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Ramsay RE, Becker D, Vazquez B, Birnbaum AK, Misra SN, Carrazana E, Rabinowicz AL. Acute Abortive Therapies for Seizure Clusters in Long-Term Care. J Am Med Dir Assoc 2023:S1525-8610(23)00405-X. [PMID: 37253432 DOI: 10.1016/j.jamda.2023.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 04/10/2023] [Accepted: 04/11/2023] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To describe acute seizure treatment for the long-term care setting, emphasizing rescue (acute abortive) medications for on-site management of acute unexpected seizures and seizure clusters. DESIGN Narrative review. SETTING AND PARTICIPANTS People with seizures in long-term care, including group residences. METHODS PubMed was searched using keywords that pertained to rescue medications, seizure emergencies/epilepsy, seizure action plans, and long-term care. RESULTS Seizure disorder, including epilepsy, is prevalent in long-term care residences, and rescue medications can be used for on-site treatment. Diazepam rectal gel, intranasal midazolam, and diazepam nasal spray are US Food and Drug Administration (FDA)-approved seizure-cluster rescue medications, and intravenous diazepam and lorazepam are approved for status epilepticus. Benzodiazepines differ by formulation, route of administration, absorption, and metabolism. Intranasal formulations are easy and ideal for public use and when rectal treatment is challenging (eg, wheelchair). Intranasal, intrabuccal, and rectal formulations do not require specialized training to administer and are easier for staff at all levels of training compared with intravenous treatment. Off-label rescue medications may have anecdotal support; however, potential disadvantages include variable absorption and onset of action as well as potential risks to patients and caregivers/care partners. Delivery of intravenous-administered rescue medications is delayed by the time needed to set up and deliver the medication and is subject to dosing errors. Seizure action plans that include management of acute seizures can optimize the quality and timing of treatment, which may reduce emergency service needs and prevent progression to status epilepticus. CONCLUSIONS AND IMPLICATIONS Seizure disorder is prevalent across all ages but is increased in older adults and in those with intellectual and developmental disabilities. Prompt intervention may reduce negative outcomes associated with acute unexpected seizures and seizure clusters. Seizure action plans that include acute seizures can improve the treatment response by detailing the necessary information for staff to provide immediate treatment.
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Affiliation(s)
- R Eugene Ramsay
- International Center for Epilepsy, St. Bernard Parish Medical Center, New Orleans, LA, USA.
| | - Danielle Becker
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Blanca Vazquez
- Comprehensive Epilepsy Center, New York University, New York, NY, USA
| | - Angela K Birnbaum
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | | | - Enrique Carrazana
- Neurelis, Inc, San Diego, CA, USA; John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
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O'Dwyer R, Foster E, Leppik I, Kwan P. Pharmacological treatment for older adults with epilepsy and comorbid neurodegenerative disorders. Curr Opin Neurol 2023; 36:117-123. [PMID: 36762636 DOI: 10.1097/wco.0000000000001143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW An increased interest in epilepsy in older adults has emerged as the global population ages. The purpose of this article is to review the literature regarding the pharmacological treatment of epilepsy in older adults, highlighting issues specifically pertinent to those living with comorbid neurodegenerative disorders. RECENT FINDINGS Although new original research remains sparse, in the last 5 years, there has been a growing number of studies addressing the relationship between epilepsy and neurodegenerative disorders. Accurate diagnosis is incredibly challenging with electroencephalogram findings often requiring circumspect interpretation. Older individuals are often excluded from or under-represented in clinical trials, and there are sparse guidelines offered on the management of these patients, with even less available in reference to those with neurodegenerative comorbidities. SUMMARY We propose that seizures occurring earlier in the neurodegenerative process should be treated aggressively, with the goal to inhibit neuro-excitotoxicity and the associated neuronal loss. By strategically choosing newer antiseizure medications with less adverse effects and a holistic approach to treatment, a patient's time living independently can be conserved. In addition, we advocate for original, multinational collaborative research efforts.
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Affiliation(s)
- Rebecca O'Dwyer
- Rush Epilepsy Center, Rush University Medical Center, Chicago, Illinois, USA
| | - Emma Foster
- Central Clinical School, Monash University
- Neurology Department, The Alfred, Melbourne, Victoria, Australia
| | - Ilo Leppik
- MINCEP Epilepsy Care, University of Minnesota, Minneapolis, Minnesota, USA
| | - Patrick Kwan
- Central Clinical School, Monash University
- Neurology Department, The Alfred, Melbourne, Victoria, Australia
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Lemus HN, Sarkis RA. Epilepsy care in nursing facilities: Knowledge gaps and opportunities. Epilepsy Behav 2023; 138:108997. [PMID: 36442262 DOI: 10.1016/j.yebeh.2022.108997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022]
Abstract
Epilepsy in the elderly is a complex disease, often underdiagnosed, and inadequately treated. It requires a multi-disciplinary approach and care coordination especially if the patient resides in a nursing facility. Episodes of loss of consciousness falls, or amnestic events in those living in a nursing facility require a detailed description and an urgent assessment to rule out an epileptic seizure. Prompt recognition of seizures and the implementation of treatment protocols in those with recurrent seizures are needed to prevent unnecessary emergency visits. Although there is a myriad of antiseizure medications (ASM) to treat seizures, clinicians should be aware of common interactions, side effects, and changes in pharmacodynamics with age. There is a limited number of ASMs that have been properly studied in clinical trials to assess tolerability and efficacy in the elderly, and an over-reliance on enzyme-inducing ASMs. Strategies to improve the knowledge of health care providers include electronic resources, treatment protocols, and improving awareness of the efficacy, drug-drug interaction, and short-term and long-term monitoring of ASM side effects.
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Affiliation(s)
| | - Rani A Sarkis
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
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Leppik IE, Birnbaum AK, Svensden K, Eberly LE. New Onset (Incidence) of Epilepsy and Seizures in Nursing Home Residents. J Am Med Dir Assoc 2022; 23:1589.e11-1589.e15. [PMID: 35779573 PMCID: PMC10069272 DOI: 10.1016/j.jamda.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 05/27/2022] [Accepted: 06/01/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The point prevalence of epilepsy is high in nursing homes (NH), but the incidence of epilepsy after admission is unknown. This study was done to determine the incidence of epilepsy/seizure (epi/sz) comorbid with other conditions in older adult NH residents. DESIGN Retrospective evaluation of Minimum Data Set records to identify new onset epi/sz in NH residents. SETTING AND PARTICIPANTS Five cross-sectional cohorts of all residents in any Medicare/Medicaid certified NH in the United States on July 15 of each year 2003-2007. MEASURES Epi/sz was identified by International Classification of Diseases, Ninth Revision codes (345.xx or 780.39) or check box on the Minimum Data Set. Those with no such code on admission and with 1 to 3 plus years of follow-up (n = 3,609,422) were followed through 2007 or end of stay. RESULTS Overall incidence of epi/sz was 16.42/1000 patient years (PY). Incidence was highest in the first year after admission and declined thereafter. There were more women (n = 2,523,951) than men (n = 1,089,631), but men had a higher incidence (21.17/1000PY) compared with women (14.81/1000PY). Although the 65‒74 years of age cohort included fewer residents (n = 594,722) compared with the age 85 years + cohort (n = 1,520,167), the younger residents had the highest incidence (28.53/1000 PY) compared with the oldest, 10.22/1000 PY for the age 85+ years cohort. The highest incidences were among those with brain tumor (122.55/1000PY), followed by head injury (45.66/1000PY). Overall, 714,340 had a diagnosis of stroke, and incidence was 27.52/1000PY. Those with none of selected risk factors had an overall incidence of 12.45/1000PY. CONCLUSIONS AND IMPLICATIONS The incidence of epi/sz in older individuals after admission to a NH is high. There is a need to develop practice approaches to best manage this large cohort. There does not appear to be a uniform approach to managing new onset epilepsy in NHs at this time. Studies to develop evidence for practice guidelines are needed.
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Affiliation(s)
- Ilo E Leppik
- Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA; Department of Neurology, University of Minnesota, Minneapolis, MN, USA.
| | - Angela K Birnbaum
- Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Kenneth Svensden
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Lynn E Eberly
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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Adachi N, Ito M. Epilepsy in patients with schizophrenia: Pathophysiology and basic treatments. Epilepsy Behav 2022; 127:108520. [PMID: 34999502 DOI: 10.1016/j.yebeh.2021.108520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 12/18/2021] [Accepted: 12/19/2021] [Indexed: 11/03/2022]
Abstract
Schizophrenia is a chronic psychiatric disorder that may lead to epilepsy. However, there are limited findings on the issues. This narrative review aimed to provide a practical perspective on epilepsy in patients with schizophrenia using the current treatment systems for epilepsy. While there has been a debate on the relationship between epilepsy and schizophrenia, i.e., antagonism, affinity, and coincidence, recent large cohort studies have revealed a high frequency of epilepsy in patients with schizophrenia (4-5 times higher than that of general population). The high incidence observed is likely to be due to the bidirectionality between epilepsy and schizophrenia and additional schizophrenia-related conditions, e.g., antipsychotic drugs (APD), substance abuse, and head injury. As for symptomatology of epilepsy, only one small-size study showed that seizures of patients with schizophrenia are equivalent to those of patients without schizophrenia. Patients with schizophrenia exhibit the first seizure in their twenties or later, which are mostly focal seizures. Most of seizures in patients with schizophrenia can be controlled with conventional antiepileptic drugs. Few patients with schizophrenia develop treatment-resistant epilepsy. However, since drug interactions can be more complicated due to multiple conditions, such as pre-existing polypharmacy, heavy smoking, irregular eating, and comorbid metabolic disorders, cautious monitoring for clinical symptoms is required. To improve seizure control and adherence, non-pharmacological approaches are also recommended. Thus far, for seizure treatments in patients with schizophrenia, we have to use many empirical findings or substitute certain findings from population without schizophrenia because evidence is insufficient. The accumulation of clinical findings may contribute to the development of efficient treatment systems.
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Affiliation(s)
- Naoto Adachi
- Adachi Mental Clinic, Sapporo, Japan; Jozen Clinic, Sapporo, Japan.
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Healthcare Resource Utilization Among Patients with Focal Seizures Treated with Eslicarbazepine Acetate in the US Long-Term Care Setting: A Retrospective Claims Database Analysis. Neurol Ther 2021; 10:673-691. [PMID: 33826104 PMCID: PMC8571427 DOI: 10.1007/s40120-021-00244-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 03/16/2021] [Indexed: 11/28/2022] Open
Abstract
Introduction The aim of this study was to compare healthcare resource utilization (HCRU) before and after initiation of eslicarbazepine acetate (ESL) in the long-term care (LTC) setting (rehabilitation center, mental health center, LTC non-skilled nursing facility/assisted-living facility, home health, assisted living, nursing home, other/unknown). Methods This retrospective analysis used IQVIA’s New Data Warehouse, which includes deterministically linked LTC, prescription, and professional fee claims data and IQVIA Hospital Charge Data Master database. The study period was 1 April 2013 to 31 December 2019. The index date was the date of ESL initiation in the LTC setting. Inclusion criteria were: (1) ≥ 1 new ESL prescription between 1 April 2014 and 31 December 2018; (2) diagnosis of focal seizure (FS) during the 12 months pre-index date; and (3) no ESL prescription during the 12-month period pre-index. A 12-month pre-post analysis compared epilepsy-specific and all-cause HCRU before and after ESL initiation. Categorical variables were compared with McNemar’s tests. Results A total of 307 patients (mean age 52.2 years, 57.7% male) with FS were included, of whom 24.8% were in nursing homes. Patients used a mean of 3.1 antiseizure drugs prior to initiation of ESL, and 87.9% of patients initiated ESL as adjunctive treatment. There were significant reductions in proportion of patients with epilepsy specific physician office visits, emergency department (ED) visits, hospitalizations, and all-cause physician office visits and hospitalizations in the post-index period compared to the pre-index period (P < 0.05). Similar results were observed in sensitivity (patients with an epilepsy diagnosis) and subgroup analyses [presence or absence of intellectual developmental disorders or age (≥ 65 and < 65 years)]. Conclusion Proportion of patients with epilepsy-specific physician office visits, ED visits, hospitalizations, and all-cause physician office visits and hospitalizations were significantly reduced following initiation of ESL in patients with FS in LTC. Supplementary Information The online version contains supplementary material available at 10.1007/s40120-021-00244-5.
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Grill P, Marwick C, De Souza N, Burton JK, Hughes C, Guthrie B. The burden of psychotropic and anticholinergic medicines use in care homes: population-based analysis in 147 care homes. Age Ageing 2021; 50:183-189. [PMID: 32706851 DOI: 10.1093/ageing/afaa122] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND older people living in care-homes are particularly vulnerable to adverse effects of psychotropic and anticholinergic drugs. METHODS anonymised dispensed prescription data from all 4,478 residents aged ≥ 60 years in 147 care-homes in two Scottish health boards were analysed. Psychotropic medicines examined were antipsychotics, antidepressants, hypnotic/anxiolytics, opioids and gabapentinoids. Anticholinergic burden was measured using the modified anticholinergic risk scale (mARS). Variation between care-homes and associations with individual and care-home characteristics were examined using multilevel logistic regression. RESULTS 63.5% of residents were prescribed at least one psychotropic drug, and 27.0% two or more, most commonly antidepressants (41.6%), opioids (20.3%), hypnotic/anxiolytics (16.9%) and antipsychotics (16.7%). 48.1% were prescribed an anticholinergic drug, and 12.1% had high anticholinergic burden (mARS ≥ 3). Variation between care-homes was high for antipsychotics (intra-cluster correlation coefficient [ICC] 8.2%) and hypnotics/anxiolytics (ICC = 7.3%), and moderate for antidepressants (ICC = 4.7%) and anticholinergics (ICC = 2.8%). Prescribing of all drugs was lower in the oldest old. People with dementia were more likely to be prescribed antipsychotics (adjusted OR = 1.45, 95%CI 1.23-1.71) but less likely to be prescribed anticholinergics (aOR = 0.61, 95%CI 0.51-0.74). Prescribing of antipsychotics was higher in Tayside (aOR = 1.52, 95%CI 1.20-1.92), whereas prescribing of antidepressants (particularly tricyclic-related) was lower (aOR = 0.66, 95%CI 0.56-0.79). There was no association with care-home regulator quality scores. CONCLUSION care-home residents have high psychotropic and anticholinergic burden, with considerable variation between care-homes that is not related to existing measures of quality of care. Research to better understand variation between care-homes and the interaction with local prescribing cultures is needed.
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Affiliation(s)
- Paula Grill
- Undergraduate Medical Student, School of Medicine, University of Dundee, Dundee, UK
| | - Charis Marwick
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Nicosha De Souza
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Jennifer Kirsty Burton
- Academic Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Carmel Hughes
- School of Pharmacy, Queen’s University Belfast, Belfast, UK
| | - Bruce Guthrie
- Usher Institute, School of Medicine, University of Edinburgh, Edinburgh, UK
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Rohracher A, Kalss G, Kuchukhidze G, Neuray C, Leitinger M, Höfler J, Kreidenhuber R, Rossini F, Volna K, Mauritz M, Poppert N, Lattanzi S, Brigo F, Trinka E. New anti-seizure medication for elderly epilepsy patients - a critical narrative review. Expert Opin Pharmacother 2020; 22:621-634. [PMID: 33111598 DOI: 10.1080/14656566.2020.1843636] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Introduction: The number of elderly patients with epilepsy is growing in resource rich countries due to demographic changes and increased longevity. Management in these patients is challenging as underlying etiology, co-morbidities, polypharmacy, age-related pharmacokinetic and pharmacodynamic changes need to be considered.Areas covered: Lacosamide, eslicarbazepine acetate, brivaracetam, and perampanel have been approved in the USA and Europe for monotherapy and/or adjunctive treatment of seizures in the last few years. The authors review the pharmacological properties and safety profile of these drugs and provide recommendations for their use in in the elderly.Expert opinion: There are only limited data available on more recent antiseizure medications (ASMs). Drugs with a low risk of interaction (lacosamide, brivaracetam) are preferred choices. Once daily formulations (perampanel and eslicarbazepine acetate) have the advantage of increased compliance. Intravenous formulations (brivaracetam and lacosamide) are useful in emergency situations and in patients who have difficulties to swallow. Dose adjustments are necessary for all ASMs used in the elderly with slow titration and lower target doses than in the regulatory trials. The adverse event profile does not significantly differ from that found in the general adult population.
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Affiliation(s)
- A Rohracher
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
| | - G Kalss
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
| | - G Kuchukhidze
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
| | - C Neuray
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
| | - M Leitinger
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
| | - J Höfler
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
| | - R Kreidenhuber
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
| | - F Rossini
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
| | - K Volna
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
| | - M Mauritz
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
| | - N Poppert
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
| | - S Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - F Brigo
- Department of Neurology, Franz Tappeiner Hospital, Meran, Italy
| | - E Trinka
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
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Temporal Trends in the Use of Anticholinergic Drugs Among Older People Living in Long-Term Care Facilities in Helsinki. Drugs Aging 2020; 37:27-34. [PMID: 31705445 PMCID: PMC6965041 DOI: 10.1007/s40266-019-00720-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background The use of drugs with anticholinergic properties (DAPs) is common among older adults despite their known adverse effects, such as cognitive decline. Professionals should pay attention to DAPs, since evidence on their adverse effects has been accumulating during the last decade. However, to our knowledge previous studies exploring temporal trends in the use of DAPs are scarce. Objective The aim of this study was to assess temporal trends in the use of DAPs from 2003 to 2017 in long-term care facilities in Helsinki. Methods Four cross-sectional studies were conducted in 2003, 2007, 2011, and 2017. Participants included older people (≥ 65 years) living in nursing homes (NHs) in 2003 (n = 1979), 2011 (n = 1568), and 2017 (n = 750), and in assisted living facilities (ALFs) in 2007 (n = 1336), 2011 (n = 1556), and 2017 (n = 1673) in Helsinki, Finland. Data on demographics, medication use, and diagnoses were collected by structured questionnaires. The assessments were conducted as a point prevalence over 1 day. The use of DAPs and the total anticholinergic burden were defined by the Anticholinergic Risk Scale (ARS). Results In ALFs, there has been an increasing trend in the use of DAPs over a 10-year period (41.2% in 2007 and 53.7% in 2017). In NHs, by contrast, the use of DAPs remained quite stable (52.3% in 2003 and 52.4% in 2017). The burden of DAPs measured by ARS score decreased in NHs and remained stable in ALFs. Marked changes occurred in the DAPs used; antidepressants, especially mirtazapine, increased in both settings, whereas the use of hydroxyzine and urinary antispasmodics nearly disappeared. The proportion of users of DAP antipsychotics increased in ALFs. Participants with dementia had a lower anticholinergic burden than those without dementia, in both settings. Conclusions Despite increased knowledge of the harms of DAPs, they remain widely used. Physicians seem to be aware of the harms of DAPs among people with dementia, and some other favorable trends in prescribing were also observed. Clinicians should especially consider the indications behind the use of DAP antidepressants and antipsychotics, and carefully weigh their potential benefits and harms.
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Zhao D, Shridharmurthy D, Alcusky MJ, Yuan Y, Nunes AP, Hume AL, Baek J, Lapane KL. The Prevalence and Factors Associated with Antiepileptic Drug Use in US Nursing Home Residents. Drugs Aging 2020; 37:137-145. [PMID: 31845208 DOI: 10.1007/s40266-019-00732-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Antiepileptic drugs (AEDs) are commonly used by nursing home residents, both on- and off-label. The landscape of AED use has changed over the past two decades; however, despite this, contemporaneous research on AED use in US nursing home residents is scant. OBJECTIVE The aim of this study was to estimate the prevalence of AED use, describe prescribing patterns, identify factors associated with AED use, and assess whether these factors differ among AEDs with expanded indications in older adults (i.e. gabapentin, pregabalin, topiramate, and lamotrigine). METHODS We conducted a cross-sectional study among 549,240 long-stay older residents who enrolled in fee-for-service Medicare and lived in 15,111 US nursing homes on 1 September 2016. Demographics and conditions associated with AED indications, epilepsy comorbidities, and safety data came from the Minimum Data Set Version 3.0 (MDS 3.0). Medicare Part D claims were used to identify AED use. Robust Poisson models and multinomial logistic models for clustered data estimated adjusted prevalence ratios (aPR), adjusted odds ratios (aOR), and 95% confidence intervals (CIs). RESULTS Overall, 24.0% used AEDs (gabapentin [13.3%], levetiracetam [4.7%], phenytoin [1.9%], pregabalin [1.8%], and lamotrigine [1.2%]). AED use was associated with epilepsy (aPR 3.73, 95% CI 3.69-3.77), bipolar disorder (aPR 1.20, 95% CI 1.18-1.22), pain (aPRmoderate/severe vs. no pain 1.42, 95% CI 1.40-1.44), diabetes (aPR 1.27, 95% CI 1.26-1.28), anxiety (aPR 1.12, 95% CI 1.11-1.13), depression (aPR 1.17, 95% CI 1.15-1.18), or stroke (aPR 1.08, 95% CI 1.06-1.09). Residents with advancing age (aPR85+ vs. 65-74 years 0.73, 95% CI 0.73-0.74), Alzheimer's disease/dementia (aPR 0.87, 95% CI 0.86-0.88), or cognitive impairment (aPRsevere vs. no impairment 0.62, 95% CI 0.61-0.63) had decreased AED use. Gabapentinoid use was highly associated with pain (aORmoderate/severe vs. no pain 2.07, 95% CI 2.01-2.12) and diabetes (aOR 1.79, 95% CI 1.76-1.82), but not with an epilepsy indication. CONCLUSIONS AED use was common in nursing homes, with gabapentin most commonly used (presumably for pain). That multiple comorbidities were associated with AED use underscores the need for future studies to investigate the safety and effectiveness of AED use in nursing home residents.
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Affiliation(s)
- Danni Zhao
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA.
| | - Divya Shridharmurthy
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Matthew J Alcusky
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Yiyang Yuan
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Anthony P Nunes
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Anne L Hume
- Department of Family Medicine, Alpert Medical School, Brown University, Memorial Hospital of Rhode Island, Providence, RI, 02903, USA.,Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, 02881, USA
| | - Jonggyu Baek
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Kate L Lapane
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
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Abstract
The use of psychotropic drugs (antipsychotics, benzodiazepines and benzodiazepine-related drugs, and antidepressants) is common, with a prevalence estimates range of 19-29% among community dwelling older adults. These drugs are often prescribed for off-label use, including neuropsychiatric symptoms. The older adult population also has high rates of pneumonia and some of these cases may be associated with adverse drug events. In this narrative review, we summarize the findings from current observational studies on the association between psychotropic drug use and pneumonia in older adults. In addition to studies assessing the use of psychotropics, we included antiepileptic drugs, as they are also central nervous system-acting drugs, whose use is becoming more common in the aging population. The use of antipsychotics, benzodiazepine, and benzodiazepine-related drugs are associated with increased risk of pneumonia in older adults (≥ 65 years of age), and these findings are not limited to this age group. Minimal and conflicting evidence has been reported on the association between antidepressant drug use and pneumonia, but differences between study populations make it difficult to compare findings. Studies regarding antiepileptic drug use and risk of pneumonia in older persons are lacking, although an increased risk of pneumonia in antiepileptic drug users compared with non-users in persons with Alzheimer's disease has been reported. Tools such as the American Geriatric Society Beers Criteria and the STOPP/START criteria for potentially inappropriate medications aids prescribers to avoid these drugs in order to reduce the risk of adverse drug events. However, risk of pneumonia is not mentioned in the current criteria and more research on this topic is needed, especially in vulnerable populations, such as persons with dementia.
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Affiliation(s)
- Blair Rajamaki
- School of Pharmacy, Faculty of Health Sciences, Kuopio Campus, University of Eastern Finland, P.O. Box 1627, 70211, Kuopio, Finland
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland
| | - Sirpa Hartikainen
- School of Pharmacy, Faculty of Health Sciences, Kuopio Campus, University of Eastern Finland, P.O. Box 1627, 70211, Kuopio, Finland
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland
| | - Anna-Maija Tolppanen
- School of Pharmacy, Faculty of Health Sciences, Kuopio Campus, University of Eastern Finland, P.O. Box 1627, 70211, Kuopio, Finland.
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.
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Bantel C, Hoffmann F, Jobski K. Pain And The Use Of Gabapentinoids In German Nursing Home Residents - Results From An Analysis Based On Statutory Health Insurance Data. J Pain Res 2019; 12:3175-3184. [PMID: 31819602 PMCID: PMC6878919 DOI: 10.2147/jpr.s221579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 10/03/2019] [Indexed: 11/23/2022] Open
Abstract
Background Gabapentinoids (gabapentin and pregabalin) are psychoactive medications that are increasingly used for different conditions. Since there is evidence that psychotropic drugs, in general, are often inappropriately prescribed in elderly patients, we aimed to determine frequency and indications of gabapentinoid prescribing for nursing home residents. Methods We analyzed data from a large German statutory health insurance database. Included were records from people ≥65 years-of-age, who were admitted to a nursing home between January 2010 and December 2014. We determined the number and proportion of common indications for on- and off-label prescriptions, the most frequent co-medications, and the characteristics of patients and prescribers. Results Of 127,277 residents, 9539 (7.5%) received gabapentinoids and 4852 initiated treatment (4.0%; with 66.3% pregabalin). Median age of gabapentinoid initiators was 84 years (78.5% females). In these users, on-label prescribing was found in 57.4%, predominantly for neuropathic pain. Other painful conditions were also chief causes (84.7%) for off-label prescribing. Gabapentinoids were mainly started by general practitioners (64.5%) while pain specialists contributed <2%. Forty-six percent of users received additional opioids and in 27.5% gabapentinoids were prescribed only once. Conclusion Gabapentinoids were frequently used in nursing home residents. Regular co-prescribing with opioids and psychotropic drugs might indicate employment to improve pain or assist treatment of conditions that are frequently associated with disruptive behavior such as dementia. However, more research is needed to better understand decision-making regarding gabapentinoid prescribing, especially in view of aggressive marketing, uncertain analgesic effects, problematic side effects, and uncritical use in the elderly.
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Affiliation(s)
- C Bantel
- Department of Anesthesiology, Critical Care, Emergency and Pain Medicine, Universität Oldenburg, Klinikum Oldenburg, Oldenburg, Germany.,Department of Surgery & Cancer, Anaesthetics Section, Imperial College London, London, UK
| | - F Hoffmann
- Department of Health Services Research, Carl Von Ossietzky University Oldenburg, Oldenburg, Germany
| | - K Jobski
- Department of Health Services Research, Carl Von Ossietzky University Oldenburg, Oldenburg, Germany
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13
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Kaur U, Chauhan I, Gambhir IS, Chakrabarti SS. Antiepileptic drug therapy in the elderly: a clinical pharmacological review. Acta Neurol Belg 2019; 119:163-173. [PMID: 30953298 DOI: 10.1007/s13760-019-01132-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 03/28/2019] [Indexed: 01/02/2023]
Abstract
Seizure disorder is the third most common neurological disorder in the elderly after stroke and dementia. With the increasing geriatric population, the situation of clinicians seeing more and more elderly epilepsy patients is very likely. Not only is the diagnosis of epilepsy tedious in the elderly, its management raises many challenging issues for the treating physicians. Altered physiology, age-related decline in organ function, and plasma protein binding and altered pharmacodynamics make the elderly patients with seizure disorder a difficult group to treat. This is further complicated by the presence of comorbidities and polypharmacy which increase the chances of drug interactions. The adverse effects that might be tolerated well in younger populations may be disastrous for the aged. Although the newer antiepileptic drugs are found to have a favorable safety profile, there is relative scarcity of randomized-controlled trials involving older and newer antiepileptics in the geriatric population. This review tries to compile the available literature on management of epilepsy in the elderly population including evidence of safety and efficacy of newer and older antiepileptics with special reference to the 'geriatric giants'. It also deals with the interactions between antiepileptic medications and other commonly prescribed drugs in the elderly such as anti-hypertensives and antiischemic agents. The recommended guidelines of various international bodies are also analyzed from the perspective of elderly with seizure disorder.
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Affiliation(s)
- Upinder Kaur
- Department of Pharmacology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Indal Chauhan
- Department of Pharmacology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Indrajeet Singh Gambhir
- Department of Geriatric Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Sankha Shubhra Chakrabarti
- Department of Geriatric Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India.
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14
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Baftiu A, Feet SA, Larsson PG, Burns ML, Henning O, Sætre E, Molden E, Granas AG, Johannessen SI, Landmark CJ. Utilisation and polypharmacy aspects of antiepileptic drugs in elderly versus younger patients with epilepsy: A pharmacoepidemiological study of CNS-active drugs in Norway, 2004-2015. Epilepsy Res 2018; 139:35-42. [DOI: 10.1016/j.eplepsyres.2017.11.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 10/07/2017] [Accepted: 11/09/2017] [Indexed: 12/13/2022]
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