Kuopio 75+ study: does advanced age predict more common use of psychotropics among the elderly?

A cross-sectional study of psychotropic drug use in the elderly: Consuming patterns, risk factors and potentially inappropriate use

OBJECTIVES

The aims of the present study were: (1) to describe psychotropic drug consumption patterns in an outpatient population aged 65 years and older; (2) to determine the impact of a number of demographic and clinical factors on psychotropic consumption; and (3) to determine the ratio of potentially inappropriate psychotropic agents prescribed to the above population.

METHODS

Cross-sectional, observational study of outpatients aged 65 years and older. Data on sociodemographic and clinical variables were collected. Psychotropic drugs were classified into three categories: anxiolytics-hypnotics, antidepressants, and antipsychotics. To determine the risk factors for psychotropic drug use among these patients, a multivariate logistic regression model was developed and subsequently validated using bootstrap resampling techniques. To identify the psychotropic drugs to be avoided, a review of treatments received by the patients was performed based on the 2015 version of the Beers criteria.

RESULTS

The study included 225 outpatients of whom 30.7% were on psychotropic drugs for chronic treatment. The highest likelihood of psychotropic utilisation corresponded to the following profile: female, living in a nursing home, having two or more prescribing physicians, and having received six or more different diagnoses. According to Beers criteria, 51 patients (22.7% of the sample and 73.9% of patients on psychotropic drugs) had been prescribed at least one potentially inappropriate psychotropic drug.

CONCLUSION

Elderly patients commonly use psychotropic medications and are the most vulnerable to the adverse effects of these drugs. It is necessary to re-evaluate the pertinence and accuracy of these medical prescriptions.

Psychotropic Polypharmacy in Adults 55 Years or Older: A Risk for Impaired Global Cognition, Executive Function, and Mobility

Objectives

With their broad spectrum of action, psychotropic drugs are among the most common medications prescribed to the elderly. Consequently, the number of older adults taking multiple psychotropic drugs has more than doubled over the last decade. To improve knowledge about the deleterious effects of psychotropic polypharmacy, we investigated whether there is a threshold number of psychotropic molecules that could lead to impairment of global cognition, executive function, or mobility. Furthermore, relationships between the number of psychotropic molecules and cognitive and mobility impairment were examined.

Design

Cross-sectional study

Setting

University Hospital of Caen (France) and advertisements in medical offices

Participants

Community-dwelling older adults 55 years and older (n = 177; 69.8 ± 9.3 years; 81% women)

Measurements

Number of psychotropic molecules taken daily, global cognition assessed with the Mini Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA), processing speed with the Trail Making Test (TMT) A, executive function with the TMT B and TMT B-A, and mobility with the Time Up and Go (TUG). The threshold numbers of psychotropic molecules were determined by ROC curves analysis. Based on these threshold values, multinomial logistic regression adjusting for covariates was then performed.

Results

Logistic regressions showed that the threshold of two daily psychotropic molecules, identified by the ROC curves analysis, increases the risk of impaired executive function (p = .05 and.005 for the TMT B and TMT B-A, respectively), global cognition (p = .006 and.001 for the MMSE and MoCA, respectively), and mobility (p = .005 for the TUG), independent of confounding factors, including comorbidities. Furthermore, psychotropic polypharmacy would affect mobility through executive functions.

Conclusion

Impairment of global cognition, executive function, and mobility when as few as two psychotropic molecules are consumed in relatively healthy young older adults should alert physicians when prescribing combinations of psychotropic medications.

Decreasing the load? Is a Multidisciplinary Multistep Medication Review in older people an effective intervention to reduce a patient's Drug Burden Index? Protocol of a randomised controlled trial

INTRODUCTION

Older people often use medications with anticholinergic or sedative side effects which increase the risk of falling and worsen cognitive impairment. The Drug Burden Index (DBI) is a measure of the burden of anticholinergic and sedative medications. Medication reviews are typically done by a pharmacist in collaboration with a general practitioner to optimise the medication use and reduce these adverse drug events. We will evaluate whether a Multidisciplinary Multistep Medication Review (3MR) is an effective intervention to reduce a patient's DBI.

METHODS

A randomised controlled trial including 160 patients from 15 community pharmacies will be conducted. Per pharmacy, 1 pharmacist will perform a structured 3MR in close collaboration with the general practitioner, including the objective to reduce the DBI.

ANALYSIS

Primary outcome--the difference in proportion of patients having a decrease in DBI ≥ 0.5 in the intervention and control groups at follow-up. Secondary outcomes--anticholinergic and sedative side effects, falls, cognitive function, activities of daily living, quality of life, hospital admission, and mortality.

ETHICS AND DISSEMINATION

The burden of patients will be kept at a minimum. The 3MR can be considered as usual care by the pharmacist and general practitioner. Medical specialists will be consulted, if necessary. The intervention is specifically aimed at older community-dwelling patients in an attempt to optimise prescribing, in particular, to reduce medication with anticholinergic and sedative properties. Study results will be published in peer-reviewed journals and will be distributed through information channels targeting professionals.

TRIAL REGISTRATION NUMBER

NCT02317666; Pre-results.

One-time counselling decreases the use of benzodiazepines and related drugs among community-dwelling older persons

BACKGROUND

evidence about possibilities to help older persons to withdraw the long-term use of benzodiazepines (BZD) is scarce. Effective and practicable methods are needed.

OBJECTIVE

the study aimed to assess the persistence of one-time counselling by a geriatrician to reduce psychotropic drugs, especially BZD and related drugs (RD).

DESIGN

a prospective randomised controlled trial with a 12-month follow-up was conducted.

SUBJECTS

five hundred ninety-one community-dwelling people aged 65 or older participated in the study.

METHODS

instructions to withdraw, reduce or change psychotropic drugs were given to the intervention group. A 1-h lecture about these drugs and their adverse effects was given later on. No changes in the drug therapy were suggested for the controls.

RESULTS

the number of regular users of BZD and RD decreased by 35% (12/34) (odds ratios (OR) = 0.61, 95% confidence interval (95% CI) 0.44-0.86) in the intervention group while it increased by 4% (2/46) (OR = 1.05, 95% CI 0.81-1.36) in the controls (P = 0.012). No significant changes in the users of other types of psychotropics were found.

CONCLUSION

one-time counselling of psychotropics and other fall-risk-increasing drugs by a geriatrician followed with a 1-h lecture about adverse effects of these drugs had positive effects in decreasing the number of regular users of BZD and RD, and these effects persisted for the total 12-month intervention period.

Sedative load and mortality among residents of long-term care facilities: a prospective cohort study

BACKGROUND

Older people are often prescribed multiple drugs with sedative properties. Most research has focused on specific classes of sedative and psychotropic drugs. The cumulative effect of taking multiple drugs with sedative properties has been termed 'sedative load'. Few previous studies have investigated the sedative load among residents of long-term care facilities. No previous studies have assessed the possible association between sedative load and mortality.

OBJECTIVE

The objective of this study was to describe the sedative load among residents of long-term care facilities, and to investigate a possible association between sedative load and mortality.

METHODS

This was a prospective cohort study. The study population comprised all 1444 residents of 53 long-term care wards in seven hospitals in Helsinki during September 2003. Of the eligible residents, 1087 residents or their proxies provided written informed consent to participate. Medical, medication and follow-up mortality data were available for 1004 residents. The main outcome measures were sedative load and all-cause mortality.

RESULTS

The mean age of the residents was 81.3 (SD 10.9) years, and the mean number of regularly used drugs per resident was 7.1 (SD 3.4). Fifteen percent of residents were categorized as non-users of sedative drugs, 32% as users of some drugs with sedative properties and 53% as residents with a high sedative load. There was a bivariate association between having a higher sedative load and younger age (p < 0.001), male sex (p = 0.006), not being widowed (p = 0.001), diagnosis of depression (p < 0.001), diagnosis of psychiatric illness other than depression (p < 0.001), not being diagnosed with dementia (p = 0.009) and a shorter duration of institutional care (p = 0.02). Unadjusted analysis revealed that having a higher sedative load was associated with increased survival (p = 0.04, log rank test). However, in the adjusted Cox proportional hazard model, only poor nutritional status (hazard ratio [HR] 1.55; 95% CI 1.32, 1.82), male sex (HR 1.37; 95% CI 1.12, 1.69), increasing age (HR 1.04; 95% CI 1.03, 1.05) and co-morbidity (HR 1.07; 95% CI 1.02, 1.13) were significantly associated with risk of death.

CONCLUSIONS

There is a very high rate of sedative and psychotropic drug use among residents of long-term care facilities in Helsinki. However, having a high sedative load was not associated with an increased risk of death. Further research is needed to investigate the possible association between sedative load and mortality using alternative models and methods, and in different resident populations.

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.

Concomitant use of analgesics and psychotropics in home-dwelling elderly people-Kuopio 75 + study

AIMS

To investigate the extent of concomitant use of analgesic and psychotropic medicines among home-dwelling elderly people aged at least 75 years in Finland.

METHODS

This was a population-based study in Finland, performed as part of Kuopio 75 + study focusing on the clinical epidemiology of diseases, medication and functional capacity. A random sample of 700 persons was drawn from the total population of the city of Kuopio, eastern Finland, aged 75 years on January 1, 1998 (n = 4518). Ninety-nine persons could not be examined and 78 were living in long-term institutions, so that the number of home-dwelling elderly persons amounted to 523. A trained nurse interviewed the participants about their use of medicines, and a geriatrician examined their overall physical and mental status. Dementia and depression were diagnosed according to the DSM IV criteria. Both regular and irregular prescribed and nonprescribed drug use was recorded.

RESULTS

Every fourth elderly person (27.2%) used analgesics and psychotropics concomitantly, this use becoming twice as common with advancing age (19.6% in the age group 75-79 years, 38.2% among the oldest, aged 85 + years). Concomitant use of psychotropics and opioids also became more common with increasing age (2.8% in age group 75-79 years and 9.6% in the oldest group, aged 85 + years). The use of opioids was nearly twice as common among concomitant users (19.7%) than among those using only analgesics (11.3%). Concomitant users suffered from interfering daily pain and daily pain at rest more commonly than nonusers of analgesics. Depression, sleeping problems and polypharmacy were more common among the concomitant users, who had also had more hip fractures than the rest.

CONCLUSIONS

Concomitant use of analgesics and psychotropics becomes more common with advancing age and is a potential risk factor for adverse drug effects.

Capability for daily activities in old people with rheumatoid arthritis: a population based study

OBJECTIVE

To describe the functional capacity for daily activities in old people with clinical rheumatoid arthritis (including juvenile rheumatoid arthritis (JRA)) in a population based cohort.

METHODS

A cohort of 700 people was randomly collected from the population older than 75 years in a Finnish town. Altogether 601 persons (86%) participated. Data were collected from clinical records and by interview, clinical examination, and questionnaire. Ability to carry out activities of daily living (ADL) was assessed by the Barthel index, and the IADL (instrumental activities of daily living) by the Lawton and Brody questionnaire.

RESULTS

16 people had clinical rheumatoid arthritis (one with JRA). The prevalence was 16/601 (2.7% (95% confidence interval, 1.7% to 4.5%)). Eight patients with rheumatoid arthritis (50%) obtained the best possible ADL figures, while three (19%) had very poor results. Seven (44%) could not dress themselves without help. Three (19%) were unable to walk, and five (31%) could not climb stairs. Sex and age adjusted results showed no statistical difference (ADL and IADL) between patients with clinical rheumatoid arthritis and rest of the cohort. Four patients (25%) had dementia, which was associated with the poor functional capacity.

CONCLUSIONS

The prevalence of the disease was unexceptional. The ability of old people with rheumatoid arthritis to carry out activities of daily living did not differ from the general population, but the disease may lead to severe disability on an individual level, especially when associated with dementia. It therefore remains a considerable challenge to the health care and social systems.