: a machine learning approach for spine and lower extremity procedures

In Taiwan, two key indicators of clinical care quality are pressure injuries and falls. Falls can have significant physical impacts, ranging from minor injuries like bruises to major injuries such as fractures, sprains, and severe head trauma. To assess fall risk early and implement preventive measures, this study analyzed 2,948 medical records of patients who underwent spinal and lower limb surgeries at the Veterans General Hospital in Taichung, Taiwan. Data collected included patient demographics, vital signs, health conditions, diagnoses, and medications, as well as information on their admission type and any recorded falls, to identify factors contributing to inpatient falls and to establish early warning measures. This study accounted for patients' history of falls during model training, followed by variable selection and outcome modeling using logistic regression and random forest methods. Results showed that logistic regression with fall history as part of the training data is an effective approach. Patients admitted by wheelchair or stretcher for spine or lower limb surgeries had an increased fall risk. Each additional year of age also increased fall risk. In patients with arthritis, the odds of falling decreased. Conversely, the use of psychotropic and antihypertensive drugs raised fall risk. While sleeping pills reduced it. Each degree increase in body temperature and poor vision were also associated with higher fall odds. These findings support improvements in patient care quality and help reduce caregiver workload by refining fall risk assessment processes.

The Prevalence of Falls Among Older Adults Living in Long-Term Care Facilities in the City of Cape Town

Falls are a prevalent health concern with a multi-factorial origin and causing numerous complications for older adults, especially those in low- and middle-income countries, such as South Africa. This study aimed to determine the prevalence of falls among older adults living in different types of long-term care facilities in the City of Cape Town. A total of 258 males and females aged between 60 and 95 years were recruited. Data collection occurred from September 2021 to January 2022. Participants were categorized into low, moderate, or high fall risk using the fall-risk assessment tool. Descriptive statistics summarized participant characteristics and fall prevalence. The chi-squared test determined significant associations between facility type, marital status, and educational level, and their relationship to falling. Spearman's rank correlation coefficient assessed associations between fall occurrence and various risk factors. Findings indicated that the prevalence of falls was 32.6%. Falls were significantly associated with behaviors such as agitation or confusion, and other unmentioned risk factors. Participants living in facilities run by non-profit organizations, and who had a lower education level or were single or widowed, had a higher fall prevalence. The use of anti-depressant and anti-diabetic medications was significantly linked to increased fall risk. These findings can inform future research and the development of strategies to prevent falls among older adults, particularly in LTC facilities.

Predictive Factors and the Predictive Scoring System for Falls in Acute Care Inpatients: Retrospective Cohort Study

Background

Falls in hospitalized patients are a serious problem, resulting in physical injury, secondary complications, impaired activities of daily living, prolonged hospital stays, and increased medical costs. Establishing a fall prediction scoring system to identify patients most likely to fall can help prevent falls among hospitalized patients.

objectives

This study aimed to identify predictive factors of falls in acute care hospital patients, develop a scoring system, and evaluate its validity.

Methods

This single-center, retrospective cohort study involved patients aged 20 years or older admitted to Shizuoka General Hospital between April 2019 and September 2020. Demographic data, candidate predictors at admission, and fall occurrence reports were collected from medical records. The outcome was the time from admission to a fall requiring medical resources. Two-thirds of cases were randomly selected as the training set for analysis, and univariable and multivariable Cox regression analyses were used to identify factors affecting fall risk. We scored the fall risk based on the estimated hazard ratios (HRs) and constructed a fall prediction scoring system. The remaining one-third of cases was used as the test set to evaluate the predictive performance of the new scoring system.

Results

A total of 13,725 individuals were included. During the study period, 2.4% (326/13,725) of patients experienced a fall. In the training dataset (n=9150), Cox regression analysis identified sex (male: HR 1.60, 95% CI 1.21-2.13), age (65 to <80 years: HR 2.26, 95% CI 1.48-3.44; ≥80 years: HR 2.50, 95% CI 1.60-3.92 vs 20-<65 years), BMI (18.5 to <25 kg/m²: HR 1.36, 95% CI 0.94-1.97; <18.5 kg/m²: HR 1.57, 95% CI 1.01-2.44 vs ≥25 kg/m²), independence degree of daily living for older adults with disabilities (bedriddenness rank A: HR 1.81, 95% CI 1.26-2.60; rank B: HR 2.03, 95% CI 1.31-3.14; rank C: HR 1.23, 95% CI 0.83-1.83 vs rank J), department (internal medicine: HR 1.23, 95% CI 0.92-1.64; emergency department: HR 1.81, 95% CI 1.26-2.60 vs department of surgery), and history of falls within 1 year (yes: HR 1.66, 95% CI 1.21-2.27) as predictors of falls. Using these factors, we developed a fall prediction scoring system categorizing patients into 3 risk groups: low risk (0-4 points), intermediate risk (5-9 points), and high risk (10-15 points). The c-index indicating predictive performance in the test set (n=4575) was 0.733 (95% CI 0.684-0.782).

Conclusions

We developed a new fall prediction scoring system for patients admitted to acute care hospitals by identifying predictors of falls in Japan. This system may be useful for preventive interventions in patient populations with a high likelihood of falling in acute care settings.

Development and validation of a nomogram for individualizing fall risk in patients with hematologic malignancies

Inpatient falls are common adverse events especially for patients with hematologic malignancies. A fall-risk prediction model for patients with hematologic malignancies are still needed. Here we conducted a multicenter study that prospectively included 516 hospitalized patients with hematologic malignancies, and developed a nomogram for fall risk prediction. Patients were divided into the modeling group (n = 389) and the validation group (n = 127). A questionnaire containing sociodemographic factors, general health factors, disease-related factors, medication factors, and physical activity factors was administered to all patients. Logistic regression analysis revealed that peripheral neuropathy, pain intensity, Morse fall scale score, chemotherapy courses, and myelosuppression days were risk factors for falls in patients with hematologic malignancies. The nomogram model had a sensitivity of 0.790 and specificity of 0.800. The calibration curves demonstrated acceptable agreement between the predicted and observed outcomes. Therefore, the nomogram model has promising accuracy in predicting fall risk in patients with hematologic malignancies.

Comparative analysis of psychiatric medications and their association with falls and fractures: A systematic review and network meta-analysis

An association between psychiatric medications and falls and fractures in people taking them has been demonstrated, but which class or medication leads to the greatest risk of falls or fractures should be further investigated. The aim of this study was to compare and rank the magnitude of risk of falls and fractures due to different psychiatric medications. Eight databases were searched for this meta-analysis and evaluated using a frequency-based network meta-analysis. The results included a total of 28 papers with 14 medications from 5 major classes, involving 3,467,314 patients. The results showed that atypical antipsychotics were the class of medications with the highest risk of falls, and typical antipsychotics were the class of medications with the highest risk of resulting in fractures. Quetiapine ranked first in the category of 13 medications associated with risk of falls, and class Z drugs ranked first in the category of 6 medications associated with risk of fractures. The available evidence suggests that atypical antipsychotics and typical antipsychotics may be the drugs with the highest risk of falls and fractures, respectively. Quetiapine may be the medication with the highest risk of falls, and class Z drugs may be the medication with the highest risk of fractures.

A novel multistep approach to standardize the reported risk factors for in-hospital falls: a proof-of-concept study

Background

Uncertainty and inconsistency in terminology regarding the risk factors (RFs) for in-hospital falls are present in the literature.

Objective

(1) To perform a literature review to identify the fall RFs among hospitalized adults; (2) to link the found RFs to the corresponding categories of international health classifications to reduce the heterogeneity of their definitions; (3) to perform a meta-analysis on the risk categories to identify the significant RFs; (4) to refine the final list of significant categories to avoid redundancies.

Methods

Four databases were investigated. We included observational studies assessing patients who had experienced in-hospital falls. Two independent reviewers performed the inclusion and extrapolation process and evaluated the methodological quality of the included studies. RFs were grouped into categories according to three health classifications (ICF, ICD-10, and ATC). Meta-analyses were performed to obtain an overall pooled odds ratio for each RF. Finally, protective RFs or redundant RFs across different classifications were excluded.

Results

Thirty-six articles were included in the meta-analysis. One thousand one hundred and eleven RFs were identified; 616 were linked to ICF classification, 450 to ICD-10, and 260 to ATC. The meta-analyses and subsequent refinement of the categories yielded 53 significant RFs. Overall, the initial number of RFs was reduced by about 21 times.

Conclusion

We identified 53 significant RF categories for in-hospital falls. These results provide proof of concept of the feasibility and validity of the proposed methodology. The list of significant RFs can be used as a template to build more accurate measurement instruments to predict in-hospital falls.

The Administration of Lemborexant at Admission is Not Associated with Inpatient Falls: A Multicenter Retrospective Observational Study

Purpose

There has been no large-scale investigation into the association between the use of lemborexant, suvorexant, and ramelteon and falls in a large population. This study, serving as a pilot investigation, was aimed at examining the relationship between inpatient falls and various prescribed hypnotic medications at admission.

Patients and Methods

This study was a sub-analysis of a multicenter retrospective observational study conducted over a period of 3 years. The target population comprised patients aged 20 years or above admitted to eight hospitals, including chronic care, acute care, and tertiary hospitals. We extracted data on the types of hypnotic medications prescribed at admission, including lemborexant, suvorexant, ramelteon, benzodiazepines, Z-drugs, and other hypnotics; the occurrence of inpatient falls during the hospital stay; and patients' background information. To determine the outcome of inpatient falls, items with low collinearity were selected and included as covariates in a forced-entry binary logistic regression analysis.

Results

Overall, 150,278 patients were included in the analysis, among whom 3,458 experienced falls. The median age of the entire cohort was 70 years, with men constituting 53.1%. Binary logistic regression analysis revealed that the prescription of lemborexant, suvorexant, and ramelteon at admission was not significantly associated with inpatient falls.

Conclusion

The administration of lemborexant, suvorexant, and ramelteon at admission may not be associated with inpatient falls.

Identification of the simultaneous use of multiple hypnotics as a risk factor for falls in hospitalized patients by a matched case-control study

AIM

The risk of falls owing to simultaneous use of multiple hypnotics has not been clarified. The aim of this study was to assess the association between the simultaneous use of 2 hypnotics and the occurrence of falls in hospitalized patients.

METHODS

A matched case-control study was conducted at Tokyo Medical University Hospital in Tokyo, Japan, utilizing data from medical records. Cases were 434 hospitalized patients who experienced falls during their hospital stay between January 2016 and December 2016, and controls were 434 hospitalized patients without falls, individually matched by age, sex, and clinical department. The outcome was the occurrence of an in-hospital fall. The associations between the use of 1 hypnotic and falls, and between the use of 2 hypnotics and falls were assessed by conditional logistic regression analyses. The main multivariable conditional logistic regression model was adjusted for potential risk factors, including the use of other classes of psychotropics (antipsychotics, antidepressants, and anxiolytics), in addition to patient characteristics.

RESULTS

The main multivariable conditional logistic regression analyses showed that the simultaneous use of 2 hypnotics (odds ratio [OR] = 2.986; 95% confidence interval [CI], 1.041-8.567), but not the use of a single hypnotic (OR = 1.252; 95% CI, 0.843-1.859), was significantly associated with an increased OR of falls.

CONCLUSION

The simultaneous use of 2 hypnotics is a risk factor for falls among hospitalized patients, whereas the use of a single hypnotic may not.

Association between psychotropics use and occurrence of falls in hospitalized patients: A matched case-control study

Aim

Understanding the appropriate prescription of psychotropics for hospitalized patients in terms of preventing falls is an important issue. The aim of this study was to assess the associations between the occurrence of falls and the use of various individual psychotropics in hospitalized patients.

Methods

A retrospective matched case-control study was conducted on adult patients admitted to every department of Tokyo Medical University Hospital, with the outcome being in-hospital falls. A total of 447 hospitalized patients who had had in-hospital falls at some point in their hospitalization between January 2016 and December 2016 were included as cases. A total of 447 hospitalized patients who did not have in-hospital falls, and were individually matched to the cases by sex, age, and clinical department, were included as controls. All data were extracted from electronic medical records. Conditional logistic regression analyses were conducted to assess the association between the exposure to 16 psychotropic medications and the occurrence of in-hospital falls. The multivariable logistic regression model adjusted sex, age, clinical department, body mass index, fall risk score on the fall risk assessment measure, and use of psychotropic medications.

Results

The multivariable conditional logistic regression model showed a significant association between the use of risperidone (odds ratio [OR] = 3.730; 95% confidence interval [CI] = 1.229-11.325) and flunitrazepam (OR = 4.120; 95% CI = 1.105-15.364) and an increased OR of falls among hospitalized patients.

Conclusion

The use of risperidone and flunitrazepam were identified as risk factors for falls among hospitalized patients.

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.

Potentially inappropriate medications and their effect on falls during hospital admission

OBJECTIVE

to investigate the effect of potentially inappropriate medications (PIMs) on inpatient falls and to identify whether PIMs as defined by STOPPFall or the designated section K for falls of STOPP v2 have a stronger association with inpatient falls when compared to the general tool STOPP v2.

METHODS

a retrospective observational matching study using an electronic health records dataset of patients (≥70 years) admitted to an academic hospital (2015-19), including free text to identify inpatient falls. PIMs were identified using the STOPP v2, section K of STOPP v2 and STOPPFall. We first matched admissions with PIMs to those without PIMs on confounding factors. We then applied multinomial logistic regression analysis and Cox proportional hazards analysis on the matched datasets to identify effects of PIMs on inpatient falls.

RESULTS

the dataset included 16,678 hospital admissions, with a mean age of 77.2 years. Inpatient falls occurred during 446 (2.7%) admissions. Adjusted odds ratio (OR) (95% confidence interval (CI)) for the association between PIM exposure and falls were 7.9 (6.1-10.3) for STOPP section K, 2.2 (2.0-2.5) for STOPP and 1.4 (1.3-1.5) for STOPPFall. Adjusted hazard ratio (HR) (95% CI) for the effect on time to first fall were 2.8 (2.3-3.5) for STOPP section K, 1.5 (1.3-1.6) for STOPP and 1.3 (1.2-1.5) for STOPPFall.

CONCLUSIONS

we identified an independent association of PIMs on inpatient falls for all applied (de)prescribing tools. The strongest effect was identified for STOPP section K, which is restricted to high-risk medication for falls. Our results suggest that decreasing PIM exposure during hospital stay might benefit fall prevention, but intervention studies are warranted.

Mild cognitive impairment: associations with sleep disturbance, apolipoprotein e4, and sleep medications

OBJECTIVE

Mild cognitive impairment (MCI) is associated with increased memory problems although the ability to complete daily life activities remains relatively intact. This study examined: (1) if sleep disturbance increased the hazard of MCI; (2) if APOE e4 carriers with sleep disturbance experience an increased risk of MCI; and, (3) if prescription sleep medications provide a protective effect against MCI. We hypothesized that sleep disturbance increases the hazard of MCI, this relationship is stronger among APOE e4 carriers reporting a sleep disturbance. Furthermore, we hypothesized that sleep medications decrease the hazard of MCI.

METHODS

To determine whether sleep medication mediates the risk of developing MCI for individuals with sleep disturbance and/or APOE e4, we analyzed the National Alzheimer's Coordinating Center Uniform Data Set. We selected participants with normal cognition at baseline (n = 6798), and conduced survival analyses.

RESULTS

Our main findings indicated that the hazard of MCI was significantly associated with sleep disturbance. The hazard remained among those who did not use sleep medication. Trazodone and zolpidem users did not have a significant hazard of MCI, but the significant hazard remained for those who did not use these medications. APOE e4 carriers had a significantly higher hazard of MCI. Among e4 carriers who used trazodone or zolpidem, there was not a statistically significant risk of MCI.

CONCLUSION

This study demonstrated the potential utilization of trazodone and zolpidem in the treatment of sleep disturbance while potentially mitigating the risk of MCI. While trazodone and zolpidem have been shown to positively impact sleep disturbance in individuals with normal cognition, further research should explore these findings given that these medications are potentially inappropriate for older adults.

Eight-Year Follow-up of Hypnotic Delivery by Adults Aged 50 and Older from an Insurance Database

Study objectives

This study sought to (1) identify patterns of hypnotic use among persons aged 50 and older for 8 years and (2) describe characteristics and correlates associated with them.

Methods

A representative sample of national health insurance system beneficiaries was followed up from 2006 through 2013; individuals were grouped according to hypnotic delivery trajectories by latent class mixed models.

Results

We identified four different temporal trajectories of hypnotic delivery among users. Delivery was occasional for 40% and regular for 60% (quasi-continuous "use": 27%; increasingly frequent over time: 17%; decreasingly frequent: 16%). Quasi-continuous "users" received hypnotics for more than 70% of the follow-up period and occasional "users" for less than 8%. We found no clear evidence of dose escalation. The three regular-delivery trajectories shared similar correlates (psychiatric disorders, somatic comorbidity, and coprescriptions of antidepressants or antipsychotics), but association with somatic comorbidity was highest by far for quasi-continuous "users."

Conclusions

Our results suggest that chronic hypnotic use covers different patterns resulting from different long-term temporal delivery trajectories. Because difficulties in stopping or reducing use may vary greatly according to these trajectories, patients may need individualized management approaches.

Safety of brotizolam in hospitalized patients

PURPOSE

The objective of this study was to evaluate the safety of brotizolam in hospitalized patients.

METHODS

A single-center, comparative retrospective cohort analysis of patients hospitalized in internal medicine wards. Patients treated with brotizolam were compared to patients not treated with any benzodiazepines during hospitalization. Primary outcome was any of the following safety events: mechanical ventilation, delirium, and falls.

RESULTS

Six hundred patients were included after exclusion in the final analysis; 300 treated with brotizolam (treatment) and 300 not treated with any benzodiazepines (comparator). The brotizolam-treated patients were older with more comorbidities and psychotropic medications. After adjustment using multivariate logistic regression analysis with propensity score, the primary outcomes occurred at significantly higher rates in treated patients than in untreated patients (17 vs. 2 events; OR = 7.33). Any psychotropic medication administered during hospitalization was found by logistic regression to be the main independent risk factor for the studied safety outcomes while age, comorbidities, and the cause of hospitalization were not.

CONCLUSIONS

Treatment with brotizolam during hospitalization in internal medicine wards is linked to a higher risk of respiratory deterioration, delirium, and falls. Use of psychotropic medications during hospitalization is the main independent risk factor of safety outcomes. Further research is needed to fully evaluate the risks and benefits of sleep induction medications in hospitals.

South Korean geriatrics on Beers Criteria medications at risk of adverse drug events

Background

The Beers Criteria released by the American Geriatrics Society includes a list of drugs to avoid in the geriatric population and is frequently used as a safety resource in geriatric pharmacotherapy.

Objective

To evaluate the exposure of South Korean geriatrics to potentially inappropriate medications according to the Beers Criteria and the risk of adverse events from these medications.

Methods

This study included medications recommended to be avoided in patients 65 years or older regardless of concomitant drug therapy or disease. The exposure of South Korean geriatrics to each of the study medications were examined using health claims data of 2011. The number of South Korean geriatrics at risk of experiencing adverse drug events from the study medications were estimated by multiplying the number of patients exposed to the medication in 2011 and the incident rate of the event obtained from literature sources.

Results

This study examined 166,822 geriatrics for Beers Criteria medication exposure and adverse drug event risk. The most prevalent Beers Criteria medication prescribed in South Korean geriatrics >1 day was chlorpheniramine (53.9%) and the adverse drug event with the highest number of this geriatric population at risk of was amitriptyline related dry mouth (4.9%). The proportion of South Korean geriatrics on chronic Beers Criteria medications >1 day at risk of adverse drug events from these medications was significantly higher than in US geriatrics (0.005 vs. 0.001, 2-way ANOVA post hoc pairwise t-test P<0.0001).

Conclusions

In 2011, over half of South Korean geriatrics was exposed to medications recommended to be avoided in geriatrics and their adverse drug event risk warrants close monitoring of their occurrence.

Sleeping Pill Administration Time and Patient Subjective Satisfaction

STUDY OBJECTIVES

Taking hypnotic agents 30 min before bedtime is the usual suggested administration time, but some patients report dissatisfaction with their sleeping pills. We investigated whether the timing of sleeping pill administration influences patient subjective satisfaction with these drugs.

METHODS

One hundred twelve patients with primary insomnia currently taking benzodiazepine or nonbenzodiazepine gamma-aminobutyric acid (GABA) agonists as sleeping pills were selected. The time of administration for their sleeping pills, bedtime, sleep onset time, and wake up time were obtained from their medical records. Subjects were also categorized into satisfied or dissatisfied groups.

RESULTS

Hypnotic agents administration time (p < 0.001) and bedtime (p < 0.001), but not sleep onset or wake up time, occurred later in the night in the satisfied group. The durations from administration of pills to sleep onset (33.6 ± 20.7 min) and to wake up time (7.2 ± 1.2 h) were significantly shorter in the satisfied group when compared to the dissatisfied group (135.9 ± 73.4 min and 9.3 ± 1.5 h for time to sleep onset and wake up, respectively). Logistic regression analysis revealed that patient subjective satisfaction with hypnotic agents could be predicted by a short duration from administration of pills to sleep onset (odds ratio = 0.01; 95% confidence interval [0.001-0.09]) and a short duration from administration of pills to wake up time (0.53; [0.31-0.89], F = 49.9, p < 0.001).

CONCLUSIONS

Taking sleeping pills at a later time and a shorter interval between pill administration and wake up time may increase patient subjective satisfaction with hypnotic agents. We propose that physicians advise patients to take sleeping pills approximately 7 h before their usual getting-out-of-bed time instead of the current standard of 30 min before bedtime.

Benzodiazepine Initiation and Dose Escalation

BACKGROUND

Benzodiazepines (BZDs) place patients at a significant risk of falling. The current literature does not address if this risk is increased during initiation or dose escalations of BZDs.

OBJECTIVE

To determine if initiation or dose escalations of BZD regimens are associated with an increased risk of falls in hospitalized patients compared with patients maintained on their home dose or who had their dose decreased from baseline.

METHODS

This retrospective case-control study evaluated hospitalized patients aged 45 years or older who received a BZD. Patients who did not fall were collected in a 3:1 ratio to patients who fell. Comparisons were made between BZD regimens prior to admission and those 48 hours prior to the index date. The date of fall served as the index date for patients who fell, and the median time-to-fall served as the index date for all other patients.

RESULTS

A total of 132 patients were included in the study (33 falls and 99 without a fall). No significant differences were noted in demographics, baseline mobility, or past medical history. Patients who fell had a significantly longer median length of stay (15 vs 10 days; P = 0.025). Additionally, patients who fell were more likely to have had their BZD regimen initiated or dose escalated compared with patients who did not fall (63.6% vs 41.4%; P = 0.043).

CONCLUSIONS

The risk of falling while on a BZD is increased on initiation and dose escalations. Hospitals should ensure judicious use of BZDs in inpatients to reduce the risk of falls.

Clinical and sociodemographic correlates of severe insomnia in psychotropic drug-free, Asian outpatients with major depressive disorder

BACKGROUND

Little has been known regarding the correlates of severe insomnia in major depressive disorder (MDD). This post-hoc analysis aimed to examine the sociodemographic and clinical correlates of severe insomnia in psychotropic drug-free, Asian adult outpatients with MDD.

METHODS

Participants were psychotropic drug-free patients with MDD, aged 18-65 years. By using the Symptom Checklist-90 Items, Revised (SCL-90-R), a score of 4 (severe distress) on any one of three insomnia items was defined as severe insomnia. Other measures included the Montgomery-Asberg Depression Rating Scale (MADRS), the Fatigue Severity Scale (FSS), the nine psychopathology subscales of SCL-90-R, the Physical and Mental Component Summaries of Short Form Health Survey (SF-36 PCS and SF-36 MCS), and the Sheehan Disability Scale (SDS).

RESULTS

Of 528 participants, their mean age being 39.5 (SD=13.26) years, 64.2% were females, and 239 (45.3%) had severe insomnia. The logistic regression model revealed that low educational qualifications (less than secondary school completion), high SCL-90-R Depression scores, high SCL-90-R Anxiety scores, and low SF-36 PCS scores were independently correlated with severe insomnia (p's<.05).

LIMITATIONS

Insomnia was determined only by the patient's distress. Middle insomnia was not assessed. Psychotropic drug-free patients with MDD are not commonly seen in psychiatric practice.

CONCLUSION

Severe insomnia is common in patients with MDD. It is closely related with low educational qualification, subjective depression and anxiety severity, and poor physical health. These findings may implicate the treatment of comorbid MDD and severe insomnia, for example, sleep hygiene education, pharmacological treatment.

Hypnotics and the Occurrence of Bone Fractures in Hospitalized Dementia Patients: A Matched Case-Control Study Using a National Inpatient Database

BACKGROUND

Preventing falls and bone fractures in hospital care is an important issue in geriatric medicine. Use of hypnotics is a potential risk factor for falls and bone fractures in older patients. However, data are lacking on the association between use of hypnotics and the occurrence of bone fracture.

METHODS

We used a national inpatient database including 1,057 hospitals in Japan and included dementia patients aged 50 years or older who were hospitalized during a period of 12 months between April 2012 and March 2013. The primary outcome was the occurrence of bone fracture during hospitalization. Use of hypnotics was compared between patients with and without bone fracture in this matched case-control study.

RESULTS

Of 140,494 patients, 830 patients suffered from in-hospital fracture. A 1:4 matching with age, sex and hospital created 817 cases with fracture and 3,158 matched patients without fracture. With adjustment for the Charlson comorbidity index, emergent admission, activities of daily living, and scores for level walking, a higher occurrence of fractures were seen with short-acting benzodiazepine hypnotics (odds ratio, 1.43; 95% confidence interval, 1.19-1.73; P<0.001), ultrashort-acting non-benzodiazepine hypnotics (1.66; 1.37-2.01; P<0.001), hydroxyzine (1.45; 1.15-1.82, P=0.001), risperidone and perospirone (1.37; 1.08-1.73; P=0.010). Other drug groups were not significantly associated with the occurrence of in-hospital fracture.

CONCLUSIONS

Short-acting benzodiazepine hypnotics and ultrashort-acting non-benzodiazepine hypnotics may increase risk of bone fracture in hospitalized dementia patients.

Hyponatremia and hypokalemia as risk factors for falls

BACKGROUND/OBJECTIVES

Fall accidents may reduce an individual's quality of life and ability to perform the activities of daily life, and may delay recovery from illness. Consequently, medical institutions need to take measures to prevent falls. There are various risk factors for falls, including advanced age, illness and medication effects. Although hyponatremia and hypokalemia have been reported to increase the rate of falls, how they affect falls is not fully understood.

SUBJECTS/METHODS

We retrospectively examined 2948 patients, ⩾18 years old who had been hospitalized for ⩾3 days at Gifu (Japan) Municipal Hospital between May 2012 and April 2013 to determine the effects of hyponatremia and hypokalemia on the risk of falls. After the patients had been divided into fall and non-fall groups, their data were subjected to univariate and multiple regression analysis to identify significant differences.

RESULTS

The univariate analysis results revealed significant differences between the groups in terms of age (⩾65 years); the presence of hyponatremia, hypokalemia, central nervous system disease, cardiovascular disease and/or peripheral nerve/muscular disease; intake of medications that increase the risk of falls; and increased sedative dosage. The multivariate analysis results revealed significant differences between the groups in terms of the presence of hyponatremia (odds ratio (OR), 1.751; 95% confidence interval (CI), 1.020-3.005), hypokalemia (OR, 2.209; 95% CI, 1.280-3.813), central nervous system disease (OR, 2.492; 95% CI, 1.629-3.814) and/or age ⩾65 years (OR, 2.180; 95% CI, 1.242-3.826).

CONCLUSIONS

The results indicated that the presence of hyponatremia or hypokalemia increases the risk of falls.

New and emerging pharmacotherapeutic approaches for insomnia

Advances in understanding the neurochemistry of sleep and waking have stimulated new pharmacological directions in the treatment of insomnia. While the sedation of historic insomnia medications was discovered serendipitously, now compounds can be developed for specific molecular targets with known sleep-related actions. Numerous investigational compounds, including some entirely novel approaches, are being evaluated currently as possible insomnia treatments. In recent years the US Federal Drug Administration (FDA) has approved medications with new pharmacodynamic and pharmacokinetic properties thereby extending the options for personalized pharmacotherapy. The FDA is reviewing new applications for innovative sleep-promoting medications currently, including suvorexant and tasimelteon. Presently the FDA-approved insomnia treatment medications include benzodiazepine receptor agonists available in immediate-release, extended-release, and alternative delivery oral absorption formulations; a melatonin receptor agonist; and a histamine receptor antagonist. Clinical indications include insomnia associated with difficulty with sleep onset, sleep maintenance, and middle-of-the-night awakenings. Alternative approaches to treating insomnia have included prescription medications employed on an off-label basis for insomnia, over-the-counter sleep aids, and assorted unregulated substances marketed to enhance sleep.