Potential adverse outcomes of psychotropic and narcotic drug use in Canadian seniors

The Effects of Benzodiazepine Use and Abuse on Cognition in the Elders: A Systematic Review and Meta-Analysis of Comparative Studies

OBJECTIVE

Benzodiazepines (BZD) are one of the most frequently prescribed drugs worldwide. However, the cognitive effects of benzodiazepines in the elderly are highly debated. This systematic review and meta-analysis aims to explore the following two questions in the elderly population: (i) Do BZD lead to any impairments in cognitive functions in elderly users? and (ii) Which specific cognitive domains are most affected by BZD use and abuse?

METHODS

First, we performed a literature search following the PRISMA guidelines. Electronic databases, including PubMed, PsycINFO, EMBASE, Cochrane Library, and Web of Science were searched until May 14^th, 2020. After selecting the relevant articles, we integrated the results of the selected studies with a standardized cognitive classification method. Next, we performed meta-analyses with the random-effects model on the cognitive results. Finally, we specifically examined the cognitive impairments of BZD in the abuse subgroup.

RESULTS

Of the included studies, eight of the thirteen had meta-analyzable data. Compared to the controls, elderly BZD users had significantly lower digital symbol test scores (n=253; SMD: -0.61, 95% CI: -0.91 to 0.31, I² = 0%, p < 0.0001). There was no significant difference in Mini-Mental State Examination, Auditory Verbal Learning Test, and Stroop Color and Word Test scores between BZD users and controls. According to the subgroup analyses, BZD abusers performed significantly worse than controls in Mini-Mental State Examination (n=7726; SMD: -0.23, 95% CI: -0.44 to -0.03, I² = 86%, p = 0.02), while there was no significant difference between the regular BZD users and the controls (n=1536; SMD: -0.05, 95% CI: -0.59 to 0.48, I² = 92%, p =0.85).

CONCLUSION

In the elderly population, the processing speed (digital symbol test scores) was significantly impaired in BZD users; global cognition (Mini-Mental State Examination scores) was significantly impaired in BZD abusers but not in BZD regular users. This study provides insight into the factors that interact with BZD cognitive effects, such as aging, testing tools, and abuse. Clinicians should be cautious when prescribing BZD for the elderly.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, identifier CRD42019124711.

Fall-Risk-Increasing Drugs: A Systematic Review and Meta-Analysis: II. Psychotropics

BACKGROUND AND OBJECTIVE

Falls are a major public health problem in older adults. Earlier studies showed that psychotropic medication use increases the risk of falls. The aim of this study is to update the current knowledge by providing a comprehensive systematic review and meta-analysis on psychotropic medication use and falls in older adults.

METHODS AND DESIGN

This study is a systematic review and meta-analysis. A search was conducted in Medline, PsycINFO, and Embase. Key search concepts were "falls," "aged," "medication," and "causality." Studies were included that investigated psychotropics (antipsychotics, antidepressants, anxiolytics, sedatives, and hypnotics) as risk factors for falls in participants ≥60 years of age or participants with a mean age of ≥70 years. Meta-analyses were performed using generic inverse variance method pooling unadjusted and adjusted odds ratio (OR) estimates separately.

RESULTS

In total, 248 studies met the inclusion criteria for qualitative synthesis. Meta-analyses using adjusted data showed the following pooled ORs: antipsychotics 1.54 [95% confidence interval (CI) 1.28-1.85], antidepressants 1.57 (95% Cl 1.43-1.74), tricyclic antidepressants 1.41 (95% CI 1.07-1.86), selective serotonin reuptake inhibitors 2.02 (95% CI 1.85-2.20), benzodiazepines 1.42 (95%, CI 1.22-1.65), long-acting benzodiazepines 1.81 (95%, CI 1.05-3.16), and short-acting benzodiazepines 1.27 (95%, CI 1.04-1.56) Most of the meta-analyses resulted in substantial heterogeneity that did not disappear after stratification for population and healthcare setting.

CONCLUSIONS

Antipsychotics, antidepressants, and benzodiazepines are consistently associated with a higher risk of falls. It is unclear whether specific subgroups such as short-acting benzodiazepines and selective serotonin reuptake inhibitors are safer in terms of fall risk. Prescription bias could not be accounted for. Future studies need to address pharmacologic subgroups as fall risk may differ depending on specific medication properties. Precise and uniform classification of target medication (Anatomical Therapeutic Chemical Classification) is essential for valid comparisons between studies.

A retrospective review of fall risk factors in the bone marrow transplant inpatient service

Purpose The purpose of this study was to compare medications and potential risk factors between patients who experienced a fall during hospitalization compared to those who did not fall while admitted to the Blood and Marrow Transplant inpatient setting at The James Cancer Hospital. Secondary objectives included evaluation of transplant-related disease states and medications in the post-transplant setting that may lead to an increased risk of falls, post-fall variables, and number of tests ordered after a fall. Methods This retrospective, case-control study matched patients in a 2:1 ratio of nonfallers to fallers. Data from The Ohio State University Wexner Medical Center (OSUWMC) reported fall events and patient electronic medical records were utilized. A total of 168 adult Blood and Marrow Transplant inpatients with a hematological malignancy diagnosis were evaluated from 1 January 2010 to 30 September 2012. Results Univariable and multivariable conditional logistic regression models were used to assess the relationship between potential predictor variables of interest and falls. Variables that were found to be significant predictors of falls from the univariable models include age group, incontinence, benzodiazepines, corticosteroids, anticonvulsants and antidepressants, and number of days status-post transplant. When considered for a multivariable model age group, corticosteroids, and a cancer diagnosis of leukemia were significant in the final model. Conclusion Recent medication utilization such as benzodiazepines, anticonvulsants, corticosteroids, and antidepressants placed patients at a higher risk of experiencing a fall. Other significant factors identified from a multivariable analysis found were patients older than age 65, patients with recent corticosteroid administration and a cancer diagnosis of leukemia.

Incident opioid drug use among older adults with chronic obstructive pulmonary disease: a population-based cohort study

AIMS

The purpose of the present study was to describe the scope, pattern and patient characteristics associated with incident opioid use among older adults with chronic obstructive pulmonary disease (COPD).

METHODS

This was a retrospective population-based cohort study using Ontario, Canada, healthcare administrative data. Study participants were individuals aged 66 years and older with physician-diagnosed COPD, identified using a validated algorithm, who were not receiving palliative care. We examined the incidence of oral opioid receipt between 1 April 2003 and 31 March 2012, as well as several patterns of incident opioid drug use.

RESULTS

Among 107,109 community-dwelling and 16,207 long-term care resident older adults with COPD, 72,962 (68.1%) and 8811 (54.4%), respectively, received an incident opioid drug during the observation period. Among long-term care residents, multiple opioid dispensings (8.8%), dispensings for >30 days' duration (up to 19.8%), second dispensings (35-43%) and early refills (24.2%) were observed. Incident opioid dispensing was also observed to occur during COPD exacerbations (6.9% among all long-term care residents; 18.1% among long-term care residents with frequent exacerbations). These same patterns of incident opioid use occurred among community-dwelling individuals, but with relatively lower frequencies.

CONCLUSIONS

New opioid use was high among older adults with COPD. Potential safety concerns are raised by the degree and pattern of new opioid use, but further studies are needed to evaluate if adverse events are associated with opioid drug use in this older and respiratory-vulnerable population.

Use of benzodiazepines and association with falls in older people admitted to hospital: a prospective cohort study

BACKGROUND

Hypnosedatives are commonly prescribed for anxiety and sleep problems. Changes in pharmacokinetics and pharmacodynamics of benzodiazepines (BZDs) during ageing may increase their potential to cause adverse outcomes.

OBJECTIVE

This study aimed to investigate the use of BZDs in acute care settings and explore their association with falls.

METHODS

A prospective cohort study was undertaken of patients aged over 70 years consecutively admitted to 11 acute care hospitals in Australia. Data were collected using the interRAI Acute Care assessment tool. Falls were recorded prospectively (in hospital) and retrospectively (in the 90 days prior to admission).

RESULTS

Of 1,412 patients, 146 (10.3 %) were taking BZDs at admission and 155 (11.3 %) at discharge. Incidence rates of in-hospital fallers for users and non-users of BZDs were not statistically different [incidence rate ratio 1.03, 95 % confidence interval (CI) 0.58-1.82]. There was also no significant association between benzodiazepine use at admission and history of falls in the previous 90 days compared with non-users. However, patients on diazepam were significantly more likely to have a history of falls than all other benzodiazepine users (70.8 vs. 36.1 %; p = 0.002), particularly when compared with oxazepam users (70.8 vs. 25.0 %; p < 0.001). Adjusting for confounders, use of diazepam at admission was positively associated with a history of falls compared with all other benzodiazepine users (odds ratio 3.0; 95 % CI 1.1-8.5; p = 0.036).

CONCLUSIONS

Different BZDs may vary in their propensity to predispose to falls, with diazepam having the strongest association. The selection of particular BZDs for older patients should be carefully evaluated.

Greater number of narcotic analgesic prescriptions for osteoarthritis is associated with falls and fractures in elderly adults

OBJECTIVES

To evaluate the changes in types of medications prescribed for pain before and after withdrawal of certain selective cyclooxygenase 2 (COX-2) inhibitors in 2004 and to determine whether there was an association with fall events in elderly adults with a diagnosis of osteoarthritis (OA).

DESIGN

A nested case-control design using electronic medical records compiled between 2001 and 2009.

SETTING

Electronic medical records for care provided in an integrated health system in rural Pennsylvania over a 9-year period (2001-09), the midpoint of which rofecoxib and valdecoxib were pulled from the market.

PARTICIPANTS

Thirteen thousand three hundred fifty-four individuals aged 65 to 89 with a diagnosis of OA.

MEASUREMENTS

The incidence of falls and fractures was examined in relation to analgesics prescribed: narcotics, COX-2 inhibitors, and nonsteroidal anti-inflammatory drugs (NSAIDs). The comparison sample of individuals who did not fall was matched 3:1 with those who fell according to age, sex, and comorbidity.

RESULTS

Narcotic analgesic prescriptions were associated with a significantly greater risk of falls and fractures. The likelihood of experiencing a fall/fracture was higher in participants prescribed narcotic analgesics than those prescribed a COX-2 inhibitor (odds ratio (OR) = 3.3, 95% confidence interval (CI) = 2.5-4.3) or NSAID (OR = 4.1, 95% CI = 3.7-4.5).

CONCLUSION

Use of narcotic analgesics is associated with risk of falls and fractures in elderly adults with OA, an observation that suggests that the current guidelines for the treatment of pain, which include first-line prescription of narcotics, should be reevaluated.

A systematic review of amnestic and non-amnestic mild cognitive impairment induced by anticholinergic, antihistamine, GABAergic and opioid drugs

BACKGROUND

Mild cognitive deficits are experienced by 18% of community-dwelling older adults, many of whom do not progress to dementia. The effect of commonly used medication on subtle impairments in cognitive function may be under-recognized.

OBJECTIVE

The aim of the review was to examine the evidence attributing amnestic or non-amnestic cognitive impairment to the use of medication with anticholinergic, antihistamine, GABAergic or opioid effects.

METHODS

MEDLINE and EMBASE were searched for randomized, double-blind, placebo-controlled trials of adults without underlying central nervous system disorders who underwent detailed neuropsychological testing prior to and after oral administration of drugs affecting cholinergic, histaminergic, GABAergic or opioid receptor pathways. Seventy-eight studies were identified, reporting 162 trials testing medication from the four targeted drug classes. Two investigators independently appraised study quality and extracted relevant data on the occurrence of amnestic, non-amnestic or combined cognitive deficits induced by each drug class. Only trials using validated neuropsychological tests were included. Quality of the evidence for each drug class was assessed based on consistency of results across trials and the presence of a dose-response gradient.

RESULTS

In studies of short-, intermediate- and long-acting benzodiazepine drugs (n = 68 trials), these drugs consistently induced both amnestic and non-amnestic cognitive impairments, with evidence of a dose-response relationship. H(1)-antihistamine agents (n = 12) and tricyclic antidepressants (n = 15) induced non-amnestic deficits in attention and information processing. Non-benzodiazepine derivatives (n = 29) also produced combined deficits, but less consistently than benzodiazepine drugs. The evidence was inconclusive for the type of cognitive impairment induced by different bladder relaxant antimuscarinics (n = 9) as well as for narcotic agents (n = 5) and antipsychotics (n = 5). Among healthy volunteers >60 years of age, low doses of commonly used medications such as lorazepam 0.5 mg, oxybutynin immediate release 5 mg and oxycodone 10 mg produced combined deficits.

CONCLUSION

Non-amnestic mild cognitive deficits are consistently induced by first-generation antihistamines and tricyclic antidepressants, while benzodiazepines provoke combined amnestic and non-amnestic impairments. Risk-benefit considerations should be discussed with patients in order to enable an informed choice about drug discontinuation or substitution to potentially reverse cognitive adverse effects.

Newly initiated opioid treatment and the risk of fall-related injuries. A nationwide, register-based, case-crossover study in Sweden

BACKGROUND

There is growing epidemiological evidence that opioids may increase the risk of unintentional injuries and it is plausible that the time of initiation is most critical in that respect. Studies on fall-related injuries remain few, limited and mostly focused on specific groups of elderly patients.

OBJECTIVE

The objective of this study was to assess the short-term effects of newly prescribed opioids on the risk of fall-related injuries in the general adult population.

METHODS

A case-crossover design was applied on national register data linking, at the individual level, fall-injury information involving adults aged 18 years and above identified in the Swedish National Inpatient Register (during the period 1 May 2006 to 31 December 2009) and dispensed drugs from the Swedish Prescribed Drug Register (n=167,257 cases with a first fall-related injury). All types of opioid substances were considered, classified according to the Anatomical Therapeutic Chemical (ATC) classification system. We investigated newly dispensed opioids 28 days preceding the injury, compared with an earlier, and equally long, control period following a 3-month washout period. Conditional logistic regression was used to estimate odds ratio (OR) and 95% confidence interval (CI). The analyses were also conducted stratified by age group, by type of fall and for each period of 1 week during the 28-day period.

RESULTS

From among the fall-injured patients, 7,450 patients (4.5%) had a new opioid dispensation within 28 days prior to the injury, of which the most frequent types were tramadol (2.0%) and codeine (1.1%). Consistently increased risks of fall-related injuries associated with a new prescription of any opioid were found and they were most pronounced among young adults, 18-29 years of age (OR, 7.17; 95% CI 5.04-10.2). The closer the dispensation date to the injury, the higher the odds: an OR of 5.14 (95% CI 4.76-5.55) during the first week of opioid treatment and 1.23 (95% CI 1.10-1.38) for the fourth week. Of the documented falls, the risk was most pronounced for falls from 'another, high level' (OR, 5.33; 95% CI 3.99-7.10).

CONCLUSIONS

Newly prescribed opioids may trigger injurious falls. The effect lowers over time and is less pronounced with increasing age. The risk is also higher for fall from height.

Contributions of environment, comorbidity, and stage of dementia to the onset of walking and eating disability in long-term care residents

OBJECTIVES

To estimate the relative effects of environment, comorbidities, stage of dementia and other variables on disability onset.

DESIGN

A 1-year prospective cohort study was conducted in which the walking and eating abilities of long-term care residents were observed fortnightly. Structural equation modeling was used to assess the contributions of individual and environmental factors to the onset of disability.

SETTING

Fifteen nursing homes in western Canada.

PARTICIPANTS

One hundred twenty residents with middle-stage Alzheimer disease or related dementia.

MEASUREMENTS

Environmental quality was assessed using the Professional Environmental Assessment Protocol, comorbidity using the Charlson Comorbidity Index, and stage of dementia using the Global Deterioration Scale.

RESULTS

More-advanced baseline dementia had a direct effect on onset of walking and eating disability (standardized maximum likelihood estimate (SMLE) = 0.24, P = .006). Resident environment (SMLE = -0.25, P = .007) and comorbidities (SMLE = 0.32, P < .001) influenced disability onset approximately as strongly as stage of dementia. Smaller and publicly owned facilities provided superior environmental quality, which indirectly contributed to a delay in onset of walking and eating disability.

CONCLUSION

Environmental quality and extent of comorbidity are at least as important as progression of dementia in initiating or delaying the onset of disability.

Potentially inappropriate prescribing of benzodiazepines for older adults and risk of falls during a hospital stay: a descriptive study

BACKGROUND

Falls have been identified as a potential adverse event associated with the administration of psychotropic medications to older patients.

OBJECTIVE

The objective of this exploratory study was to examine the association between potentially inappropriate prescribing of benzodiazepines, as defined by the Beers criteria, by older adults (at least 65 years of age) and the risk of having a fall during acute inpatient care.

METHODS

This 1-year retrospective cross-sectional study of discharges from a tertiary care hospital in Halifax, Nova Scotia, used pharmacy data to identify the prescription of benzodiazepines listed in the updated Beers criteria as being associated with an increased risk of falls. These data were linked with information on in-hospital falls from occurrence report forms.

RESULTS

For 5831 (58.1%) of the 10 044 discharges, the patient had received a prescription for at least one benzodiazepine during the hospital stay. A total of 574 falls were reported (for 374 patients), and 226 (39.4%) of the falls resulted in an injury. According to the Beers criteria, for 936 (9.3%) of the discharges, the patient had received a prescription for at least one potentially inappropriate benzodiazepine. However, there was no statistically significant difference between patients with a prescription for a potentially inappropriate benzodiazepine and those receiving an appropriate or no benzodiazepine in terms of occurrence of falls (4.5% versus 3.8%, p = 0.30) or fall-related injuries (2.6% versus 1.8%, p = 0.08). The median length of stay was about 3 days longer for the former group (9 versus 6 days, p < 0.001).

CONCLUSIONS

The findings from the current study do not support use of the Beers criteria related to benzodiazepines alone for identifying patients at risk of falls or injuries.

Medication use and functional status decline in older adults: a narrative review

BACKGROUND

Functional status is the cornerstone of geriatric care and serves as an indicator of general well-being. A decline in function can increase health care use, worsen quality of life, threaten independence, and increase the risk of mortality. One of several risk factors for decline in functional status is medication use.

OBJECTIVE

Our aim was to critically review published articles that have examined the relationship between medication use and functional status decline in the elderly.

METHODS

The MEDLINE and EMBASE databases were searched for English-language articles published from January 1986 to June 2011. Search terms included aged, humans, drug utilization, polypharmacy, inappropriate prescribing, anticholinergics, psychotropics, antihypertensives, drug burden index, functional status, function change or decline, activities of daily living, gait, mobility limitation, and disability. A manual search of the reference lists of the identified articles and the authors' article files, book chapters, and recent reviews was conducted to retrieve additional publications. Only articles that used rigorous observational or interventional designs were included. Cross-sectional studies and case series were excluded from this review.

RESULTS

Nineteen studies met the inclusion criteria. Five studies addressed the impact of suboptimal prescribing on function, 3 of which found an increased risk of worse function in community-dwelling subjects receiving polypharmacy. Three of the 4 studies that assessed benzodiazepine use and functional status decline found a statistically significant association. One cohort study identified no relationship between antidepressant use and functional status, whereas a randomized trial found that amitriptyline, but not desipramine or paroxetine, impaired certain measures of gait. Two studies found that increasing anticholinergic burden was associated with worse functional status. In a study of hospitalized rehabilitation patients, users of hypnotics/anxiolytics (eg, phenobarbital, zolpidem) had lower relative Functional Independence Measure motor gains than nonusers. Use of multiple central nervous system (CNS) drugs (using different definitions) was linked to greater declines in self-reported mobility and Short Physical Performance Battery (SPPB) scores in 2 community-based studies. Another study of nursing home patients did not report a significant decrease in SPPB scores in those taking multiple CNS drugs. Finally, 2 studies found mixed effects between antihypertensive use and functional status in the elderly.

CONCLUSIONS

Benzodiazepines and anticholinergics have been consistently associated with impairments in functional status in the elderly. The relationships between suboptimal prescribing, antidepressants, and antihypertensives and functional status decline were mixed. Further research using established measures and methods is needed to better describe the impact of medication use on functional status in older adults.

Opioid analgesics and the risk of fractures in older adults with arthritis

OBJECTIVES

To compare the risk of fracture associated with initiating opioids with that of nonsteroidal anti-inflammatory drugs (NSAIDs) and the variation in risk according to opioid dose, duration of action, and duration of use.

DESIGN

Retrospective cohort study.

SETTING

Two statewide pharmaceutical benefit programs for persons aged 65 and older.

PARTICIPANTS

Twelve thousand four hundred thirty-six initiators of opioids and 4,874 initiators of NSAIDs began treatment between January 1, 1999, and December 31, 2006. Mean age at initiation of analgesia was 81; 85% of participants were female, and all had arthritis.

MEASUREMENTS

Cox proportional hazards models, adjusted for several potential confounders, quantified fracture risk. Study outcomes were fractures of the hip, humerus or ulna, or wrist, identified using a combination of diagnosis (International Classification of Diseases, Ninth Revision, Clinical Modification) and procedure (Common Procedural Terminology) codes.

RESULTS

There were 587 fracture events among the participants initiating opioids (120 fractures per 1,000 person-years) and 38 fracture events among participants initiating NSAIDs (25 fractures per 1,000 person-years) (hazard ratio (HR)=4.9, 95% confidence interval (CI)=3.5-6.9). Fracture risk was greater with higher opioid dose. Risk was greater for short-acting opioids (HR=5.1, 95% CI=3.7-7.1) than for long-acting opioids (HR=2.6, 95% CI=1.5-4.4), even in participants taking equianalgesic doses, with differential fracture risk apparent for the first 2 weeks after starting opioids but not thereafter.

CONCLUSION

Older people with arthritis who initiate therapy with opioids are more likely to experience a fracture than those who initiate NSAIDs. For the first 2 weeks after initiating opioid therapy, but not thereafter, short-acting opioids are associated with a greater risk of fracture than are long-acting opioids.

Medication use as a risk factor for inpatient falls in an acute care hospital: a case-crossover study

AIMS

The present study aimed to evaluate the associations between medication use and falls and to identify high risk medications that acted as a trigger for the onset of falls in an acute care hospital setting.

METHODS

We applied a case-crossover design wherein cases served as their own controls and comparisons were made within each participant. The 3-day period (days 0 to -2) and the 3-day periods (days -6 to -8, days -9 to -11 and days -12 to -14) before the fall event were defined as the case period and the control periods, respectively. Exposures to medications were compared between the case and control periods. Odds ratios (OR) and 95% confidence intervals (CI) for the onset of falls with respect to medication use were computed using conditional logistic regression analyses.

RESULTS

A total of 349 inpatients who fell during their hospitalization were recorded on incident report forms between March 2003 and August 2005. The initial use of antihypertensive, antiparkinsonian, anti-anxiety and hypnotic agents as medication classes was significantly associated with an increased risk of falls, and these ORs (95% CI) were 8.42 (3.12, 22.72), 4.18 (1.75, 10.02), 3.25 (1.62, 6.50) and 2.44 (1.32, 4.51), respectively. The initial use of candesartan, etizolam, biperiden and zopiclone was also identified as a potential risk factor for falls.

CONCLUSIONS

Medical professionals should be aware of the possibility that starting a new medication such as an antihypertensive agent, including candesartan, and antiparkinsonian, anti-anxiety and hypnotic agents, may act as a trigger for the onset of a fall.

Incidence and predictors of excess disability in walking among nursing home residents with middle-stage dementia: a prospective cohort study

BACKGROUND

Inability to walk compromises the well-being of the growing number of nursing home residents with dementia. The purpose of this study was to estimate the incidence and identify predictors of walking disability that may be remediable.

METHODS

A cohort was followed fortnightly for a year in 15 nursing homes in western Canada. The study participants comprised 120 ambulatory residents with middle-stage Alzheimer's, vascular or mixed dementia. Standardized measures of potential predictors of disability included the Charlson Comorbidity Index, Global Deterioration Scale, and Professional Environment Assessment Protocol. Walking disability was defined as using a wheelchair to go to meals in the dining room.

RESULTS

Incidence of walking disability was 40.8% (95% confidence interval (CI): 32.7-50.2). Approximately half of this (27.0%; 95% CI: 19.7-36.5) was excess disability. Residents with more advanced dementia and living in a less supportive nursing home environment experienced an increased hazard of walking disability (Hazard Ratio (HR): 2.1; 95% CI: 1.2-3.8 and HR: 2.4; 95% CI: 1.3-4.4 respectively). After adjusting for age, comorbidity and stage of dementia, predictors of excess disability in walking included using antidepressants (HR: 2.2; 95% CI: 1.02-4.6), and not using cognitive enhancers (HR: 2.6; 95% CI: 1.03-6.4).

CONCLUSIONS

Over half of walking disability in nursing home residents with middle-stage dementia may be modifiable. Creating supportive environments, ensuring access to cognitive enhancer drugs, and preventing and treating depression and the adverse effects of antidepressants, may help to reduce walking disability and excess disability.

Psychotropic Drugs and Falls in the Elderly People: Updated Literature Review and Meta-Analysis

Objective: To carry out meta-analyses on psychotropic drugs and to provide an update of the risk of falling in the elderly people related to psychotropic drugs. Design: Meta-analyses of studies on psychotropic drugs. Results: 177 studies are included, of which 71 have data on risk factors associated with psychotropic drugs. The odds ratio and 95% Cl for associations between use of psychotropic drugs and fall are 1.78 and 1.57-2.01, respectively. This result is statistically heterogeneous. This heterogeneity disappears in the group of very old participants for each class. Conclusion: Our study confirms the association between falls in the elderly people and psychotropic drugs. These results are similar to those of former meta-analyses but with different methods. It shows that these meta-analyses on psychotropic drugs have a small impact on prescribing habits. They only give evidence to support the association between psychotropic drugs and falls even if there is no proven link.

Antidepressants and falls in the elderly

Antidepressants have long been recognized as a contributory factor to falls and many studies show an association between antidepressants and falls. There are extensive data for tricyclic antidepressants (TCAs) and related drugs, and for selective serotonin reuptake inhibitors (SSRIs), but few data for other classes of antidepressants. Sedation, insomnia and impaired sleep, nocturia, impaired postural reflexes and increased reaction times, orthostatic hypotension, cardiac rhythm and conduction disorders, and movement disorders have all been postulated as contributing factors to falls in patients taking antidepressants. Sleep disturbance is a cardinal feature of depression, and all antidepressants have effects on sleep. TCAs and related drugs cause marked sedation with daytime drowsiness. SSRIs and related drugs have an alerting effect, impairing sleep duration and quality and causing insomnia, which may result in nocturia and daytime drowsiness. Daytime drowsiness is a significant risk factor for falls, both in untreated depression and in depression treated with antidepressants. Clinically significant orthostatic hypotension is common with TCAs and related drugs, the older monoamine oxidase inhibitors and serotonin-norepinephrine reuptake inhibitors (SNRIs). It occurs less commonly with SSRIs, and rarely with moclobemide and bupropion, and is not reported as a significant adverse effect of hypericum (St John's wort). Cardiac rhythm and conduction disturbances are well recognized with TCAs, tetracyclics and SNRIs, but have also been reported with SSRIs. The contribution of antidepressant-induced conduction and rhythm disturbances to falls cannot be assessed with current data. There are insufficient data to exonerate any individual antidepressant or class of antidepressants as a potential cause of falls. The magnitude of the increased risk of falling with an antidepressant is about the same as the excess risk found in patients with untreated depression.

Association between risk factors for injurious falls and new benzodiazepine prescribing in elderly persons

Background

Benzodiazepines are frequently prescribed to elderly patients' despite concerns about adverse effects leading to injurious falls. Previous studies have not investigated the extent to which patients with pre-existing risk factors for falls are prescribed benzodiazepines. The objective of this study is to assess if some of the risk factors for falls are associated with new benzodiazepine prescriptions in elderly persons.

Methods

Using provincial administrative databases, elderly Quebec residents were screened in 1989 for benzodiazepine use and non-users were followed for up to 5 years. Logistic regression models were used to evaluate potential predictors of new benzodiazepine use among patient baseline characteristics.

Results

In the 252,811 elderly patients who had no benzodiazepine prescription during the baseline year (1989), 174,444 (69%) never filled a benzodiazepine prescription and 78,367 (31%) filled at least one benzodiazepine prescription. In the adjusted analysis, several risk factors for falls were associated with statistically significant increases in the risk of receiving a new benzodiazepine prescription including the number of prescribing physicians seen at baseline (OR: 1.12; 95% CI 1.11–1.13), being female (OR: 1.20; 95% CI 1.18–1.22) or a diagnosis of arthritis (OR: 1.11; 95% CI 1.09–1.14), depression (OR: 1.42; 95% CI 1.35–1.49) or alcohol abuse (OR: 1.24; 95% CI 1.05–1.46). The strongest predictor for starting a benzodiazepine was the use of other medications, particularly anti-depressants (OR: 1.85; 95% CI 1.75–1.95).

Conclusion

Patients with pre-existing conditions that increase the risk of injurious falls are significantly more likely to receive a new prescription for a benzodiazepine. The strength of the association between previous medication use and new benzodiazepine prescriptions highlights an important medication safety issue.

Association of suboptimal prescribing and change in lower extremity physical function over time

BACKGROUND

Previous studies have found inconsistent links between suboptimal prescribing and negative patient outcomes. While suboptimal prescribing consists of multiple components, e.g. drugs to avoid in the elderly (DAE), potential drug interactions (PDI) and polypharmacy, most research has focused on the impact of drugs to avoid. This study explores the relationship between suboptimal prescribing, comorbid disease, and change in lower extremity functional limitation (LEFL).

METHODS

This prospective cohort study used data from the Hispanic Established Population for the Epidemiologic Study of the Elderly. Baseline data collection occurred between 1993 and 1994 with three additional waves of data collected approximately every 2 years. Based on the disablement process model, the dependent variable was change in LEFL over the 7-year study period. Independent variables included suboptimal prescribing: DAE, PDI and polypharmacy. Measures of pathology included comorbid diseases (stroke, cancer, hypertension, cardiovascular disease, arthritis, and diabetes). Age, gender, education, smoking, cognitive status, depression, body mass index, marital status, and self-reported health were controlled in analyses.

RESULTS

Diabetes, stroke, and arthritis were associated with a decline in LEFL. Polypharmacy mediated the relationship between diabetes and LEFL, and polypharmacy was also significantly associated with decrements in LEFL.

CONCLUSION

The effect of suboptimal prescribing on change in LEFL was limited to both direct and mediational effects of polypharmacy. Additional research exploring the association between suboptimal prescribing and a variety of quality measures using a diverse set of outcomes would improve our understanding of the impact of suboptimal prescribing more broadly defined.

Narcotic drug use among patients with lower back pain in employer health plans: a retrospective analysis of risk factors and health care services

OBJECTIVE

This study examines the risk factors of narcotic drug use, medical and pharmacy claim costs, and health services use among lower back pain (LBP) patients who use narcotic medications.

METHODS

This retrospective study used administrative claims data between September 2002 and March 2004 from 3 employer health plans that collectively contained records of 165,569 employees 18 to 64 years of age. Multivariate regression analyses were performed to examine risk factors and health care services use consequences of narcotic drug use in patients with LBP.

RESULTS

The study sample included 13,760 patients with LBP due to mechanical causes. Nearly 60% were female and the average age was 47 years. Almost half of the patients with LBP (45%) used narcotic drugs. Narcotic-using patients with LBP had significantly higher rates of comorbid conditions than patients with LBP not using narcotic drugs; hypertension (23% vs 13%), arthritis (14% vs 4%), depression (10% vs 5%), anxiety (6% vs 3%), and cancer (2% vs 1%) (P<0.001). Patients with LBP with 2 identified psychological comorbid conditions, depression and anxiety, on average used more narcotic medications. Patients with LBP who had surgery were significantly more likely to use narcotic drugs within 1 week of procedure than those patients without surgery (P<0.001). In contrast, patients with LBP who had chiropractic services for LBP were less likely to take narcotic drugs within 7 days after services compared to those without chiropractic services (P<0.001). Furthermore, controlling for health conditions, patients with LBP who took narcotic medications were significantly more likely than patients not taking narcotics to have an emergency room visit within 30 days after the initial narcotic drug prescription dates (P<0.001). Narcotic-using patients with LBP accounted for 62% of health care costs among all patients with LBP. The average monthly health care cost for a narcotic-using LBP patient was $1222, compared to $430 for a LBP patient not using narcotic drugs (P<0.001).

CONCLUSIONS

The subjects with LBP who used narcotic medications were more likely to have additional coexisting health conditions and used more health care services than nonusing patients with LBP (P<0.001). Unadjusted health care services costs, including pharmacy claims costs, were significantly higher in patients with LBP using narcotic drugs than in nonusing patients with LBP (P<0.001).

Medication as a risk factor for falls: critical systematic review

BACKGROUND

Falls in older people are associated with poor prognosis. Medication use is a potential cause of falls. Our aim was to systemically review all original articles examining medication use as a risk factor for falls or fall-related fractures in people aged >/=60 years.

METHODS

We searched English articles in Medline (1996-2004) indexed under "falls" or "accidental falls" and "pharmaceutical preparations" or specific groups of drugs. We excluded studies not meeting the age criterion, not controlled with nonusers of target medicines or nonfallers, or with no clear definition of target medication.

RESULTS

Twenty-eight observational studies and one randomized controlled trial met the inclusion criteria. The number of participants ranged from 70 to 132,873. The outcome measure was a fall in 22 studies and a fracture in 7 studies. The main group of drugs associated with an increased risk of falling was psychotropics: benzodiazepines, antidepressants, and antipsychotics. Antiepileptics and drugs that lower blood pressure were weakly associated with falls.

CONCLUSIONS

Central nervous system drugs, especially psychotropics, seem to be associated with an increased risk of falls. The quality of observational studies needs to be improved, for many appear to lack even a clear definition of a fall, target medicines, or prospective follow-up. Many drugs commonly used by older persons are not systematically studied as risk factors for falls.

The relationship between pain and mental flexibility in older adult pain clinic patients

OBJECTIVE

Persistent pain and cognitive impairment are each common in older adults. Mental flexibility, memory, and information-processing speed may be particularly vulnerable in the aging brain. We investigated the effects of persistent pain on these cognitive domains among community-dwelling, nondemented older adults.

SETTING

Older Adult Pain Management Program.

DESIGN

A total of 56 new patients (mean age 76.1 years) were recruited to describe 1) rates of persistent pain conditions and pain intensity; 2) cognition (mental flexibility, short-term memory, and psychomotor speed); 3) severity of depression; and 4) sleep quality. All patients had nonmalignant pain for at least 3 months. Pain intensity was measured with the McGill Pain Questionnaire and depression severity with the 17-item Hamilton Rating Scale for Depression. Cognition was assessed with 1) Mini-Mental State Exam; 2) Number-Letter-Switching and Motor Speed subtests of the Delis-Kaplan Executive Function System Trail Making Test; 3) Digit Symbol Subtest (DSST) of the Wechsler Adult Intelligence Scales-III; and 4) free and paired recall of the DSST digit-symbol pairs. Multiple linear regression modeled whether these variables predicted poorer cognitive outcomes, after adjusting for the effects of opioids, sleep impairment, depression, medical comorbidity, and years of education.

RESULTS

In univariate analysis, pain severity was associated with a greater impairment on number-letter switching (r = -0.42, P = 0.002). This association remained after adjusting for the effects of depression, sleep, medical comorbidity, opioid use, and years of education (t = -1.97, P = 0.056).

CONCLUSIONS

In community dwelling older adults, neither pain nor mood was associated with measures of short-term memory or information-processing speed. However, pain severity was associated with decreased performance on a test of number-letter switching, indicating a relationship between pain and mental flexibility.

Predictors of Falling in Older Maryland Drivers: A Structural-Equation Model

Falls can impair health and reduce quality of life among older adults. Although many factors are related to falling, few analyses examine causal models of this behavior. In this study, factors associated with falling were explored simultaneously using structural-equation modeling. A variety of cognitive, physical-performance, and health measures were administered to 694 older adult drivers from the state of Maryland. The observed and latent variables of age, cognitive ability, physical functioning, health, and falling behavior were used to create a causal model. The model revealed that being older was associated with declines in cognition, and such cognitive declines predicted increased falling. Similarly, poorer health was related to poorer physical functioning, which, in turn, also predicted increased falling. This model indicates that in addition to existing fall-prevention interventions aimed at improving physical functioning, interventions to improve cognition and health might also be effective. It is speculated that fear of falling, which often results in reduced mobility among older adults, might account for the lack of a direct relationship between age and falling. This hypothesis should be examined in further research.

Modeling cumulative dose and exposure duration provided insights regarding the associations between benzodiazepines and injuries

BACKGROUND AND OBJECTIVES

Accurate assessment of medication impact requires modeling cumulative effects of exposure duration and dose; however, postmarketing studies usually represent medication exposure by baseline or current use only. We propose new methods for modeling various aspects of medication use history and employment of them to assess the adverse effects of selected benzodiazepines.

STUDY DESIGN AND SETTING

Time-dependent measures of cumulative dose or duration of use, with weighting of past exposures by recency, were proposed. These measures were then included in alternative versions of the multivariable Cox model to analyze the risk of fall related injuries among the elderly new users of three benzodiazepines (nitrazepam, temazepam, and flurazepam) in Quebec. Akaike's information criterion (AIC) was used to select the most predictive model for a given benzodiazepine.

RESULTS

The best-fitting model included a combination of cumulative duration and current dose for temazepam, and cumulative dose for flurazepam and nitrazepam, with different weighting functions. The window of clinically relevant exposure was shorter for flurazepam than for the two other products.

CONCLUSION

Careful modeling of the medication exposure history may enhance our understanding of the mechanisms underlying their adverse effects.

Drugs and falls in community-dwelling older people: a national veterans study

OBJECTIVE

The aim of this study was to identify which specific medications within recognized major problematic drug categories that increase risk of falling were prescribed to veterans before their out-patient treatment for a fall.

METHODS

This was a retrospective, cross-sectional national secondary outpatient data analysis with an age- and sex-matched comparison group. The setting was the national Veterans Health Administration (VHA) ambulatory health care system in fiscal year (FY) 2004. The study population was VHA patients aged>or=65 years who had fall-related outpatient clinical health care encounters in FY 2004 (as indicated by diagnostic codes) and who received >or=1 outpatient medication during the study period. The age- and sex-matched comparison group consisted of an equal number of patients with nonspecific chest pain. The percentage of patients in each group receiving medications (at the time of the outpatient encounter) that affect the cardiovascular system (CVS), central nervous system (CNS), or musculoskeletal system (MSS) was compared with Bonferrom-adjusted P values.

RESULTS

The study sample consisted of 20,551 patients; the comparison group included the same number of patients. More patients with fall-coded encounters used CNS drugs than those with nonspecific chest pain (42.05% vs 29.29%). Also, within the CNS category, more patients with fall-coded encounters used antiparkinsonian medications (3.67% vs 1.32%), Alzheimer's disease medications (ie, cholinesterase inhibitors [5.40% vs 2.35%]), anticonvulsants/barbiturates (8.95% vs 5.18%), antidepressants (22.50% vs 14.16%), antipsychotics (4.68% vs 2.01%), opioid analgesics and narcotics (11.21% vs 9.09%), and benzodiazepines (7.60% vs 5.96%) (all, P<0.002). More patients with nonspecific chest pain received CVS drugs compared with the fall-coded group (69.13% vs 63.07%; P<0.002). Within the CVS category, more patients in the nonspecific chest pain group received angiotensin-II receptor antagonists, angiotensin-converting enzyme inhibitors, beta-blockers, calcium channel blockers, vasodilators, diuretics, and antiarrhythmics (all, P<0.002). No differences were noted between groups in the MSS category, except for NSAIDs, which more patients in the nonspecific chest pain group used than in the fall-coded group (6.44% vs 5.63%; P<0.002).

CONCLUSION

In this study, subjects with a health care encounter for a fall (as indicated by diagnostic code) were prescribed significantly more CNS-category medications than subjects in the age- and sex-matched comparison group.

Medication use as a risk factor for falls among hospitalized elderly patients

PURPOSE

The relationship between medication use and falls among hospitalized elderly patients was studied.

METHODS

Sixty-two patients 65 years of age or older who fell during hospitalization were randomly selected from incident reports of falls and matched for age, sex, and discharge date with 62 patients who did not fall. Data on demographic characteristics, vital signs, laboratory test variables, drug therapy, and the presence of other known risk factors for falls were collected retrospectively and compared between the groups.

RESULTS

Nonsteroidal antiinflammatory drug (NSAID) use was more frequent in patients who fell than in control patients. NSAID use was a significant predictor of falls and was associated with a 10-fold increase in the likelihood of falling. Opioid analgesics were given more frequently to control patients and were not associated with falls. Dementia, the only non-medication-related independent predicator of falls, was associated with a 21-fold greater risk of falling.

CONCLUSION

In hospitalized elderly patients, there was a significant association between NSAID use and falls, an effect largely accounted for by low-dose aspirin.

Predicting and preventing adverse drug reactions in the very old

The size of the elderly population has been increasing steadily for several years. Individuals in this age group often have several concomitant diseases that require treatment with multiple medications. These drugs, for various reasons and especially as a consequence of potential accumulation, may be associated with adverse reactions. Of the numerous factors that can favour the occurrence of these adverse drug reactions, the most important are the pathophysiological consequences of aging, particularly as these apply to the very old. Although absorption of drugs is not usually reduced in the elderly, diffusion, distribution and particularly elimination decline with age. Furthermore, while hepatic metabolic function is fairly normal, renal function is usually markedly depressed in very old individuals, and this can translate into clinical consequences if it is not taken into account. This is why, before administration of any drug in the elderly, evaluation of glomerular filtration rate is essential. Validated estimations such as those obtained from the classical Cockcroft-Gault formula or from more recent methodologies are required. In addition to reductions in various organ functions, factors connected with very old age such as frailty, falls, abnormal sensitivity to medications and polypathology, all of which tend to be more common in the last years of life, all directly impact on adverse drug reaction occurrence. Given these characteristics of the elderly population, the best way to reduce the prevalence of adverse drug reactions in this group is to limit drug prescription to essential medications, make sure that use of prescribed agents is clearly explained to the patient, give drugs for as short a period as possible, and periodically re-evaluate all use of drugs in the elderly.

Prevalence of psychotropic drug use in nursing homes for the aged in Quebec and in the French-speaking area of Switzerland

BACKGROUND

The use of psychotropic drugs is high in institutionalised elderly, which raises the question of its appropriateness. This study aimed to: (1) estimate the use of psychotropics, for each family, in terms of the prevalence and dosage among the elderly in nursing homes in French-speaking Switzerland and Quebec; and (2) assess, for each family of psychotropic drugs and for each care facility, the prevalence of use and departure from average prescription (ratio of observed-to-expected prevalence).

METHOD

An administrative database was used for this cross-sectional analysis. The sample included 8183 Quebec and 7592 Swiss long-term care residents. Three classes of psychotropics (antipsychotics, antidepressants, hypnotics-anxiolytics) were defined as dichotomous variables. Logistic regressions were conducted to identify residents characteristics associated with the use of each psychotropic type and to compute expected prevalence.

RESULTS

Swiss residents were slightly older and less dependent than Quebec residents. Use of psychotropic drugs was higher in Swiss than in Quebec residents, on the whole as well as for each family of drug. A total of 78.1% of Swiss residents used at least one drug as compared to 66.9% in Quebec. Ninety percent of residents were given less than 7 defined daily doses per week, irrespective of the drug family. According to Beer's criteria, only 4.9% of prescriptions were inadequate. In Quebec and in Switzerland, the prevalence of antidepressant use was associated with the prevalence of hypnotic-anxiolytic use. No ratios of observed-to-expected reached statistical significance.

INTERPRETATION

There was a considerable use of psychotropics in Quebec and Switzerland with, seemingly, no dramatic departure from the average practice. Our data cannot tell if there is a global overuse of psychotropics, but indicated that dosage and medication selection seem adequate. Physicians should critically reassess the necessity of prescribed medications for their patients.

Benzodiazepines and injury: a risk adjusted model

BACKGROUND

Benzodiazepines (BZD) are one class of medications that are generally acknowledged to be a risk factor for injuries.

OBJECTIVE

Our objective was to link outpatient prescription data with clinical data in order to develop a risk adjusted binary model that associates BZD usage with the risk for a healthcare encounter for an injury.

METHODS

In total, 3 years of outpatient BZD prescription data, totaling 133 872 outpatient BZD prescriptions for 13 745 patients for a VA medical center, were combined with data from inpatient and outpatient administrative databases. The model incorporated Elixhauser comorbidity measures with 1-year look back period, along with hospital discharges, marital status, age, mean arterial pressure and body mass index. The model also included the dose of the drug, converted to valium equivalents and its duration. The model was analyzed using generalized estimation equations (GEE).

RESULTS

Dose, duration, discharges and various comorbidities were associated with an increased risk for injury, while being married reduced the risk. Increased body mass was associated with increased injury risk. Increased mean arterial pressure was associated with decreased risk.

CONCLUSIONS

These findings offer guidance on how specific combinations of risk factors and potential protective effects may impact accidental injury risk. Clinicians prescribing or adjusting BZDs can use these results to more accurately tailor medication regimens for a patient. Our findings suggest that clinicians should also consider the nature of the social support system available to the patient in assessing total injury risk.

Outpatient Medications and Hip Fractures in the US

BACKGROUND

Certain medications have been linked to falls. One of the most severe fall-related injuries in the elderly is a hip fracture.

OBJECTIVE

The objective of this study was to examine the use of medications known to increase fall risk that were prescribed on an outpatient basis to veterans prior to hospital admission for hip fracture.

METHODS

We identified and analysed the use of outpatient fall-related medications in 2212 unique patients with hip fractures admitted in fiscal year 2003 to Veterans Health Administration hospitals compared with that for matched controls (exact match for age and sex) admitted for acute myocardial infarction (MI) or pneumonia. We analysed the medications selected from the three drug categories most often linked with an increased risk for falls. These categories included medications that affected the cardiovascular (CVS), CNS or the musculoskeletal system (MSS). The unit of analysis was the hip fracture linked with outpatient medications in the study group compared with matched control groups of patients with hospitalisations for an acute MI or pneumonia.

RESULTS

Of the 2212 hip-fracture patients, 70% had fall-related medications prior to hospitalisation for hip fracture. The most notable differences in usage were seen in the drug classes antiepileptics/barbiturates, antidepressants (2-fold difference in use of selective serotonin reuptake inhibitors [SSRIs] and tricyclic antidepressants [TCAs]), and antiparkinson's drugs (nearly 4-fold difference between cases and controls). There were also notable differences in usage of antipsychotics (3-fold difference for hip-fracture cases compared with acute MI) and cholinesterase inhibitors (nearly 2-fold difference for hip-fracture cases compared with pneumonia or acute MI). The most notable differences in polypharmacy combinations were CVS and CNS categories with differences of 9.44% (absolute) and 43% (relative) for hip-fracture patients over acute MI, and 4.83% (absolute) and 18% (relative) for hip-fracture patients over pneumonia patients.

CONCLUSIONS

This is the first national Veterans Health Administration hip fracture hospitalisation study that temporally linked outpatient fall-related medications in hip-fracture patients with matched controls. We found that of veterans with hip-fracture hospitalisations, 70% were prescribed outpatient medications from selected major drug categories that may potentially increase fall risk. Moreover, over one-third of hip-fracture patients received concomitant prescriptions of drugs from multiple selected drug categories. Hip-fracture patients, compared with matched controls of acute MI and pneumonia, had the largest pronounced differences in prescribed medications in the antiepileptics, antidepressants, antipsychotics and antiparkinson's drug classes. Although a randomised clinical trial is the 'gold standard' for determining causation issues, exposing patients, particularly the elderly, to the potential risk of injurious falls would raise serious patient safety research approval issues. If the relationship between selected drugs and falls is indeed to some extent causative, future retrospective multivariate analyses could quantify the magnitude of these effects.

Effect of Concomitant Use of Benzodiazepines and Other Drugs on the Risk of Injury in a Veterans Population

BACKGROUND

Benzodiazepines comprise a class of drugs that when used as monotherapy are generally acknowledged to pose a risk for injury by increasing the likelihood of falls, fall-related injuries, adverse drug events and car accidents. Benzodiazepines may also be used concomitantly with other high risk medications that may further exacerbate the risk of injury. The aim of this study is to examine the occurrence of the concomitant use of benzodiazepines and other drugs and then quantify the indirect effect of these drug combinations on the likelihood of an injury-related health care episode.

METHODS

A multivariate model was specified that included outpatient prescription data and inpatient/outpatient medical utilisation records for 13,745 patients at a Veterans Administration hospital system over a 3-year period (1999-2001). We analysed 1,33,872 outpatient benzodiazepine prescriptions and >1.5 million non-benzodiazepine prescriptions for the study population. Micromedex software was used to identify combinations of benzodiazepines and other drugs that are likely to result in 'major' interactions. We then further restricted our focus to the use of these drug combinations within a 30-day period prior to an injury-related medical event. The adjusted odds ratio on a variable characterising concomitant use of a benzodiazepine and another drug within this period was used to quantify the relative risk of injury. The principal outcome was the estimated risk of an injury-related health care episode within a 30-day period when taking both a benzodiazepine and another drug with a 'major' severity rating as defined by Micromedex. The risk of injury was adjusted for comorbidities, hospital discharges, marital status, age, mean arterial pressure and body mass index, as well as the dose of benzodiazepine (converted to diazepam equivalents) and duration of benzodiazepine treatment.

RESULTS

Of the 1,110 unique individuals who experienced an injury, 790 (71.2%) patients had used a benzodiazepine in combination with another drug. Furthermore, only 4.3% (320/7522) of the patients taking benzodiazepines who did not have concomitant drug use experienced an injury. The occurrence of this concomitant use increased the odds of an injury >2-fold in the model. Dose and duration of benzodiazepine use, as well as certain comorbidities, were also associated with an increased risk for injury, whereas being married reduced the risk.

CONCLUSIONS

This is the first large-scale study to quantify the impact of concomitant use of benzodiazepines and other drugs on the risk of injury in a population of Veterans Administration patients. It demonstrates the utility of expanding the focus of inappropriate medication usage to include analyses that link potentially inappropriate drug use with health care utilisation for injuries.

Complexity of medication use in the Veterans Affairs healthcare system: Part II. Antidepressant use among younger and older outpatients

CONTEXT

A previous study, described in Part I of this report, found that 71% of a sample of 5,003 general outpatients in the Veterans Affairs healthcare system were receiving a unique drug regimen (i.e., total specific drug entities regardless of dose, formulation, or administration schedule). The simplest regimens contained only one drug, while the most complex regimens exceeded 20 different drugs. The purpose of the present study was to determine if patients receiving a specific therapeutic class of medications (e.g., antidepressants) have more homogeneous drug regimens.

OBJECTIVE

to examine the extent and complexity of multiple medication use in younger and older adult outpatients receiving antidepressants compared with those not receiving antidepressants. The study focused on drugs that act systemically or gastrointestinally and hence have the potential to interact.

DESIGN, SETTING, AND PARTICIPANTS

Two subsets of stratified random samples of outpatients selected from prescription databases of U.S. Veterans Integrated Service Network 15. The first group involved 1,991 patients deemed to be on antidepressants (AD patients): 891 aged < 60 years and 1,100 aged > or = 60 years. The second group involved 3,732 patients who had received no antidepressants within the previous 365 days but who had a supply of at least one other current prescription (NoAD patients): 1,195 aged < 60 years and 2,535 aged > or = 60 years; 2 missing age information.

MAIN OUTCOME MEASURES

number of drugs, frequency of drug regimens, level of multiple medication use including and excluding antidepressants.

RESULTS

Younger AD patients received 3 more drugs than younger NoAD patients. 23.6% of younger AD patients, versus 5.9% of younger NoAD patients, received > or = 8 drugs. Older AD patients received 2 more drugs than older NoAD patients. 37.6% of older AD patients, versus 12.8% of older NoAD patients, received > or = 8 drugs. In both the AD and NoAD groups, 62%-96% of patients of all ages were receiving unique drug regimens. Each drug regimen containing 2 or more drugs occurred in fewer than 1% of patients.

CONCLUSIONS

AD patients were receiving more complex drug regimens and had a higher frequency of unique drug regimens than NoAD patients, even when the results were adjusted for age group and number of prescribers. The high prevalence of unique drug combinations in all patient groups in this study indicates that clinicians in this system have only limited experience with the total effects of all of the medications their patients are receiving and thus cannot rely on experience to guard against adverse multi-drug interactions. This fact is a particular concern with psychiatric medications because adverse DDIs involving these medications can mimic psychiatric symptoms and may therefore be more difficult to detect.

Unconventional indicators of drug dependence among elderly long-term users of benzodiazepines

A quarter of the elderly population is prescribed benzodiazepines (BZD). This has led to growing concerns about drug dependence and the validity of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for dependence to a substance. This study aimed to understand how dependence was experienced by long-term BZD users. Interviews were conducted with 45 elderly persons who had been using BZDs for an average of nine years. These users' comments suggest six indicators of dependence: self-identifying as a dependent user, invoking multiple stressors to justify BZD use, using BZD to cope with anticipated stressors, trivializing the dangers of BZDs, keeping a supply in reserve, having previously tried and failed to stop, and reducing the dosage. Our results stress the need to take a more elaborate, person-centered view of dependence.

More than the epidemiology of Alzheimer's disease: contributions of the Canadian Study of Health and Aging

OBJECTIVE

To highlight contributions to knowledge made by the Canadian Study of Health and Aging (CSHA).

METHOD

The CSHA began in 1991, with follow-ups in 1996 and 2001. It was national in scope, with 18 study centres and a coordinating centre. It included 10 263 participants; of these, 9008 were in the community, and 1255 were in institutions. In each phase, community participants were screened for cognitive impairment, and where appropriate, cognitive status was determined by a detailed clinical examination. Data on possible risk factors for dementia were collected at baseline. Data on caring for people with dementia were collected in each phase.

RESULTS

The prevalence of dementia was established at 8% of those aged 65 years and over; incidence (new cases each year) was about 2%. Cognitive impairment not dementia (CIND) was more than twice as common as dementia. Factors affecting the risk of institutionalization, mortality, and the health of caregivers were examined. The costs of dementia were conservatively estimated at dollar 3.9 billion in 1991. Risk factors for Alzheimer's disease (AD) and vascular dementia are presented; it is noteworthy that physical activity appeared to protect against all forms of cognitive decline, particularly for women. Clinical contributions include the development of norms for several neuropsychological tests. Other topics include the health of those with CIND, predicting dementia, medication use, frailty and healthy aging, and urinary incontinence.

CONCLUSION

The CSHA has contributed substantially to knowledge of the epidemiology of dementia, including AD, and to many other topics relevant to seniors' health.

Potentially inappropriate medication use by elderly Mexican Americans

BACKGROUND

Use of inappropriate medications by the elderly is a public health concern with potentially serious health consequences. Research indicates relatively high rates of inappropriate prescription drug usage for older whites and African Americans. However, rates for older Mexican Americans are unknown.

OBJECTIVE

To examine the prevalence and predictors of inappropriate prescription medication use by older Mexican Americans.

METHODS

A cross-sectional study of 3050 Mexican Americans aged > or =65 years living in the southwestern US was conducted. In-home interviews in 1993 and 1994 assessed prescription medication use. Descriptive statistics and logistic regression models were used to estimate prevalence and risk of inappropriate prescription drug use.

RESULTS

Approximately 12% (n = 365) of the sample had used at least 1 of 32 potentially inappropriate prescription medications within 2 weeks of the baseline assessment. Four drugs, chlorpropamide, propoxyphene, amitriptyline, and dipyridamole, accounted for 54% of all inappropriate prescribing. Unmarried subjects, those with >/=1 chronic diseases, high depressive symptoms, frequent physician visits, and combined Medicaid and Medicare insurance were more likely to have used at least 1 of the 32 potentially inappropriate drugs.

CONCLUSIONS

The prevalence of inappropriate medication use is lower in older Mexican Americans than in similar white and African American populations. More studies are needed on the pattern of inappropriate prescribing over time and on intervention programs to reduce potentially adverse health outcomes in older Mexican Americans most at risk.

Cognitive effects of long-term benzodiazepine use in older adults

This study examined the potential for cognitive morbidity associated with the long-term use of benzodiazepine (BZ) sedative-hypnotics in a sample of healthy older adults. Tests of memory, attention and processing speed were conducted prior to and 1 month after drug discontinuation for 25 BZ-users and at similar intervals for 26 healthy control subjects. After controlling for differences in affective status between BZ-users and controls, there were no significant group differences in cognitive performance. However, BZ-users showed greater gains on tests of attention and speed of processing at repeat testing compared with controls this improvement was not attributable to a change in affective status. These findings suggest that there may be subtle and reversible effects of long-term BZ use on speed-dependent tasks in older adults. However, the magnitude of these effects is quite small and may be of little clinical significance in the healthy elderly.

A look at the problem of falls among people with cancer

People with cancer often have multiple risk factors for falls. A major risk factor is aging; because people often are diagnosed with cancer at an older age or are living longer with cancer, many are at risk for falls. Additional risk factors include impaired physical function, sensory-neurologic deficits, use of multiple medications, and deconditioning, often caused by treatment-induced fatigue. Of all types of accidents, falls pose the most serious threat to the elderly. Fall injuries can have serious consequences related to reduced physical functioning and quality of life. A detailed understanding and awareness of the risk factors (both intrinsic and extrinsic) and problems associated with falls can assist oncology nurses to be vigilant in the identification of patients at high risk for falls. These patients may benefit from protocols used in other patient populations, new interventions, or the use of assistive devices.

Correlates of psychotropic drug use in the elderly compared to adults aged 18-64: results from the Quebec Health Survey

This study documents correlates of psychotropic drug use among older adults and compares the results observed in this group to those observed in individuals aged 18-64. A multivariate logistic regression analysis using data from the Quebec Health Survey (1992-1993) was employed to study predisposing and facilitating factors of this behavior. Results showed that 22% of the elderly reported having used anxiolytics, sedatives or hypnotics during the two days preceding the survey, compared to 4.9% of the respondents aged 18-64. Combining both samples, perceived health status, physical functional status, and health services utilization for psychological distress symptoms were the main health factors associated with psychotropic drug use. A significant difference was observed between the two age groups with regard to the association between the respondents' health status and the use of anxiolytics, sedatives or hypnotics. When the effect of other explanatory factors was controlled, older adults in poor health used anxiolytics, sedatives or hypnotics 2.21 times more than individuals aged 18-64 with a similar health condition, whereas older adults in good health used these drugs 7.49 times more than healthy individuals aged 18-64. Furthermore, after controlling for the effect of the respondents' physical and psychological health status, our results showed that more women than men used psychotropic drugs (OR = 1.57; 99% CI = 1.26-1.94). Low-income respondents were also more likely to report using these medications (OR = 1.53; 99% CI = 1.22-1.90). These results were interpreted as supporting the socio-cultural hypothesis of psychotropic drug use, which suggests that the prescribing and utilization of psychotropic drugs is influenced not only by symptoms but also by the social characteristics of individuals. It is suggested that future research may contribute to a better understanding of psychotropic drug utilization in the older adult community-dwelling population by examining consumers' attitudes and health care providers' social values concerning the appropriateness of this behavior.

Antipsychotic medications and the elderly: effects on cognition and implications for use

Despite being frequently prescribed in the elderly, antipsychotic medications are commonly associated with adverse effects in this population, including sedative, orthostatic and extrapyramidal adverse effects. Growing evidence suggests that antipsychotics can also cause deleterious cognitive effects in some elderly patients. Preclinical and growing clinical evidence indicates that inhibitory effects on dopaminergic, cholinergic and histaminergic neurochemical systems may account for antipsychotic-associated cognitive impairment in the elderly. A review of published reports of the cognitive effects of antipsychotics in the elderly suggests that newer antipsychotic medications may possess a more favourable cognitive profile than that of traditional agents in this population. The cognitive effect that a specific antipsychotic will have in the elderly, however, is likely better predicted by considering the pharmacodynamic action of an individual agent in combination with the pathophysiology of the condition being treated. Agents with relatively weak dopamine inhibiting effects (e.g. clozapine and quetiapine), for example, would theoretically have a cognitive profile superior to that of agents with higher degrees of dopaminergic inhibition (all traditional agents, risperidone, olanzapine and ziprasidone) when used for conditions associated with diminished dopamine function (e.g. idiopathic Parkinson's disease). Drugs with weak anticholinergic effects (high-potency traditional agents, risperidone, quetiapine and ziprasidone) would theoretically be less likely to cause cognitive impairment than agents with high degrees of cholinergic receptor blocking actions (clozapine and olanzapine) when treating patients with impaired cholinergic function (e.g. Alzheimer's disease). Cholinergic agonist effects of clozapine and olanzapine may, however, mitigate potential adverse cognitive effects associated with the cholinergic blocking actions of these agents. Large, rigorous trials comparing the cognitive effects of antipsychotics with diverse pharmacodynamic actions are lacking in the elderly and are needed.

Easy rider wheelchair biking. A nursing-recreation therapy clinical trial for the treatment of depression

Depression is a common condition among long-term care residents with limited treatment options available. There are few nonpharmacological interventions available to this population. This study examined the use of a prescribed, therapeutic recreation-nursing intervention, wheelchair biking, for treatment of symptoms of depression in older adults in a long-term care setting. A classical experimental design was used and was guided by the Roy Adaptation Model. Forty residents were pretested for depression and randomly assigned to two groups. A 2-week trial of biking therapy was provided to the treatment group. All participants were posttested. Findings indicated there was a statistically significant improvement in depression scores for the treatment group and no significant change for the control group. This study contributes to the body of knowledge of nursing regarding options for the treatment of depression in older adults, and is an encouraging indicator that psychosocial interventions may be effective in reducing depression.

Treatment of sleep disturbance in Alzheimer's disease

The prevalence of Alzheimer's disease (AD) is rapidly increasing as growing numbers of people around the world are living to old age. Sleep disturbances are a common, and often highly disruptive, behavioral symptom associated with AD. Nevertheless, the study of sleep in AD is relatively new. Little is known about the moderating factors that may alter a given patient's risk for developing sleep problems, or that may influence severity of presentation and persistence. Current treatments for improving sleep in AD fall into three broad categories: (i) pharmacological; (ii) cognitive-behavioral or psycho-educational strategies; and (iii) biological/circadian therapies. There are few studies demonstrating the efficacy of these treatments with community-dwelling AD patients, although studies with persons in institutional settings are promising. In this review, it is suggested that sleep problems in AD are multi-factorial, and influenced by a variety of demographic, physical, psychiatric and situational factors. These factors vary in how readily they can be modified and in how relevant they are to any individual case. Thus, when developing a treatment plan for sleep problems in a dementia patient, it is important to evaluate the underlying causes as well as the context in which the problems are occurring, and to target the intervention accordingly.

Dimensions of care for dementia sufferers in long-term care institutions: are they related to outcomes?

OBJECTIVES

This study empirically examined whether dimensions of care cluster in special care units (SCUs) compared with non-SCUs. The relationship between SCU status plus separate measures of the dimensions of care and outcomes for dementia sufferers was then investigated.

METHODS

Data were drawn from the Intermediate Care Facility Project. The sample (N = 510) included residents with dementia, aged 65 and older, in intermediate care facilities throughout the province of British Columbia. Canada. Longitudinal data included 6 outcomes: cognitive function, behavioral problems of agitation and social skills, physical functioning, and quality of life measured through affect and expressive language skills. Separate multiple linear regression equations were estimated, relating each of these outcomes to 5 dimensions of care: preadmission and admission procedures. staff training and education, nonuse of physical and chemical restraints, flexible care routines and resident-relevant activities, and the environment.

RESULTS

The results showed there is virtually no clustering of dimensions along SCU/non-SCU lines. Neither SCU status nor the individual dimensions were highly predictive of outcomes. Residents' affect at t1 emerged as a characteristic that was significantly correlated with other outcomes.

DISCUSSION

This Canadian research can be added to the few but growing number of rigorous studies that suggest SCUs are not homogeneous and do not necessarily provide better care than non-SCUs. Moreover, it raises questions about the benefits of "best practice" dimensions of care, regardless of SCU status.

Suboptimal use of antidepressants in the elderly: a population-based study in Nova Scotia

This descriptive, retrospective, population-based study assessed patterns of antidepressant medication use in elderly patients in Nova Scotia during fiscal years 1993 through 1996. Individuals > or =65 years of age who were registered with Nova Scotia's Seniors Pharmacare program and filled a prescription for an antidepressant medication during the specified period were included in the study. We determined the number of individuals who filled > or =1 prescription for an antidepressant, the number whose prescription for an antidepressant could be matched with a diagnosis of depression in the physician's billing database, the number who used antidepressants that were judged inappropriate based on published criteria for medication prescribing in the elderly, the number who used a therapeutic antidepressant dose based on published dosing guidelines for the elderly, and the number who used antidepressants for > or =6 months. A total of 12,048, 12,317, and 13,419 individuals filled prescriptions for antidepressants during the 1993 to 1994, 1994 to 1995, and 1995 to 1996 fiscal years, respectively. In each fiscal year, approximately 70% had received a diagnosis of depression based on the International Classification of Diseases, Ninth Revision, Clinical Modification, making it likely that 70% of antidepressant users were receiving these drugs for a primary diagnosis of depression. The number of antidepressant prescriptions that were classified as inappropriate for use in the elderly was 67% in 1993 to 1994, 61% in 1994 to 1995, and 55% in 1995 to 1996. These decreases over time were statistically significant (P < 0.001). Among those using serotonin reuptake inhibitors, secondary tricyclic antidepressants, or tertiary tricyclic antidepressants, 79%, 45%, and 31%, respectively, appeared to be using therapeutic doses. Of 23,553 antidepressant treatment courses, 11,028 (47%) were for < or =180 days. During the study, a significant number of elderly individuals were prescribed antidepressant medications that are judged by expert consensus to be inappropriate for use in this population because of an unfavorable toxicity profile, although the number declined significantly from year to year (P < 0.001 for year-to-year comparisons). Many individuals also appeared to be using antidepressant doses that are probably subtherapeutic, but this finding seemed heavily dependent on the class of antidepressant used. Nearly half of the individuals studied appeared to be treated for inadequately short periods.

Benzodiazepine use and cognitive function among community-dwelling elderly

OBJECTIVE

To evaluate the relation between benzodiazepine use and cognitive function among community-dwelling elderly.

METHODS

This prospective cohort study included 2765 self-reporting subjects from the Duke Established Populations for Epidemiologic Studies of the Elderly. The subjects were cognitively intact at baseline (1986-1987) and alive at follow-up data collection 3 years later. Cognitive function was assessed with the Short Portable Mental Status Questionnaire (unimpaired versus impaired and change in score) and on the basis of the number of errors on the individual domains of the Orientation-Memory-Concentration Test. Benzodiazepine use was determined during in-home interviews and classified by dose, half-life, and duration. Covariates included demographic characteristics, health status, and health behaviors.

RESULTS

After control for covariates, current users of benzodiazepine made more errors on the memory test (beta coefficient, 0.35; 95% confidence interval [CI], 0.10 to 0.61) than nonusers. Further assessment of the negative effects on memory among current users suggested a dose response in which users taking the recommended or higher dose made more errors (beta coefficient, 0.57; 95% CI, 0.26 to 0.88) and a duration response in which long-term users made more errors (beta coefficient, 0.39; 95% CI, 0.05 to 0.73) than nonusers. Users of agents with long half-lives and users of agents with short half-lives both had increased memory impairment (beta coefficient, 0.32; 95% CI, 0.01 to 0.64 and beta coefficient, 0.38; 95% CI, 0.02 to 0.75, respectively) relative to nonusers. Previous benzodiazepine use was unrelated to memory problems, and current and previous benzodiazepine use was unrelated to level of cognitive functioning as measured with the other 4 tests.

CONCLUSIONS

The results suggested that current benzodiazepine use, especially in recommended or higher doses, is associated with worse memory among community-dwelling elderly.