Use of Sleep-Promoting Medications in Nursing Home Residents

The sleep patterns and their associations with mental health among nursing home residents: a latent profile approach

BACKGROUND

Nursing home residents commonly experience poor sleep conditions. However, few studies have explored the potential sleep patterns among nursing home residents. This study aimed to identify the sleep patterns in nursing home residents, compare residents' characteristics across sleep patterns, and examine the relationships between sleep patterns and residents' mental health (i.e., depressive and anxiety symptoms).

METHODS

This cross-sectional study was conducted in 27 nursing homes in Jinan, China, from March to June 2018. In total, 353 participants were recruited via convenience sampling, and of which, 326 completed the survey. A latent profile analysis was performed to identify sleep patterns based on the seven dimensions of the Pittsburgh Sleep Quality Index. Bivariate analyses were conducted to compare residents' characteristics among the sleep patterns. Mixed-effects logistic regression analyses were adopted to investigate the relationships between sleep patterns and residents' mental health.

RESULTS

Three sleep patterns were identified, including 'good sleepers', 'poor sleepers without hypnotic use', and 'poor sleepers with hypnotic use'. Residents' gender, education, pain, instrumental activities of daily living, and number of chronic conditions were significantly differentiated across the sleep patterns. Compared with 'good sleepers', 'poor sleepers without hypnotic use' were significantly associated with more depressive symptoms (OR = 3.73, 95% CI = 2.09, 6.65, p < 0.001), but not with anxiety symptoms (OR = 2.04, 95% CI = 0.97, 4.29, p = 0.062); whereas 'poor sleepers with hypnotic use' had significantly more depressive (OR = 5.24, 95% CI = 2.54, 10.79, p < 0.001) and anxiety symptoms (OR = 5.02, 95% CI = 2.13, 11.83, p < 0.001).

CONCLUSIONS

This study reveals three distinct sleep patterns in nursing home residents and their significant associations with residents' mental health. These findings can inform future research to develop appropriate and tailored intervention strategies for improving sleep and promoting mental health for nursing home residents.

Efficacy and safety of Z-substances in the management of insomnia in older adults: a systematic review for the development of recommendations to reduce potentially inappropriate prescribing

BACKGROUND

Z-drugs are usually prescribed as first line pharmacological therapy for insomnia. However, the benefits and risks of Z-drugs may differ for older adults. This systematic review investigated the available evidence on the efficacy and safety of Z-drugs in the management of insomnia in older adults.

METHODS

The Cochrane database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed/MEDLINE and EMBASE were searched for systematic reviews, meta-analyses, controlled interventional and observational studies using a pre-formulated search term. The target population was older adults (≥65 years old) with insomnia. Studies were included if they reported efficacy and/or safety outcomes of the use of Z-drugs for the management of insomnia compared to placebo, usual or no treatment, or other pharmacological agents.

RESULTS

Eighteen studies were included (8 interventional and 10 observational studies). In short-term interventional studies, Z-drugs were similarly or better efficacious in improving both sleep and daytime parameters than placebo or other pharmacological treatments, while showing good results on measures of safety. However, in longer-term observational studies, Z-drugs significantly increased the risk for falls and fractures in comparison to no treatment or melatonin agonists.

CONCLUSIONS

Analyzing the evidence from short-term interventional studies, Z-drugs appear effective and safe for treatment of insomnia in older adults, but they may have unfavorable side effects when used for longer periods of time. We, therefore, recommend discontinuing Z-drugs, principally because of the high risk for falls and fractures. Nonetheless, quality and quantity of evidence are low. Due to the scarcity of data, especially concerning drug dependence after longer periods of treatment and due to the significantly increased risk for falls and fractures, further studies are needed to evaluate the benefit-risk profile of Z-drugs use in older patients, particularly for long-term use.

Non-benzodiazepine hypnotic use for sleep disturbance in people aged over 55 years living with dementia: a series of cohort studies

BACKGROUND

Sleep disturbance affects around 60% of people living with dementia and can negatively affect their quality of life and that of their carers. Hypnotic Z-drugs (zolpidem, zopiclone and zaleplon) are commonly used to treat insomnia, but their safety and efficacy have not been evaluated for people living with dementia.

OBJECTIVES

To estimate the benefits and harms of Z-drugs in people living with dementia with sleep disturbance.

DESIGN

A series of observational cohort studies using existing data from (1) primary care linked to hospital admission data and (2) clinical cohort studies of people living with dementia.

DATA SOURCES

Primary care study - Clinical Practice Research Datalink linked to Hospital Episode Statistics and Office for National Statistics mortality data. Clinical cohort studies - the Resource Use and Disease Course in Dementia - Nursing Homes (REDIC) study, National Alzheimer's Coordinating Centre (NACC) clinical data set and the Improving Well-being and Health for People with Dementia (WHELD) in nursing homes randomised controlled trial.

SETTING

Primary care study - 371 primary care practices in England. Clinical cohort studies - 47 nursing homes in Norway, 34 Alzheimer's disease centres in the USA and 69 care homes in England.

PARTICIPANTS

Primary care study - NHS England primary care patients diagnosed with dementia and aged > 55 years, with sleep disturbance or prescribed Z-drugs or low-dose tricyclic antidepressants, followed over 2 years. Clinical cohort studies - people living with dementia consenting to participate, followed over 3 years, 12 years and 9 months, for REDIC, NACC and WHELD, respectively.

INTERVENTIONS

The primary exposure was prescription or use of Z-drugs. Secondary exposures included prescription or use of benzodiazepines, low-dose tricyclic antidepressants and antipsychotics.

MAIN OUTCOME MEASURES

Falls, fractures, infection, stroke, venous thromboembolism, mortality, cognitive function and quality of life. There were insufficient data to investigate sleep disturbance.

RESULTS

The primary care study and combined clinical cohort studies included 6809 and 18,659 people living with dementia, with 3089 and 914 taking Z-drugs, respectively. New Z-drug use was associated with a greater risk of fractures (hazard ratio 1.40, 95% confidence interval 1.01 to 1.94), with risk increasing with greater cumulative dose (p = 0.002). The hazard ratio for Z-drug use and hip fracture was 1.59 (95% confidence interval 1.00 to 2.53) and for mortality was 1.34 (95% confidence interval 1.10 to 1.64). No excess risks of falls, infections, stroke or venous thromboembolism were detected. Z-drug use also did not have an impact on cognition, neuropsychiatric symptoms, disability or quality of life.

LIMITATIONS

Primary care study - possible residual confounding because of difficulties in identifying patients with sleep disturbance and by dementia severity. Clinical cohort studies - the small numbers of people living with dementia taking Z-drugs and outcomes not necessarily being measured before Z-drug initiation restricted analyses.

CONCLUSIONS

We observed a dose-dependent increase in fracture risk, but no other harms, with Z-drug use in dementia. However, multiple outcomes were examined, increasing the risk of false-positive findings. The mortality association was unlikely to be causal. Further research is needed to confirm the increased fracture risk. Decisions to prescribe Z-drugs may need to consider the risk of fractures, balanced against the impact of improved sleep for people living with dementia and that of their carers. Our findings suggest that when Z-drugs are prescribed, falls prevention strategies may be needed, and that the prescription should be regularly reviewed.

FUTURE WORK

More research is needed on safe and effective management strategies for sleep disturbance in people living with dementia.

STUDY REGISTRATION

This study is registered as European Union electronic Register of Post-Authorisation Studies (EU PAS) 18006.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 1. See the NIHR Journals Library website for further project information.

Effects of benzodiazepines on orthostatic blood pressure in older people

BACKGROUND

Older people taking benzodiazepines (BDZs) have higher risk of falling, which is mainly attributed to cognitive and psychomotor effects. BDZs may also have hypotensive effects. We investigated the association between BDZs and orthostatic blood pressure behaviour in older people.

METHODS

We retrospectively analysed data from an outpatient clinic where people aged 60 or older underwent a geriatric assessment. Non-invasive beat-to-beat orthostatic systolic blood pressure (SBP) was assessed at regular time intervals before and after an active stand test. We compared clinical characteristics between BDZs users and non-users and also investigated if BDZs use was an independent predictor of baseline SBP. Factors associated with SBP change were investigated using a repeated measures general linear model.

RESULTS

Of 538 participants (67.7% female, mean age 72.7), 33 (6.1%) reported regular BDZs use. BDZ users had lower baseline SBP (149 versus 161 mmHg, P < 0.05). Multiple linear regression confirmed BDZs use as independent predictor of baseline SBP in N = =538. At 10 s post-stand, the SBP difference between BDZs use groups became maximum (21 mmHg); at this point, SBP still seemed to be decreasing in BDZ-users, whereas in controls it seemed to be recovering. After adjustment (age, sex, hypertension, frailty, comorbidity, antihypertensives), BDZs were associated with greater SBP reduction between baseline and 10 s post-stand (P < 0.05).

CONCLUSION

Older people taking BDZs may have a higher risk of orthostatic hypotension, perhaps due to an exaggerated immediate BP drop. This adds to other BDZ-related falls risks. BDZs should be avoided in older people at risk of falling.

Use of Falls Risk Increasing Drugs in Residents at High and Low Falls Risk in Aged Care Services

Falls are associated with considerable morbidity and mortality in aged care services and falls risk increasing drugs (FRIDs) are often overlooked as a contributor to falls. This study aims to investigate the association between the risk of falling and use of FRIDs from aged care services. Inverse-probability-weighted multinomial logistic regression was used to estimate the association between falls risk and regular FRIDs in 383 residents from six Australian aged care services. Overall, residents at high and low falls risk had similar prevalence of FRIDs. Prevalence of antipsychotics and sedative-hypnotics was low. Residents at high falls risk had higher adjusted odds of using ≥2 psychotropic medications (odds ratio [OR] = 1.75, 95% confidence interval [CI] = 1.17-2.61) and ≥2 medications that cause/worsen orthostatic hypotension (OR = 3.59, 95% CI = 2.27-5.69). High prevalence of FRIDs was mainly attributable to medications for which residents had clinical indications. Clinicians appeared to have largely avoided FRIDs that explicit criteria deem potentially inappropriate for high falls risk.

Sleep Disturbance and the Change from White to Red Lighting at Night on Old Age Psychiatry Wards: A Quality Improvement Project

Psychiatric inpatient units often maintain a degree of lighting at night to facilitate the observation of patients, but this has the potential to disrupt sleep. Certain wavelengths of light may be less likely to disturb sleep and if such lighting permitted adequate observations, patient wellbeing may be improved.

AIMS AND METHOD

This study explored the effects of changing night-lights from broad-band white to narrow-band red on the amount of sleep observed, 'as required' medication administered and number of falls, in an old age psychiatry inpatient setting. Qualitative data was also gathered with a staff questionnaire. We hypothesised that compared to the use of white lights, red lights would be associated with a greater amount of recorded sleep, lesser use of 'as required' medication and no increase in the number of falls (reflecting comparable safety).

RESULTS

Whilst there were no significant differences in quantitative measures recorded, there were more observations of sleep during the red light period than the white light period (14.1 versus 13.9 times per night) (U=627.5, z=-0.69, p=0.49) and fewer 'as required' medication administrations during the red light period compared to the white light period (3.3 versus 4.8 times per night) (U=640.0, z=0.56, p=0.57). Qualitatively, the staff of the organic assessment unit reported that patients were sleeping better and less agitated at night.

CLINICAL IMPLICATIONS

Larger and more in-depth studies are required to examine the full effectiveness of using safe, sleep-enhancing lighting on wards at night.

Role of Ramelteon in Reduction of As-Needed Antipsychotics in Elderly Patients with Delirium in a General Hospital Setting

BACKGROUND AND OBJECTIVE

Abnormalities in melatonin levels have been linked to delirium. This dysregulation may be offset with the use of ramelteon, a melatonin receptor agonist. The purpose of this study was to evaluate the role of ramelteon in decreasing the need for as-needed (PRN) use of antipsychotics in elderly patients with delirium.

METHODS

This was a single-center, retrospective study involving 488 patients who were placed on constant observation and received care by psychiatric service from May 2015 through October 2015. Of these patients, 125 patients were age 65 years or above, had a diagnosis of delirium, and had no standing orders for antipsychotics. These 125 patients were divided into the non-ramelteon group (who received no ramelteon and PRN antipsychotics) and the ramelteon group (who received ramelteon plus PRN antipsychotics). The use of PRN antipsychotics for agitation in each group was recorded.

RESULTS

The ramelteon group had a lower incidence of PRN antipsychotic use compared to those not given ramelteon (60 vs. 80%, p value = 0.001). After adjustment for race, age, length of stay, and gender, patients in the non-ramelteon group were more likely to have been given antipsychotics compared to those in the ramelteon group (odds ratio = 4.3, p value = 0.002).

CONCLUSION

Ramelteon use in elderly patients with delirium may be associated with statistically significant reduction of PRN antipsychotic use for agitation.

Prevalence, Patterns and Predictors of Psychotropic Polypharmacy Among Elderly Individuals with Parkinson's Disease In Long Term Care Settings In The United States

BACKGROUND

Elderly individuals with Parkinson's disease (PD) generally suffer from more than one psychiatric comorbidity, which necessitates the use of concurrent psychotropic medications. To the best of the author's knowledge there are no nationally representative estimates of psychotropic polypharmacy among elderly individuals with PD in the United States (US).

OBJECTIVE

Therefore, the primary objective of this study was to examine the prevalence, patterns and predictors of psychotropic polypharmacy among elderly individuals with PD in the (US).

METHODS

A retrospective, cross-sectional study design with 2004 National Nursing Home Survey (NNHS) and 2007 National Home and Hospice Care Survey (NHHCS) data was used. The analytic sample included elderly (age ≥65 years) individuals with PD. Antidepressants, antipsychotics, sedative/hypnotics, and anti-anxiety medications constituted the psychotropic medication classes. Concurrent use of two or more psychotropic medications was classified as psychotropic polypharmacy.

RESULTS

Approximately 93,648 and 37,439 elderly individuals with PD resided in nursing homes and home health settings respectively. Among elderly nursing home residents with PD, the nationally representative prevalence of psychotropic polypharmacy was 26.28%, whereas, it was 21.36% in the home health setting. Use of antidepressant medications constituted the majority of the psychotropic medication use among both nursing home (48.91%) and home health (40.98%) residents with PD. Multiple logistic regression analyses revealed that specific comorbidities were significantly associated with psychotropic polypharmacy among elderly nursing home residents with PD.

CONCLUSIONS

These findings underscore the importance of evidence-based prescribing when psychotropic medications are used in elderly individuals with PD to reduce unnecessary polypharmacy.

The association between benzodiazepine use and sleep quality in residential aged care facilities: a cross-sectional study

BACKGROUND

Benzodiazepines are commonly prescribed in residential aged care facilities (RACFs) for their sedative and anxiolytic effects. The objective of this study was to investigate the association between benzodiazepine use and sleep quality in residents of RACFs.

METHODS

A cross-sectional study involving 383 participants was conducted in six Australian RACFs. Night-time sleep quality, day-time drowsiness and day-time napping behavior were assessed using a validated questionnaire. Logistic regression was used to compute adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for the association between benzodiazepine use and sleep quality. Covariates included pain, dementia severity, depression, insomnia and other sedative use.

RESULTS

Of the 383 residents (mean age 87.5 years, 77.5% female), 96(25.1%) used a benzodiazepine on a regular basis. Residents who used long-acting benzodiazepines on a regular basis had higher night-time sleep quality than non-users (AOR = 4.00, 95%CI 1.06 - 15.15). Residents who used short-acting benzodiazepines on a PRN only basis had longer daytime napping times than non-users (AOR = 1.77, 95%CI 1.01 - 3.08). No benzodiazepine category was associated with day-time drowsiness.

CONCLUSIONS

The association between benzodiazepine use and sleep quality is dependent on the half-life and prescribing pattern of the benzodiazepine. Short-acting PRN benzodiazepines were associated with lower night time sleep quality and longer day-time napping compared to long-acting regular benzodiazepines. Longitudinal studies are needed to determine whether these findings reflect channeling of short-acting agents to residents at higher risk of sleep disorders.

Night-time continence care in Australian residential aged care facilities: findings from a grounded theory study

BACKGROUND

Continence care commonly disrupts sleep in residential aged care facilities, however, little is known about what staff do when providing continence care, and the factors that inform their practice.

AIMS

To describe nurses' and personal careworkers' beliefs and experiences of providing continence care at night in residential aged care facilities.

METHODS/DESIGN

Eighteen nurses and personal careworkers were interviewed about continence care, and 24 hours of observations were conducted at night in two facilities.

RESULTS/FINDINGS

Most residents were checked overnight. This practice was underpinned by staffs' concern that residents were intractably incontinent and at risk of pressure injuries. Staff believed pads protected and dignified residents. Decisions were also influenced by beliefs about limited staff-to-resident ratios.

CONCLUSION

Night-time continence care should be audited to ensure decisions are based on residents' preferences, skin health, sleep/wake status, ability to move in bed, and the frequency, severity and type of residents' actual incontinence.

Massage, a complementary therapy effectively promoting the health and well-being of older people in residential care settings: a review of the literature

AIMS

To explore the potential benefits of massage within daily routine care of the older person in residential care settings.

BACKGROUND

Globally, the proportion of people over 65 years is rapidly rising. Increased longevity means older people may experience a rise in physiological and psychological health problems. These issues potentially place an increased demand for quality long-term care for the older person. Complementary approaches such as massage appear to be needed in quality residential care.

DESIGN

A critical literature review was undertaken.

METHODS

A literature review pertaining to massage in the older resident was conducted using a range of online databases. Fourteen studies dated 1993-2012 met the inclusion criteria and were critically evaluated as suitable resources for this review.

RESULTS

Evidence suggests massage may be advantageous from client and nursing perspectives. Clients' perceive massage to positively influence factors such as pain, sleep, emotional status and psychosocial health. Evidence also demonstrates massage to benefit the client and organisation by reducing the necessity for restraint and pharmacological intervention. Massage may be incorporated into care provision and adopted by care providers and family members as an additional strategy to enhance quality of life for older people.

CONCLUSION

Massage offers a practical activity that can be used to enhance the health and well-being of the older person in residential care.

IMPLICATIONS FOR PRACTICE

Massage offers benefit for promoting health and well-being of the older person along with potential increased engagement of family in care provision. Integration of massage into daily care activities of the older person requires ongoing promotion and implementation.

Sleep and agitation in nursing home residents with and without dementia

BACKGROUND

The prevalence of dementia in Australian nursing homes is high. A large proportion of residents express themselves through agitated behaviors, with substantial interpersonal and day-to-day variance. One factor that may increase agitation is poor sleep. The current study aimed to determine if sleep influences symptoms of agitation in nursing home residents, and whether this effect differed by dementia status. As benzodiazepines are used widely as hypnotic medication, their impact was also considered.

METHODS

Actigraph devices worn on residents' non-dominant wrists for three days were used to obtain objective measures of sleep. Symptoms of agitation were assessed using staff responses to two standardized questionnaires - the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory - nursing home version (NPI-NH). Presence of dementia and benzodiazepine use were obtained from resident medical charts.

RESULTS

Forty-nine residents (mean age: 85.57 years) from four nursing homes in Tasmania were included in the study. Results indicated that residents were in bed for an average of 11.04 h and slept for 10.14 h per day. Significant relationships between sleep and verbal as well as non-aggressive agitation were found. No relationships between sleep and aggressive agitation were detected. A significant moderation effect of dementia was found, in which residents without dementia expressed verbal agitation when obtaining less sleep, but not residents with dementia. Benzodiazepine use did not result in significantly more sleep.

CONCLUSIONS

These results suggest that sleep could play an important role in explaining agitation, but more research is needed to explore the relationship between sleep and benzodiazepines in nursing home residents.

The Effect of a Meditative Movement Intervention on Quality of Sleep in the Elderly: A Systematic Review and Meta-Analysis

BACKGROUND/OBJECTIVES

Sleep disorders are one of the most common difficulties facing older people. Meditative movement interventions (MMIs), a new category of exercise integrating physical activity and meditation (e.g., t'ai chi, yoga, and qigong), may benefit older people with sleep problems. This systematic review synthesized the evidence on the effect of MMIs on older people's quality of sleep.

METHODS

PubMed, EMBASE, CINAHL, PsycINFO, Scopus, the Cochrane Library, the China Science and Technology Journal Database (CSTJ) and the China National Knowledge Infrastructure (CNKI) were searched-from 1950 to March 2014-for randomized controlled trials. Articles were screened and selected by two researchers. Data were extracted from the included studies using specified forms. The same researchers independently evaluated the quality of each article. A meta-analysis was conducted to examine the pooled effect of MMI on sleep quality compared with the control groups.

RESULTS

Fourteen of 1049 studies were included, involving 1225 participants. Interventions included t'ai chi, yoga, qigong, and multicomponent MMI and lasted 12-24 weeks. Ten studies had a low risk of bias. The interventions resulted in significantly better sleep quality scores than either active therapy or usual care/wait-list controls (standardized mean difference, -0.70;95% confidence interval, -0.96 to -0.43). Subgroup analyses revealed that the effect of MMI on sleep quality was not influenced by the type or duration of the intervention. However, pooled results of studies with intervention frequency of fewer than 3 times per week did not show a positive effect on sleep quality. Lower-quality studies had larger effect sizes than high-quality studies. No adverse events were reported.

CONCLUSION

The current review demonstrated that MMI had a moderate effect on improving the quality of sleep for older people with sleep complaints. However, the evidence is inconclusive because of the varying study quality and MMI modalities. This study highlights the need for higher-quality randomized, controlled trials and more sufficient fidelity of intervention implementation to confirm the results. It also highlights the need for comparing the effectiveness of MMI on different subgroups of the elderly population.

The impact of chronic benzodiazepine use on cognitive evolution in nursing home residents

OBJECTIVE

Chronic use of benzodiazepines and Z-drugs (BZD/Zs) has been linked to cognitive decline. In this one-year prospective cohort study, we explored the impact of chronic BZD/Z use on cognitive decline compared to nonusers.

METHODS

In cognitively capable BZD/Z users and nonusers in 10 Belgian nursing homes, we investigated cognition with the MiniMentalStateExamination(MMSE) at baseline and one year. A decrease of ≥ 4 points on the MMSE (clinically relevant decrease) was used in multiple logistic regression. We collected baseline demographics, functional, psychometric and social characteristics potentially influencing cognition.

RESULTS

In both the 131 BZD/Z users and 95 nonusers, the cognition decreased significantly over time, but without significant difference between the groups. Clinically relevant decrease was present in 34% BZD/Z users and 27% nonusers (NS). Controlled for age, gender, education and BZD/Z use, the significant risk factors for clinically relevant cognitive decline were depression, hearing and functional impairment. Frequent reading was associated with less MMSE decrease. Our findings could not demonstrate with statistical significance that BZD/Z use was associated with fast cognitive decline. The risk factors for fast decline were depression, hearing and functional impairment, and the absence of a reading attitude. In addition, BZD/Z use and depression were associated, indicating a complex relationship.

The use of antidepressants in Belgian nursing homes: focus on indications and dosages in the PHEBE study

BACKGROUND

Since antidepressants are prescribed for multiple indications, the use of an antidepressant cannot be equated with a diagnosis of depression.

OBJECTIVE

The objective of this study was to examine the quality of antidepressant prescribing in Belgian nursing homes, with a critical evaluation of indications and dosages, to see whether depression was appropriately treated in terms of drug choice, the indications for which antidepressants were being prescribed and whether there was underdosing.

METHODS

This analysis was based on data obtained in the Prescribing in Homes for the Elderly in Belgium (PHEBE) study, a cross-sectional, descriptive study of a representative, stratified, random sample of 1,730 residents from 76 Belgian nursing homes. The PHEBE study investigated overall drug utilization in Belgian nursing homes in 2006. Clinical and medication data for the present study were obtained from this study. A 28-item checklist of clinical conditions was designed ad hoc for the PHEBE study and sent to the residents' general practitioners (GPs) to collect clinical information. We copied the residents' medication charts, classified the drugs using the Anatomical Therapeutic Chemical (ATC) classification system codes and transferred the drug names and dosages into a database. Information on indications was retrospectively obtained from the GPs, so that we could link the indication to each medication. Minimum effective doses (MEDs) of antidepressants to treat major depression were obtained from the literature to assess underdosing.

RESULTS

The overall use of antidepressants in nursing homes was 39.5 % (95 % CI 37.2, 41.8). The physicians classified 34.2 % (95 % CI 32.0, 36.4) of the residents as having depression, and 80.9 % of these patients were treated with an antidepressant. Indications among the single antidepressant users (n = 551) were depression (66.2 %), insomnia (13.4 %), anxiety (6.2 %) and neuropathic pain (1.6 %). In the indication of depression, 74.8 % used a selective serotonin reuptake inhibitor (SSRI), predominantly citalopram, sertraline and escitalopram. Venlafaxine was used by 10.7 % of the residents. Dosages for these antidepressants were equal to or higher than the MED. But when trazodone, amitriptyline or mirtazapine were used to treat depression, respectively, 92.3, 55.5 and 44.5 % of prescribed dosages were below the MED. In the indication of insomnia, most of the time, trazodone (90.5 %) or mirtazapine (5.4 %) were used, and in lower dosages than those required for depression treatment (<MED). Tricyclic antidepressants were predominantly used for the treatment of neuropathic pain and were also used at lower dosages. Of all the residents receiving a medication for anxiety, only 13.9 % received an antidepressant (mostly an SSRI), and the remaining received a benzodiazepine.

CONCLUSIONS

The number one indication for the use of an antidepressant was depression. Within this indication, mostly the recommended SSRIs were used, in dosages equal to or higher than the MED. Furthermore, we noticed that there was substantial use of sedative antidepressants for insomnia and that the physicians preferred to prescribe benzodiazepines over the recommended SSRIs to treat anxiety chronically.

Sleep quality of benzodiazepine users in nursing homes: a comparative study with nonusers

OBJECTIVES

We aim to describe subjective sleep quality among long-term users of benzodiazepines (BZDs) in Belgian nursing homes, to compare it to nonusers, and to investigate determinants of poor sleep quality.

METHODS

All mentally competent residents from 10 nursing homes were screened and compiled in a group of long-term BZD users or in a group of nonusers based on the medication chart. We collected demographic, functional, and medication characteristics and global and specific sleep parameters using the Pittsburgh Sleep Quality Index (PSQI). Linear regression was used to investigate which parameters were associated with sleep quality.

RESULTS

Of the 300 residents, 178 (59%) were long-term BZD users and 122 were nonusers. The 2 groups did not differ in demographic and functional characteristics (mean age, 85.5 y; range, 57-100; 75% women). The users reported significantly more difficulties with falling asleep, had more midnight awakenings, felt less rested in the morning, and had a poorer self-perceived sleep quality compared to nonusers. Sleep duration and time to fall asleep did not differ. The self-perceived sleep quality was mainly determined by difficulties during initiation of sleep. After controlling for demographic, medication, and functional characteristics, BZD use remained strongly associated with poor sleep (r=0.173; P=.003), and a study centre effect (differences among nursing homes) was observed (r=0.229; P<.001).

CONCLUSION

Our findings do not support long-term effectiveness of BZDs; long-term users slept more poorly than nonusers and were even more outspoken in users of long-acting BZDs. In future longitudinal comparative studies of sleep quality, unexplained variability needs further assessment with medical, psychologic, and institutional parameters.

Psychotropic drug-induced falls in older people: a review of interventions aimed at reducing the problem

Falls are a common health problem for older people, and psychotropic medications have been identified as an important independent fall risk factor. The objective of this paper was to review the literature relating to the effect of psychotropic medications on falls in older people, with a particular focus on evidence supporting minimization of their use to reduce risk of falls. A literature search identified 18 randomized trials meeting the inclusion criteria for the review of effectiveness of psychotropic medication withdrawal studies, including four with falls outcomes. One of these, which targeted reduced psychotropic medication use in the community, reported a 66% reduction in falls, while the other studies demonstrated some success in reducing psychotropic medication use but with mixed effects on falls. Other randomized trials evaluated various approaches to reducing psychotropic medications generally or specific classes of psychotropic medications (e.g. benzodiazepines), but did not report fall-related outcomes. Overall, these studies reported moderate success in reducing psychotropic medication use, and a number reported no or limited worsening of key outcomes such as sleep quality or behavioural difficulties associated with withdrawal of psychotropic medication use. Reduced prescription of psychotropic medications (e.g. seeking non-pharmacological alternatives to their use in place of prescription in the first place or, for those patients for whom these medications are deemed necessary, regular monitoring and efforts to cease use or wean off use over time) needs to be a strong focus in clinical practice for three reasons. Firstly, psychotropic medications are commonly prescribed for older people, both in the community and especially in the residential care setting, and their effectiveness in a number of clinical groups has been questioned. Secondly, there is strong evidence of an association between substantially increased risk of falls and use of a number of psychotropic medications, including benzodiazepines (particularly, the long-acting agents), antidepressants and antipsychotic drugs. Finally, the largest effect of any randomized trial of falls prevention to date was achieved with a single intervention consisting of weaning psychotropic drug users off their medications.

Antidepressant prescribing patterns in the nursing home: second-generation issues revisited

INTRODUCTION

The object of this study was to provide an updated evaluation of the quality of antidepressant management and prescribing patterns in nursing homes in the context of organizational and resident factors.

DESIGN

Pearson correlation and chi-square analyses were conducted using information gathered from random nursing home charts.

SETTING

Nursing home facilities in and around the Louisville, KY, metropolitan area (n = 10).

PARTICIPANTS

Chart reviews were randomly chosen for 20% of long term care resident records in participating homes (n = 209).

MEASUREMENTS

Demographic information, documentation of depression diagnoses, and antidepressant prescribing patterns were evaluated using the Quality of Depression Management and Antidepressant Prescribing rating scale and information found in the Minimum Data Set 2.0.

RESULTS

Of the sample, 59.8% was prescribed antidepressants at the time of the chart review; 205 chart reviews indicated the absence or presence of a depression diagnosis. For those with documented depression diagnoses (n = 126), nearly one-quarter were not prescribed antidepressants. Of 79 chart reviews indicating no depression diagnosis, nearly a third were receiving an antidepressant. Documentation related to changes in dosing, the presence or absence of side effects, or reasons for continuation were suboptimal.

CONCLUSION

Discrepancy between antidepressant prescribing and the presence/absence of depression diagnoses continue to exist for nursing home residents. The quality of antidepressant documentation in nursing home charts continues to be inadequate. Future research should aim to explore possible solutions to these discrepancies and deficiencies in documentation.

Daily rhythms of the sleep-wake cycle

The amount and timing of sleep and sleep architecture (sleep stages) are determined by several factors, important among which are the environment, circadian rhythms and time awake. Separating the roles played by these factors requires specific protocols, including the constant routine and altered sleep-wake schedules. Results from such protocols have led to the discovery of the factors that determine the amounts and distribution of slow wave and rapid eye movement sleep as well as to the development of models to determine the amount and timing of sleep. One successful model postulates two processes. The first is process S, which is due to sleep pressure (and increases with time awake) and is attributed to a 'sleep homeostat'. Process S reverses during slow wave sleep (when it is called process S'). The second is process C, which shows a daily rhythm that is parallel to the rhythm of core temperature. Processes S and C combine approximately additively to determine the times of sleep onset and waking. The model has proved useful in describing normal sleep in adults. Current work aims to identify the detailed nature of processes S and C. The model can also be applied to circumstances when the sleep-wake cycle is different from the norm in some way. These circumstances include: those who are poor sleepers or short sleepers; the role an individual's chronotype (a measure of how the timing of the individual's preferred sleep-wake cycle compares with the average for a population); and changes in the sleep-wake cycle with age, particularly in adolescence and aging, since individuals tend to prefer to go to sleep later during adolescence and earlier in old age. In all circumstances, the evidence that sleep times and architecture are altered and the possible causes of these changes (including altered S, S' and C processes) are examined.

The state of physical environments in Australian residential aged care facilities

OBJECTIVE

This paper examines the quality and safety of the physical environment in Australian residential aged care facilities (RACFs).

DESIGN

Cross-sectional study. One assessor completed environmental audits to identify areas of the physical environment that needed to be addressed to improve the wellbeing and safety of residents.

SETTING

Nine RACFs participating in a broader falls prevention project were audited. RACFs were located in Queensland, Tasmania or Victoria and were chosen by convenience to represent high level, low level, dementia and psychogeriatric care, regional and metropolitan facilities, small and large facilities and a culturally specific facility. Main outcome measure. An environmental audit tool was adapted from a tool designed to foster older person friendly hospital environments. The tool consisted of 147 items. Results. Across all sites 450 items (34%) required action. This ranged from 21 to 44% across sites. The audit domains most commonly requiring action included signage, visual perception and lighting, and outdoor areas.

CONCLUSIONS

Although not representative of all residential facilities in Australia, this audit process has identified common environmental problems across a diverse mix of residential care facilities. Results highlight the need for further investigation into the quality of physical environments, and interventions to improve physical environments in Australian RACFs.

A 12-month follow-up study of "RedUSe": a trial aimed at reducing antipsychotic and benzodiazepine use in nursing homes

BACKGROUND

To assess the long-term impact of the "Reducing Use of Sedatives" (RedUSe) trial on antipsychotic and benzodiazepine prevalence and dosage.

METHODS

RedUSe was a six-month controlled trial conducted in 25 Tasmanian nursing homes in 2008-9 which led to significant reductions in benzodiazepine and antipsychotic use and a doubling of dose reductions of these agents. In a follow-up study, data on psychotropic use was collected from all nursing homes a year after the final RedUSe measure. Mean daily doses for each home were calculated by converting antipsychotic and benzodiazepine doses to chlorpromazine and diazepam equivalents, respectively. To determine the long-term impact of the project, 6-month and initial baseline data were compared to the 18-month follow-up data.

RESULTS

1578 residents were audited for the follow-up measure. In the 18 months since the RedUSe project was instigated, benzodiazepine prevalence fell by 25% in intervention nursing homes. Similarly, the mean daily diazepam equivalence in these homes had fallen by 24%. In contrast, after a significant reduction during the RedUSe trial, antipsychotic prevalence returned to baseline levels in intervention nursing homes, with mean chlorpromazine equivalence remaining relatively constant with time. There was a delayed reduction in benzodiazepine and antipsychotic use in the control homes.

CONCLUSIONS

Both benzodiazepine usage and mean daily diazepam equivalence continued to decline in intervention nursing homes in the year following the RedUSe trial. However, the effect of the RedUSe intervention on antipsychotic prevalence and dosage was not sustained.

The use of medications with anticholinergic properties and risk factors for their use in hospitalised elderly patients

PURPOSE

The aims of the present study were to evaluate the use of drugs with anticholinergic properties in elderly patients and to identify risk factors that increase the patient's chance of being given such medications.

METHODS

The study was performed on a sample of 1636 patients aged ≥65 years hospitalised during the period between 1 January 2008 and 31 December 2009 in three municipal hospitals. To evaluate the factors influencing the use of anticholinergic medications, we compared two groups-users and non-users of such drugs-in terms of sociodemographic and clinical characteristics as well as comorbid conditions. The most important risk factors were identified using the binary logistic regression model.

RESULTS

Hospitalisation led to a significant increase in the prevalence of anticholinergic medication users, when comparing their occurrence at the time of hospital admission and discharge (10.5% and 14.2%, respectively; p < 0.001). A significantly higher total number of prescribed drugs were found in the group of users compared with non-users, at both hospital admission (7.2 ± 3.5 vs 5.7 ± 3.1; p < 0.001) and discharge (8.7 ± 3.1 vs 7.5 ± 2.9; p < 0.001). Immobilisation, urinary incontinence and retention, constipation, gastroduodenal ulcer disease as well as neurologic and psychiatric comorbidities (depression, Parkinson's disease, epilepsy) appeared as the most important risk factors of using anticholinergic medications.

CONCLUSIONS

Physicians should be aware of the greater risk of adverse anticholinergic effects of drugs in certain therapeutic classes in the elderly. In patients with risk factors mentioned previously, special attention should be paid to active identification of anticholinergic effects of medications.

Anxiolytic and hypnotic drug misuse in Thailand: findings from a national household survey

INTRODUCTION AND AIMS

The non-medical use of prescription drugs, such as anxiolytics and hypnotics, has become a growing public health problem in Thailand. The objective of this study was to examine the patterns of non-medical use of these drugs, using data from a nationally representative sample of Thais interviewed in 2007.

DESIGN AND METHODS

A nationwide, multi-stage, household survey of 26 633 respondents aged 12-65 years living in 11 348 households throughout Thailand using a face-to-face structured interview questionnaire was carried out.

RESULTS

In 2007, 1.58% (734 288) and 1.58% (733 318) of Thais indicated that they had misused anxiolytics or hypnotics, respectively, at some time during their lives. Less than 1% had misused these drugs during the 12 months preceding the interview (426 170 or 0.92% for anxiolytics, 372 920 or 0.80% for hypnotics), fewer during the preceding 30 days (234 871 or 0.50% for anxiolytics, 225 638 or 0.48% for hypnotics).The highest prevalence of past 30 day use was in Bangkok, the lowest in Southern Thailand. More women than men, older than younger respondents, and subjects who considered they were in poor physical health or had emotional problems than those who thought otherwise used the drugs during the 30 days before the interviews.

DISCUSSION AND CONCLUSIONS

The prevalence of anxiolytic/hypnotic misuse/abuse appears to be lower than that reported from more developed countries, but a small increase in problems resulting from the use of these substances has a disproportionately large effect on the overstretched resources of a developing country.

Non-pharmacologic management of sleep disturbance in Alzheimer's disease

Sleep and wake in Alzheimer's disease (AD) are often fragmented as manifested by bouts of wakefulness at night and napping during the day. Management of sleep disturbances in AD is important because of their negative impact on both patients and caregivers. Pharmacological treatments, mainly sedative-hypnotics and antipsychotics, are often used but can be associated with significant adverse effects. Non-pharmacological treatments represent a beneficial alternative approach to the management of sleep disturbances in AD since they are associated with fewer adverse effects and their efficacy can be sustained after treatment has been completed. The aim of this article is to review non-pharmacological treatments, such as sleep hygiene, sleep restriction therapy (SRT), cognitive behavioral therapy (CBT), light therapy, and continuous positive airway pressure (CPAP), for the management of sleep/wake disturbances in AD.

An effective approach to decrease antipsychotic and benzodiazepine use in nursing homes: the RedUSe project

BACKGROUND

This study evaluated a multi-faceted, interdisciplinary intervention to reduce the use of benzodiazepines and antipsychotics in nursing homes - the "RedUSe" (Reducing Use of Sedatives) project.

METHODS

The RedUSe project was a controlled trial conducted in 25 nursing homes in Tasmania, with 13 intervention and 12 control homes. A series of pharmacist-led strategies were provided to intervention homes including two medication audit and feedback cycles, educational sessions for staff and an interdisciplinary sedative review. Data on psychotropic drug use at each nursing home were collected utilizing a customized computer program at baseline, 12 and 26 weeks. The RedUSe project was registered as a controlled trial at the Australian New Zealand Clinical Trials Registry, registration number: ACTRN12608000221358.

RESULTS

For each measure, an average of 1591 residents were audited. Over the six-month trial, there was a significant reduction in the percentage of intervention home residents regularly taking benzodiazepines (31.8% to 26.9%, p < 0.005) and antipsychotics (20.3% to 18.6%, p < 0.05), whereas control home psychotropic use did not alter significantly. For residents taking benzodiazepines and antipsychotics at baseline, there were significantly more dose reductions/cessations in intervention homes than in control homes (benzodiazepines: 39.6% vs. 17.6%, p < 0.0001; antipsychotics: 36.9% vs. 20.9%, p < 0.01).

CONCLUSIONS

RedUSe led to a significant reduction in the proportion of residents in nursing homes taking benzodiazepines and antipsychotics, and a significant increase in the number of dose reductions of these agents. Our findings suggest that a multi-faceted program, coordinated through a community pharmacy, can offer an effective approach in reducing psychotropic use in nursing homes.

Using Massage to Reduce Use of Sedative-Hypnotic Drugs With Older Adults

Despite known adverse effects, sedative-hypnotic drugs (SHDs) are widely used in institutional settings serving the elderly. Using a 2 (Intervention, Control) × 3 (Baseline, Intervention, Withdrawal) mixed design with random assignment to the intervention ( n = 15) or control ( n = 13) group, the authors sought to determine if a nonpharmacological sleep intervention (massage at bedtime) could reduce “as-needed” SHD (PRN-SHD) usage. Each phase of this pilot lasted 7 days and PRN-SHD usage was monitored via chart review. Results, indicating a 13% greater reduction in requests for PRN-SHD for the intervention group when it received massage, approached statistical significance for the quadratic planned comparisons ( p = .17) despite limited power (.28) for the observed effect size of .07. While preliminary, results suggest that massage at bedtime may reduce PRN-SHD usage with older adults. Randomized controlled studies with larger samples are needed.

Management of insomnia in elderly patients using eszopiclone

Insomnia is a common sleep complaint in the elderly. The safety and efficacy of eszopiclone, a non-benzodiazepine hypnotic, in elderly patients with chronic insomnia has been established in two 2-week and one 12-week randomized, double-blind, placebo-controlled trials. Eszopiclone 1 mg was effective in reducing sleep latency. Eszopiclone 2 mg was effective in reducing latency to sleep and for increasing sleep maintenance. Eszopiclone doses of 1 mg and 2 mg reduced the number of daytime naps and decreased the duration of naps in elderly patients. Eszopiclone 2 mg improved the quality of life measures for mood, physical health, household activities, medication, leisure activities, and self-report of physical functioning and vitality in the 2-week trials, and vitality and general health in the 12-week trial. The most commonly reported side effects in the elderly included unpleasant taste, dry mouth, dizziness, and somnolence. The concurrent use of drugs that inhibit or induce the cytochrome P450 enzyme CYP3A4 can alter concentrations of eszopiclone and the dose may need to be adjusted. The recommended starting dose of eszopiclone for difficulty falling asleep is 1 mg at bedtime. For elders who complain of difficulty maintaining sleep, eszopiclone should be initiated at 2 mg at bedtime. Overall, eszopiclone is a safe and well-tolerated treatment option for elderly patients with insomnia.

Health, medication use, and agricultural injury: A review

BACKGROUND

Agricultural work in the United States and Canada continues to be one of the most dangerous vocations. Surveillance evidence suggests that older farmers (>60 years of age) are at greater risk of serious injury than their younger counterparts. The purpose of this article was to outline illnesses and medications that may contribute to older farmers' increased risk of agricultural injury and to determine a minimum set of health-related covariates that could be used in farm injury studies.

METHODS

A review of English language literature in Medline, CINAHL, and NIOSH databases was conducted examining disease and medication factors related to farm injury.

RESULTS

Health- and disease-related factors most commonly reported as significantly contributing to agricultural injury included previous injury, hearing problems, depression, arthritis, and sleep deprivation. The use of "any medication" was identified as a significant risk factor for injury in a number of studies. The use of sleep medication was significantly related to injury in two studies.

CONCLUSIONS

Based on the findings, it is recommended that at a minimum, researchers collect information on the prevalence of previous injury, hearing problems, depression, arthritis/muscular-skeletal problems and sleep disturbance as these have been identified as significant risk factors in a number of studies. In addition, where subjects that identify any of these afflictions, further information should be sought on any medications used in their treatment which can add data on disease severity. More research and surveillance activities need to be focused on the older farm worker. This population is critical to the maintenance of the agricultural base in North America and health and safety research initiatives need to address this. By integrating research from the fields of gerontology, occupational health and safety, and injury prevention, innovative interventions could be constructed to assist the aging farmer in the continuation of safe farming.

[Increased benzodiazepine use in elderly women attending urban primary health care centers]

OBJECTIVE

To determine the overall prevalence of the chronic use of benzodiazepines and similar drugs in primary care.

DESIGN

Observational, cross-sectional study.

SETTING

Healthcare centres of the Reus-Altebrat Primary Care Service, Tarragona, Spain.

PARTICIPANTS

Patients older than 15 years, on prolonged treatment with benzodiazepines or similar drugs.

MEASUREMENTS

The variables studied were age, sex, type of healthcare centre (rural or urban), benzodiazepine, or similar drug administered and duration of treatment. RESULTS. There were 6885 patients who were on prolonged benzodiazepine or similar drug treatment, of which 70.9% were female, 73.4% were 65 years or older, and 73% attended an urban centre. The overall prevalence was 6.9%, and was higher among women than men (9.7% and 4%, respectively), and increased with age up to 27.3% among patients of 75 years or more. The stratified results showed that chronic consumption was higher among women 75 years of age or older attached to urban healthcare centres, with a prevalence of 35.7%.

CONCLUSIONS

A high percentage of our population, which includes the most fragile patients, use benzodiazepines or a similar drug in a way that is not consistent with the recommendations of clinical practice guidelines.

Use of antipsychotic medications for the management of delirium: an audit of current practice in the acute care setting

OBJECTIVE

Despite delirium being common in older hospitalized people, little is known about its management. The aims of this study are (1) to describe the pharmacological management of delirium in an acute care setting as a baseline measure prior to the implementation of newly developed Australian guidelines; and (2) to determine what areas of delirium pharmacological management need to be targeted for future practical guideline implementation and quality improvement activities.

METHODS

A medical record audit was conducted using a structured audit form. All patients aged 65 years and over who were admitted to a general medical or orthopaedic unit of the Royal Melbourne Hospital between 1 March 2006 and 28 February 2007 and coded with delirium were included. Data on the use of antipsychotic medications for the management of delirium in relation to best practice recommendations were assessed.

RESULTS

Overall 174 episodes of care were included in the analysis. Antipsychotic medications were used for the management of most patients with severe behavioral and or emotional disturbance associated with delirium. There was variation in the prescribing patterns of antipsychotic agents and the documentation of medication management plans. Less than a quarter of patients prescribed antipsychotic medication were started on a low dose and very few were reviewed on a regular basis.

CONCLUSION

A wide range of practice is seen in the use of antipsychotic agents to manage older patients with severe symptoms associated with delirium. The findings highlight the need to implement evidence-based guideline recommendations with a focus on improving the consistency in the pharmacological management and documentation processes.

Benzodiazepines and injurious falls in community dwelling elders

BACKGROUND

Benzodiazepines are frequently used medications in the elderly, in whom they are associated with an increased risk of falling, with sometimes dire consequences.

OBJECTIVE

To estimate the impact of benzodiazepine-associated injurious falls in a population of elderly persons.

METHOD

A nested case-control study was conducted using data collected during 10 years of follow-up of the French PAQUID (Personnes Agées QUID) community-based cohort. The main outcome measure was the occurrence of an injurious fall, which was defined as a fall resulting in hospitalization, fracture, head trauma or death. Controls (3 : 1) were frequency-matched to cases. Benzodiazepine exposure was the use of benzodiazepines over the previous 2 weeks reported at the follow-up visit preceding the fall.

RESULTS

Benzodiazepine use was significantly associated with the occurrence of injurious falls, with a significant interaction with age. The adjusted odds ratio for injurious falls in subjects exposed to benzodiazepines was 2.2 (95% CI 1.4, 3.4) in subjects aged > or = 80 years and 1.3 (95% CI 0.9, 1.9) in subjects aged <80 years. The population attributable risk for injurious falls in subjects exposed to benzodiazepines was 28.1% (95% CI 16.7, 43.2) for subjects aged > or =80 years. The incidence of injurious falls in subjects aged > or = 80 years exposed to benzodiazepines in the PAQUID cohort was 2.8/100 person-years. Over 9% of these falls were fatal. According to these results and to recent population estimates, benzodiazepine use could be held responsible for almost 20 000 injurious falls in subjects aged > or = 80 years every year in France, and for nearly 1800 deaths.

CONCLUSION

Given the considerable morbidity and mortality associated with benzodiazepine use and the fact that existing good practice guidelines on benzodiazepines have not been effective in preventing their misuse (possibly because they have not been applied), new methods for limiting use of benzodiazepines in the elderly need to be found.

Somnolence effects of antipsychotic medications and the risk of unintentional injury

PURPOSE

This study examined the relationship between antipsychotic medications, categorized by published somnolence effects, and unintentional injury (UI).

METHODS

The study population included patients of 18-64 years of age in a healthcare insurance database with claims from 2001 to 2004 and diagnoses of schizophrenia or affective disorder. A nested case-control design was used with cases defined by an E-code claim (a specified external cause of injury) for selected UIs. For cases, the index date referred to the first injury. For controls, the "control index date" was the date of claim if there was only a single medical claim; for patients with > or =2 claims, one was selected at random as the "control index date." Both groups had a prescription for a first-generation antipsychotic (FGA) or second-generation antipsychotic (SGA) overlapping the index date. Potential somnolence effects were defined as: low (referent)--aripiprazole/ziprasidone; medium--risperidone; high--olanzapine/quetiapine: or any single FGA. Logistic regression models were used to estimate odds ratio (OR) and 95% confidence interval (CI) for UI, adjusted for gender, age, concomitant drug, and psychiatric diagnosis.

RESULTS

Among 648 cases and 5214 controls, high-somnolence SGAs were associated with an OR of 1.41 95%CI (1.03-1.93) for risk of UI, while medium-somnolence SGAs, and FGAs had ORs of 1.17 95%CI (0.83-1.64) and 1.17 95%CI (0.79-1.74), respectively. When quetiapine and olanzapine were disaggregated, ORs were 1.61 95%CI (1.15-2.25) and 1.25 95%CI (0.89-1.74), respectively.

CONCLUSIONS

High-somnolence SGAs may lead to UI among patients. When prescribing antipsychotics, clinicians should consider potential somnolence.

Antipsychotics for delirium

BACKGROUND

Delirium occurs in up to 30% of hospitalised patients and is associated with prolonged hospital stay and increased morbidity and mortality. Recently published reports have suggested that the standard drug for delirium, haloperidol, a typical antipsychotic that may cause adverse extrapyramidal symptoms among patients, may be replaced by atypical antipsychotics such as risperidone, olanzapine or quetiapine, that are as effective as haloperidol in controlling delirium, but that have a lower incidence of extrapyramidal adverse effects.

OBJECTIVES

To compare the efficacy and incidence of adverse effects of haloperidol with risperidone, olanzapine, and quetiapine in the treatment of delirium.

SEARCH STRATEGY

The trials were identified from a search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 7 August 2006 using the search terms:haloperidol or haldol or risperidone or risperdal* or quetiapine or seroquel* or olanzapine or zyprexa* or aminotriazole or sertindole or leponex* or zeldox* or ziprasidone.

SELECTION CRITERIA

Types of studies included unconfounded, randomised trials with concealed allocation of subjects. For inclusion trials had to have assessed patients pre- and post-treatment. Where cross-over studies are included, only data from the first part of the study were examined. Interrupted time series were excluded. Length of trial and number of measurements did not influence the selection of trials for study. Where indicated, individual patient data were requested for further examination.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted data from included trials. Data were pooled where possible, and analysed using appropriate statistical methods. Odds ratios of average differences were calculated. Only 'intention to treat' data were included. Analysis included haloperidol treated patients, compared with placebo.

MAIN RESULTS

Three studies were found that satisfied selection criteria. These studies compared haloperidol with risperidone, olanzapine, and placebo in the management of delirium and in the incidence of adverse drug reactions. Decrease in delirium scores were not significantly different comparing the effect of low dose haloperidol (< 3.0 mg per day) with the atypical antipsychotics olanzapine and risperidone (Odds ratio 0.63 (95% CI 10.29 - 1.38; p = 0.25). Low dose haloperidol did not have a higher incidence of adverse effects than the atypical antipsychotics. High dose haloperidol (> 4.5 mg per day) in one study was associated with an increased incidence of extrapyramidal adverse effects, compared with olanzapine. Low dose haloperidol decreased the severity and duration of delirium in post-operative patients, although not the incidence of delirium, compared to placebo controls in one study. There were no controlled trials comparing quetiapine with haloperidol.

AUTHORS' CONCLUSIONS

There is no evidence that haloperidol in low dosage has different efficacy in comparison with the atypical antipsychotics olanzapine and risperidone in the management of delirium or has a greater frequency of adverse drug effects than these drugs. High dose haloperidol was associated with a greater incidence of side effects, mainly parkinsonism, than the atypical antipsychotics. Low dose haloperidol may be effective in decreasing the degree and duration of delirium in post-operative patients, compared with placebo. These conclusions must be tempered by the observation that they are based on small studies of limited scope, and therefore will require further corroborating evidence before they can be translated into specific recommendation for the treatment of delirium.