Prescribing of psychotropics in the elderly: why is it so often inappropriate?

Appropriateness of the Prescription and Use of Medicines: An Old Concept but More Relevant than Ever

The availability of drugs to treat diseases, control symptoms, or prevent their onset is one of the most important resources for maintaining health [...].

Mental health training programs for community pharmacists, pharmacy staff and students: A systematic review

BACKGROUND

Primary care is often the first point of contact for people living with mental disorders. Community pharmacists, pharmacy staff and students are increasingly being trained to deliver mental health care. However, there is still a gap in the literature exploring the characteristics of all available mental health training programs and their components and their influence on pharmacists, pharmacy staff and students' outcomes.

OBJECTIVES

To summarize the evidence evaluating mental health training programs completed by community pharmacists, pharmacy staff and students. More specifically, to explore the components of mental health training programs and identify those that facilitate significant improvements in outcomes.

METHODS

A systematic review was conducted following the Cochrane handbook and reported according to PRISMA guidelines. A search for published literature was conducted in three databases (PubMed, Scopus, and Web of Science) in July 2021. Eligible studies were included if they described and evaluated the impact of mental health training programs delivered to community pharmacists, pharmacy staff and pharmacy students regardless of design or comparator. The methodological quality of included studies was appraised using both the NIH quality assessment, to evaluate studies with an uncontrolled pre-post design, and the Cochrane EPOC risk of bias assessment, to evaluate studies with a controlled (randomized and non-randomized) study design.

RESULTS

Thirty-three studies were included. Most of the identified mental health training programs contained knowledge-based components and active learning activities. Changes in participants' attitudes, stigma, knowledge, confidence and skills were frequently assessed. An extensive range of self-assessment and observational instruments used to evaluate the impact of the training programs were identified. Positive improvements in participants' attitudes, knowledge and stigma were frequently identified following participation in training programs.

CONCLUSIONS

This systematic review highlights the importance of mental health training programs in increasing pharmacists', pharmacy staff and pharmacy students' skills and confidence to deliver mental health care in community pharmacy. Future research should build upon this basis and further focus on finding the most efficient measures to evaluate these training programs and assess their long-term effectiveness, allowing comparison between programs.

Geographical Variation in Medication Prescriptions: A Multiregional Drug-Utilization Study

Background

Studies have emphasized the importance of geographical factors and general practitioner (GP) characteristics in influencing drug prescriptions.

Objectives

To: (i) ascertain the prevalence rate (PR) of use of drugs in six therapeutic categories used for chronic conditions; (ii) assess how geographical characteristics and GP characteristics may influence drug prescribing.

Methods

This study is part of the EDU.RE.DRUG Project, a national collaborative project founded by Italian Medicine Agency (AIFA). Cross-sectional analyses were undertaken employing the pharmacy-claim databases of four local health units (LHUs) located in two Italian regions: Lombardy and Campania. Six drug categories were evaluated: proton-pump inhibitors; antibiotics; respiratory-system drugs; statins; agents acting on the renin−angiotensin system; psychoanaleptic drugs. The PR was estimated according to drug categories at the LHU level. A linear multivariate regression analysis was undertaken to evaluate the association between the PR and geographical area, age and sex of GPs, number of patients, and percentage of patients aged >65 per GP.

Results

LHUs in Campania showed a PR that was significantly higher than that in Lombardy. Antibiotics showed the highest PR in all the LHUs assessed, ranging from 32.5% in Lecco (Lombardy) to 59.7% in Naples-2 (Campania). Multivariate linear regression analysis confirmed the association of the PR with geographical area for all drug categories. Being located in Campania increased the possibility of receiving a drug prescription from the categories considered, with estimates more marked for antibiotics, proton-pump-inhibitors, and respiratory-system drugs.

Conclusions

This study provides information about the PR of medications used for treating common and costly conditions in Italy and highlighted a significant geographical variation. These insights could help to develop area-specific strategies to optimize prescribing behavior.

The cost of care homes for people with dementia in England: a modelling approach

OBJECTIVES

To examine the cost of care for people with dementia in institutional care settings, to understand the major cost drivers and to highlight opportunities for service development.

METHODS

Data on 277 residents with dementia in 16 UK residential or nursing homes were collected. We estimated care and support costs and fitted models to the data. Sensitivity analyses were also conducted.

RESULTS

Care home residents cost £792 weekly: 95% of the costs accounted for by direct fees. Hospital contacts contributed the largest proportion of the additional costs. Having an established diagnosis of dementia (b = 0.070; p < 0.05) was associated with higher costs. No association was found between cost and needs (b = -0.002; p = 0.818).

CONCLUSION

The absence of an association between cost and needs emphasizes the importance of a more needs-based costing system which could result in clinical and economic advantages. Copyright © 2016 John Wiley & Sons, Ltd.

Systemic model of chronic benzodiazepine use among mature adults

OBJECTIVES

Our goal was to build a systemic model of chronic use among community-dwelling mature benzodiazepine (BZD) users. BZDs are commonly prescribed for symptoms of anxiety and/or insomnia despite their documented side effects over time.

METHOD

We conducted in-depth interviews with 23 mature (50 years and over) users, 14 women and 9 men, as well as 9 general practitioners and 11 pharmacists. We chose the grounded theory approach for our analysis.

RESULTS

Results yielded a systemic model of chronic BZD use, illustrating onset and maintenance of use, and taking into account individual life context, intervening conditions (e.g. family and doctor--patient interactions) and structural factors (medicalization, ageism, influence of the media and pharmaceutical industry, etc.). Based on our findings, we suggest that intervention should go beyond medical issues and extend to the individual's perception of aging in the modern society, as well as attitudes of families and health professionals regarding long-term BZD use. Family members should be involved in the weaning process and adoption of new life habits. General practitioners should be better trained regarding geriatric psychosocial issues and offer alternatives to prescribe psychotropic drugs such as cognitive behavior therapy for insomnia. Also, as a society, we should reconsider the highly medicalized stance we take to compensate for age-related losses. The influential role of the pharmaceutical industry in the process is discussed.

CONCLUSION

We conclude that a predominantly biomedical perspective on human development diminishes patient-centered care within a socially contextualized, individual perspective.

Psychoactive prescribing for older people--what difference does 15 years make?

OBJECTIVE

The objective of the study was to review prescribing of psychoactive medications for older residents of the Tayside region of Scotland.

METHODS

The analysis used community prescribing data in 1995 and 2010 for all older residents in Tayside. For each psychoactive drug class, the name of the most recently prescribed drug and the date prescribed were extracted. The relative risk (RR) and 95% confidence intervals (CI) for patients receiving psychoactive medication in 2010 were compared with those for patients in 1995. Psychoactive prescribing was analyzed by year, age, gender, and deprivation classification. The chi-squared test was used to calculate statistical significance.

RESULTS

Total psychoactive prescribing in people over the age of 65 years has increased comparing 1995 with 2010. Antidepressant [RR = 2.5 (95% CI 2.41-2.59) p < 0.001] and opioid analgesia [RR = 1.21 (1.19-1.24) p < 0.001] prescriptions increased between 1995 and 2010. Hypnotics/anxiolytic [RR = 0.69 (0.66-0.71) p < 0.001] and antipsychotic [RR = 0.83 (0.77-0.88) p < 0.001] prescriptions decreased between 1995 and 2010. An increase in psychoactive prescribing is particularly marked in lower socioeconomic groups. Patients in the least affluent fifth of the population had RR = 1.25 (1.20-1.29) [p < 0.001] of being prescribed one to two psychoactive medications and RR = 1.81 (1.56-2.10) [p < 0.001] of being prescribed three or more psychoactive medications in 2010 compared with those in 1995. The RRs for the most affluent fifth were RR = 1.14 (1.1-1.19) [p < 0.001] and RR = 1.2 (1.01-1.42) [p < 0.001] for one to two, and three or more medications, respectively.

CONCLUSION

Psychoactive medication prescribing has increased comparing 1995 with 2010, with increases disproportionately affecting patients in lower socioeconomic groups. The availability of new psychoactive drugs, safety concerns, and economic factors may explain these increases.

Primary care hypnotic and anxiolytic prescription: Reviewing prescribing practice over 8 years

Introduction:

Over the last few years, hypnotic and anxiolytic medications have had their clinical efficacy questioned in the context of concerns regarding dependence, tolerance alongside other adverse effects. It remains unclear how these concerns have impacted clinical prescribing practice.

Materials and Methods:

This is a study reviewing community-dispensed prescribing data for patients on the East Practice Medical Center list in Arbroath, Scotland, in 2007, 2011 and 2015. Anxiolytic and hypnotic medications were defined in accordance with the British National Formulary chapter 4.1.1 and chapter 4.1.2. All patients receiving a drug within this class in any of the study years were collated and anonymized using primary care prescribing data. The patients’ age, gender, name of the prescribed drug(s), and total number of prescriptions in this class over the year were extracted.

Results:

The proportion of patients prescribed a benzodiazepine medication decreased between 2007 and 2015: 83.8% (n = 109) in 2007, 70.5% (n = 122) in 2011, and 51.7% (n = 138) in 2015 (P = 0.006). The proportion of these patients prescribed a nonbenzodiazepine drug increased between 2007 and 2015: 30% (n = 39) in 2007, 46.2% (n = 80) in 2011, and 52.4% (n = 140) in 2015 (P = 0.001). There was a significant increase in the number of patients prescribed melatonin (P = 0.020).

Discussion:

This study reports a reduction in benzodiazepine prescriptions in primary care alongside increases in nonbenzodiazepine and melatonin prescribing, with an increase in prescribing rates of this drug class overall.

Conclusion:

Changes in this prescribing practice may reflect the medicalization of insomnia, local changes in prescribing practice and alongside national recommendations.

Exploring an increased role for Australian community pharmacy in mental health professional service delivery: evaluation of the literature. J Ment Health 2015;25:550-559. [PMID: 26607639 DOI: 10.3109/09638237.2015.1101418]

BACKGROUND

Australian general practitioners primarily treat mental health problems by prescribing medication dispensed by community pharmacists. Pharmacists therefore have regular interactions with mental health consumers and carers.

AIMS

This narrative review explored the potential role of community pharmacy in mental health services.

METHOD

Medline, CINAHL, ProQuest, Emerald, PsycINFO, Science Direct, PubMed, Web of Knowledge and IPA were utilised. The Cochrane Library as well as grey literature and "lay" search engines such as GoogleScholar were also searched.

RESULTS

Four systematic reviews and ten community pharmacy randomised controlled trials were identified. Various relevant reviews outlining the impact of community pharmacy based disease state or medicines management services were also identified.

CONCLUSION

International studies involving professional service interventions for mental health consumers could be contextualised for the Australian setting. Australian studies of pharmacy professional services for chronic physical health conditions provided further guidance for the expansion of community pharmacy mental health professional services.

Mapping the terrain: A conceptual schema for a mental health medication support service in community pharmacy

OBJECTIVE

Mental health-related problems pose a serious issue for primary care, and community pharmacy could make a significant contribution, but there is a dearth of information.

METHODS

This article reports synthesis of the literature on mental health interventions across a range of pharmacy models, and pharmacy services in contexts beyond mental health. To best inform the design of a community pharmacy medication support intervention for mental health consumers, the literature was reported as a conceptual schema and subsequent recommendations for development, implementation and evaluation of the service. A broad conceptualisation was taken in this review. In addition to mental health and community pharmacy literature, policy/initiatives, organisational culture and change management principles, and evaluative processes were reviewed. Key words were selected and literature reviews undertaken using EMBASE, PubMed, CINAHL and Web of Science.

RESULTS

Recommendations were made around: medication support intervention design, consumer recruitment, implementation in community pharmacy and evaluation. Surprisingly, there is a scarce literature relating to mental health interventions in community pharmacy. Even so, findings from other pharmacy models and broader medicines management for chronic illness can inform development of a medication support service for mental health consumers. Key learnings include the need to expand medicines management beyond adherence with respect to both intervention design and evaluation.

CONCLUSION

The conceptual framework is grounded in the need for programmes to be embedded within pharmacies that are part of the health system as a whole.

[Remote consequences of the long-term uncontrolled use of anxiolytic and hypnotic drugs by elderly patients: cognitive disorders]

OBJECTIVE

Frequents cases (10-30% of the elderly population) of regular long-term use of anxiolytic and hypnotic drugs, in particular, benzodiazepines, without control of the physician is an urgent problem of medicine worldwide. Severe and irreversible cognitive impairment is a frequent and severe consequence of this use. Authors studied cognitive impairment in these cases.

MATERIAL AND METHODS

Patients were enrolled in the study from a psychiatric hospital. The study included 56 women, aged over 50 years, admitted to the hospital with the diagnosis of a mental disorder. Before admission, the patients regularly used benzodiazepines without a prescription for more than 2 months. Later on, anxiolytics were withdrawn during 1-5 days. The patients were studied during 4 weeks in the hospital. To assess the severity and dynamics of their condition, authors used MADRS, HAM-A, MMSE.

RESULTS AND CONCLUSION

Severe cognitive impairment, achieving the level of dementia, was found in 57.2% of the patients, mild or moderate of cognitive impairment was in 32.1% and only 10.7% had normal level of cognitive functioning. After 4 weeks of benzodiazepine withdrawal, the percentage of patients with dementia reduced to 21.4%, the severity of cognitive impairment was estimated as mild or moderate. A number of patients without cognitive impairment increased to 37.5%. The old age of patients was a significant negative predictor of the dynamics. An impact of the high anxiolytic dose was shown on trend level. The duration of a mental disorder and duration of uncontrollable consumption of anxiolytics and hypnotics did not exert an effect on the development and reversibility of cognitive impairment. A combination of anxiolytics with alcohol increased the risk of dementia and did not reverse the cognitive pathology.

Socioeconomic inequalities in access to specialized psychotropic prescribing among older Swedes: a register-based study

Background: Mental disorders among older adults are mainly treated with psychotropic drugs. Few of these drugs are, however, prescribed by specialized geriatricians or psychiatrists, but rather from general practitioners (GPs). Socioeconomic inequalities in access to specialist prescribing have been found in younger age groups. Hence, we aimed to investigate whether there are socioeconomic differences in access to geriatrician and psychiatrist prescribing of psychotropic drugs among older adults. Methods: By record-linkage of The Swedish Prescribed Drug Register and The Swedish Education Register, we obtained information for persons aged 75–89 years who had filled a prescription for psychotropic drugs (antipsychotics, anxiolytics, hypnotic/sedatives or antidepressants) with information on prescriber specialty from July to October 2005 (n = 221 579). Multinomial regression analysis was used to investigate whether education was associated with geriatrician and psychiatrist prescribing of psychotropic drugs. Results: The vast majority of the psychotropic drugs were prescribed by ‘GPs and other specialists’ (∼95% GPs). Older adults with higher educational level were more likely to be prescribed psychotropic drugs from psychiatrists and geriatricians. However, after adjustment for place of residence, the association between patient’s education and prescription by a geriatrician disappeared, whereas the association with seeing a psychiatrist was only attenuated. Conclusion: Access to specialized prescribing of psychotropics is unequally distributed between socioeconomic groups of older adults in Sweden. This finding was partially confounded by place of residence for geriatrician but not for psychiatrist prescribing. Further research should examine if inequalities in specialized psychotropic prescribing translate into worse outcomes for socioeconomically deprived and non-metropolitan-living older individuals.

Inappropriate use of psychotropic drugs in older individuals: implications for practice

Frailty at old age and institutionalization in nursing homes are often associated with multiple chronic diseases (multimorbidity) requiring multiple medications (polypharmacy). Among these chronic conditions, mental health problems (e.g., dementia, depression and insomnia) are common. Psychotropic drugs are frequently used as a treatment approach for these conditions, and the prevalence of their use is high among community-dwelling older adults, but even higher in nursing homes. Furthermore, within the problem of polypharmacy and inappropriate prescribing, psychotropic drugs (defined in this article as antipsychotics, benzodiazepines and antidepressants) constitute a significant proportion. The use of psychotropics in older adults remains controversial given the risk of adverse effects, in contrast to the limited effectiveness. Guidelines advise a thorough risk–benefit analysis before the initiation of psychotropics, in addition to time-limited use and discontinuation. In the future, serious efforts should be undertaken to tackle the burden of inappropriate psychotropic prescribing in older adults by incorporating a multidisciplinary approach and by offering credible alternatives.

Drug use in patients with dementia: a register-based study in the health region of Girona (Catalonia/Spain)

PURPOSE

To describe the pattern of drug consumption among patients with dementia in a geographically defined general population in Catalonia (Spain), and to determine its association with age, gender, type of dementia and severity indicators.

METHODS

Cross-sectional study that included 1,894 cases of dementia registered by the Registry of Dementias of Girona from 2007 to 2009. Prescribed drugs were categorized according to the Anatomical Therapeutic Chemical (ATC) classification. A descriptive analysis of drug consumption was stratified according to age, gender, dementia subtypes and dementia severity. Binary logistic regression models were adjusted to detect the association of these variables with drug consumption according to the ATC groups.

RESULTS

The most commonly prescribed drugs were for the central nervous system (CNS) (96.4 %), cardiovascular system (79.4 %) and digestive and metabolic system categories (77.7 %). No significant differences were found between the use of nervous system drugs and age, gender, dementia subtypes or dementia severity. The use of alimentary tract and metabolism related drugs, as well as cardiovascular and blood system drugs, were positively correlated with age and secondary dementia. The prevalence of use of cardiovascular and musculoskeletal drugs was higher in women than in men (OR: 1.34; OR: 1.26 respectively). A negative association was found between the severity of dementia and the use of musculoskeletal drugs (OR: 0.71), while its use was significantly higher in the youngest patients (OR: 1.71).

CONCLUSIONS

Almost all patients with dementia received a CNS drug, being at risk of inappropriate treatment. Treatment for comorbidities in patients with dementia should not be withheld on the basis of age or dementia severity, but rather on the benefit/risk ratio of its prescription. Further studies are needed to evaluate potentially inappropriate drug use and possible untreated conditions in this population.

A comparison between acupuncture versus zolpidem in the treatment of primary insomnia

BACKGROUND

To determine the relative efficacy of acupuncture and zolpidem in the treatment of primary insomnia, we administered a sleep quality scale to thirty-three patients with primary insomnia randomly chosen to receive one of the two therapies at a psychosomatic clinic.

METHODS

A study in the psychosomatic clinic at a teaching hospital in southern Taiwan from November 2007 to November 2008. The 19 patients in acupuncture group underwent one acupuncture session a week. The 14 patients in the control group took zolpidem 1# (10mg) every night. Members of both groups returned to our clinic once a week for four weeks. The main outcome measure was the Pittsburgh Sleep Quality Index (PSQI).

RESULTS

Both groups were found to have improved significantly. Using generalized estimating equation analysis to test the variance with group and time as factors, we found both groups improved over time at a similar rate (p=0.79). In regression analysis, setting the fourth total PSQI score to zero, the baseline PSQI score was 4.13 (p<0.001), the second score 1.32 (p=0.005), and the third 1.49 (p=0.03); men had a higher PSQI score 1.56 than women (p=0.02); the increasing age of one year would have lower PSQI score 0.08 (p<0.001) and increasing educational level of one year which would decrease PSQI score 0.25 (p=0.007).

CONCLUSIONS

Acupuncture might be used as an alternative strategy compared to zolpidem for the treatment of primary insomnia.

Drugs for insomnia

INTRODUCTION

Sleep is a vital neurochemical process involving sleep-promoting and arousal centers in the brain. Insomnia is a pervasive disorder characterized by difficulties in initiating or maintaining or non-refreshing (poor quality) sleep and clinically significant daytime distress. Insomnia is more prevalent in women and old age and puts sufferers at significant physical and mental health risks. This review summarizes published data on the current and emerging insomnia drug classes, rationale for development and associated risks/benefits. (Summary of Product Characteristics and Medline search on "hypnotic" or specific drug names and "Insomnia").

AREAS COVERED

GABA(A) receptor modulators facilitate sleep onset and some improve maintenance but increase risk of dependence, memory, cognitive and psychomotor impairments, falls, accidents and mortality. Melatonin receptor agonists improve quality of sleep and/or sleep onset but response may develop over several days. They have more benign safety profiles and are indicated for milder insomnia, longer usage and (prolonged release melatonin) older patients. Histamine H-1 receptor antagonists improve sleep maintenance but their effects on cognition, memory and falls remain to be demonstrated. Late-stage pipeline orexin OX1/OX2 and serotonin 5HT2A receptor antagonists may hold the potential to address several unmet needs in insomnia pharmacotherapy but safety issues cast some doubts over their future.

EXPERT OPINION

Current and new insomnia drugs in the pipeline target different sleep regulating mechanisms and symptoms and have different tolerability profiles. Drug selection would ideally be based on improvement in the quality of patients' sleep, overall quality of life and functional status weighed against risk to the individual and public health.

"Gender-specific drug prescription in Germany" results from prescriptions analyses

There are still considerable differences in the medication supply for men and women. While the prescription volumes for both men and women have, for some time, been similar or have even risen for the men, there are still characteristic differences between the sexes when it comes to the prescription of certain indication groups. Women are still prescribed clearly more drugs in the field of psychotropic medication, especially antidepressants, hypnotic drugs, and tranquilisers. As the American Beers criteria for quite some time now and, more recently, the German PRISCUS list have shown, the effects of such drugs are potentially dangerous, particularly for older women. The known adverse effects are, apart from dependence problems, restricted cognitive capacities, insecure or instable walking, and badly healing wounds from falling accidents that are followed by patient's nursing care dependency. In secondary prophylaxis after acute myocardial infarction, the characteristic prescription features of the various medicinal products that are used for both men and women (such as platelet aggregation inhibitors, beta-receptor blockers, ACE-inhibitors, statins) have become similar; women's still higher mortality risk appears to go back to the fact that too much time is spent before proper hospital treatment commences. In general, more attention should be paid to the right medication, the right length of treatment, and the right dosage of the medication prescribed to women; the evidence concerning women's supply of medicinal products should also be improved.

Potentially inappropriate prescribing in elderly: assessing doctor knowledge, confidence and barriers

INTRODUCTION

Inappropriate medication prescribing by doctors is an important preventable cause of morbidity and mortality in the elderly. This study investigates doctor knowledge about potentially inappropriate prescribing (PIP) in elderly, their confidence in prescribing for the elderly and explores perceived barriers.

METHODS

Family and Internal Medicine resident and attending doctors at three teaching hospitals were asked to complete a survey. Six clinical vignettes based on the 2003 Beers criteria were used to evaluate doctor knowledge about medications to avoid in the elderly. Confidence in prescribing for the elderly and perceived barriers to appropriate prescribing in elderly was assessed using a 5-point Likert scale.

RESULTS

Eighty-nine doctors completed the survey, for a response rate of 45%. Forty-four per cent of surveyed doctors estimated that over 25% of their practice consisted of patients 65 years or older. When knowledge of PIP was assessed via vignettes, the mean correct response was 3.9 (SD: 1.1, min = 1, max = 6). Only 14% of those doctors scoring ≤4 vignettes correctly had used the Beers criteria for prescribing; 31% of the doctors answering ≥5 vignettes correctly had used the Beers criteria (P = 0.08). Overall, 75% of doctors felt confident about their prescribing irrespective of their knowledge scores. Seventy per cent of surveyed doctors cited at least seven different barriers to appropriate prescribing in elderly.

CONCLUSIONS

Many primary care doctors possess a poor knowledge of PIP and are unaware of prescribing guidelines such as the Beers criteria. Our survey indicates that doctor usage of the Beers criteria might correlate with improved judgement in prescribing for the elderly. Most doctors report multiple barriers to appropriate prescribing in the elderly. Lack of formal education about prescribing guidelines was the only barrier that correlated with the doctors' level of training.

A retrospective study of drug-related problems in Australian aged care homes: medication reviews involving pharmacists and general practitioners

BACKGROUND

Drug-related problems (DRPs) in Australian aged care homes have been studied previously. However, little is known about the acceptance and implementation of pharmacists' recommendations by general practitioners (GPs) to resolve DRPs.

OBJECTIVES

The primary objective of this study was to investigate the number and nature of DRPs identified by accredited clinical pharmacists. The secondary objective was to study the GP acceptance and implementation of pharmacist recommendations to resolve DRPs.

METHODS

This was a retrospective study of 500 randomly selected, de-identified medication reviews performed by 10 accredited clinical pharmacists over 6 months across 62 aged care homes. The DRPs identified by pharmacists were subsequently classified by the drugs involved, types of problem (indication, effectiveness and safety) and medical diagnoses of the patient. GP written feedback on the medication review reports determined implementation of pharmacists' recommendations to resolve the DRPs.

RESULTS

A total of 1433 DRPs were identified in 480 of the 500 residents. Potential DRPs were frequently classified as risk of adverse drug reactions, need for additional monitoring and inappropriate choice of a drug. Alimentary, cardiovascular, central nervous system and respiratory drugs were most frequently implicated, accounting for more than 75% of the DRPs. GPs' acceptance and implementation of pharmacists recommendations were 72.5% (95% CI; 70.2, 74.8) and 58.1% (95% CI; 55.5, 60.6), respectively.

CONCLUSIONS

Over 96% of the residents had potential DRPs identified by pharmacists. GP acceptance of pharmacists' recommendations was independent of the drug category, but not independent of the disease category.

Psychotropic drug use among older people in general practice: discrepancies between opinion and practice

BACKGROUND

The use of psychotropic drugs has increased over recent years in France. GPs are the first prescribers, especially for older patients.

AIM

To analyse discrepancies between GPs' opinions and practice when prescribing psychotropic drugs to older patients.

SETTING

Postal surveys sent to GPs all over mainland France.

DESIGN OF STUDY

Cross-sectional postal study.

METHOD

A questionnaire collected data on characteristics of GPs' practices, their opinions about psychotropic drug consumption in older people, and a full description of their last older patient receiving a psychotropic drug and seen last by the GP on that particular day.

RESULTS

A total of 350 participating GPs saw 2498 patients aged > or =65 years. Among these patients, the prevalence of psychotropic use was 32.1% (803/2498) for anxiolytics/hypnotics, and 17.5% for antidepressants (438/2498). A total of 91% of GPs agreed that it was possible to reduce or stop psychotropic drugs for these patients. Characteristics of 339 patients taking psychotropic drug were reported: 85.8% (291/339) received at least one anxiolytic/hypnotic and 56.9% (193/339) received at least one antidepressant; there were prescribed for more than 1 year in 68.4% (199/291) and 43.5% (84/193) of the cases respectively. GPs stated that it was possible to reduce or stop anxiolytic/hypnotic drugs for only 27% (79/291) of these patients. Barriers to doing this were patients' refusal (79%), and the absence of any local offer of psychotherapy (73%) or alternative therapy (70%).

CONCLUSION

A mismatch exists between GPs' intent (91%) and practice (27%) regarding reduction of psychotropic prescription in individuals aged > or =65 years. The barriers encountered should be examined further to help physicians improve management of psychotropic prescription.

The prevalence of benzodiazepine dependence among community-dwelling older adult users in Quebec according to typical and atypical criteria

BACKGROUND

Use of benzodiazepines, common among older people, may lead to substance dependence. DSM-IV-TR criteria for this iatrogenic problem may apply poorly to older persons following a physician-prescribed regimen. This study, first of its kind, aimed to determine the prevalence rate of benzodiazepine dependence in older persons according to DSM-IV-TR and other atypical criteria.

METHODS

Descriptive study based on face-to-face interviews conducted in the homes of 2,785 persons aged 65 years or older who were randomly selected from across the province of Quebec, Canada.

RESULTS

Use of benzodiazepines was reported by 25.4% of respondents. Among them, 9.5% met DSM-IV-TR criteria for substance dependence. However, 43% of users reported being dependent, and one third agreed that it would be a good thing to stop taking benzodiazepines.

INTERPRETATION

Benzodiazepine substance dependence is established at one tenth of community-dwelling older persons taking these medications, although a much larger proportion self-labels as dependent.

Potential interactions of central nervous system drugs used in the elderly population

OBJECTIVE: To describe the use of CNS drugs and to identify the most frequently observed potential drug interactions in the elderly living in Southern Brazil. METHODS: A population-based, transversal and observational study was carried out during 2006-2007. Four hundred and eighty elderly individuals of both genders were randomly recruited and interviewed. A validated pharmacotherapeutic questionnaire and the Micromedex® Healthcare Series were utilized to analyze potential drug interactions. A severity rating scale employing the categories of "mild", "moderate" and "severe" was used to describe the interactions. RESULTS: A population of elderly living in Southern Brazil was interviewed and 98 reported using CNS drugs, 74.5% female and 25.5% male. Out of these patients, 32.0% reported severe or moderate pharmacological interactions related to the use of other drugs. Alprazolam and imipramine were reported to potentially interact with tobacco. Twenty potential moderate drug/ethanol interactions were found. The potential drug/caffeine interactions were classified as mild on the severity scale. CONCLUSION: Elderly being prescribed drugs that act on the CNS should be closely monitored, and furthermore, should be warned against potential drug-drug, drug-ethanol, and drug-tobacco interactions.

A comparison of benzodiazepine and related drug use in Nova Scotia and Australia

OBJECTIVE

Benzodiazepines can be a problem if used for long periods, or in at-risk populations, such as the elderly. We compared the use of benzodiazepine and related prescription medicines in Nova Scotia and Australia.

METHODS

The Nova Scotia Pharmacare Program and the Pharmaceutical Benefits Scheme in Australia were used to obtain dispensing data in comparable populations for all publicly subsidized benzodiazepines and related compounds. Usage was compared from 2000 to 2003, using the World Health Organization anatomical therapeutic chemical and defined daily dosage (DDD) system. We also determined differences in the types of benzodiazepines prescribed.

RESULTS

The use of benzodiazepines increased at a steady but comparable rate in both areas. However, the use of benzodiazepines in Nova Scotia was more than double that of Australia in 2000 (123 and 48 DDD/1000 beneficiaries per day, respectively) through 2003 (138 and 57 DDD/1000 beneficiaries per day, respectively). Eight different benzodiazepines made up 90% of the drug use in Nova Scotia by contrast to only 4 different benzodiazepines in Australia.

CONCLUSIONS

Large differences exist between the type and rate of benzodiazepine prescribing in Nova Scotia and Australia, with Nova Scotia reporting more than twice as much use. Benzodiazepine use in both jurisdictions is increasing. The Canadian findings are especially concerning as benzodiazepine use in the Atlantic provinces has been reported to be less than other provinces. The variations between the 2 jurisdictions may be due to factors such as fewer benzodiazepines available in Australia, differences in prescriber, patient attitudes and behaviours, or different initiatives to influence benzodiazepine use.

Healthcare outcomes associated with beers' criteria: a systematic review

OBJECTIVE

To examine healthcare outcomes associated with Beers' criteria of inappropriate medication use based on a literature review.

DATA SOURCES

A search of MEDLINE, International Pharmaceutical Abstracts, and Cumulative Index to Nursing and Allied Health Literature was conducted to identify articles published from October 1991 to October 2006. The following key words were used: Beers, inappropriate, medication, drug, use, prescribing, and elderly. A manual search was also conducted using the references listed in the articles identified through the database search.

STUDY SELECTION AND DATA EXTRACTION

Studies that examined the impact or outcomes of Beers' criteria of inappropriate medication use (1991, 1997, and 2003 critera) were selected. Each article was examined for study setting, data source, study sample, study design, criteria, analysis and covariates, type of healthcare outcome, and study findings. Of 235 articles retrieved, 18 presented studies that examined healthcare outcomes associated with inappropriate medication use based on Beers' criteria. Specifically, setting-specific evidence as well as overall evidence was examined from the selected studies. The review considered evidence of association if more than 50% of the findings were statistically significant.

DATA SYNTHESIS

Most of the 18 studies evaluated were retrospective cohort studies involving patients 65 years of age or older from diverse healthcare settings. In community settings, there was no evidence of association with respect to mortality and other healthcare use, and evidence regarding quality of life and costs was inconclusive. However, inappropriate medication use was associated with hospitalization measures in community elderly. In nursing homes, there was no evidence of association with mortality and the association with hospitalization measures was inconclusive. In hospitals, there was inconclusive evidence to make any generalizations. Across healthcare settings, inappropriate medication use was associated with adverse drug reactions and costs but not with other outcome measures.

CONCLUSIONS

There is evidence that Beers' criteria of inappropriate medication use is associated with adverse healthcare impact in the community-dwelling elderly. With increasing use of Beers' criteria as quality-of-care measures, there is a need to strengthen the predictive validity of these criteria in all healthcare settings.

Psychotropics use in the Spanish elderly: predictors and evolution between years 1993 and 2003

PURPOSE

This study mainly aimed at describing the prevalence of psychotropic medication consumption in the Spanish elderly population between the years 1993 and 2003.

METHODS

Descriptive, cross-sectional study covering the Spanish population aged 65 years and over, using data drawn from the 1993 and 2003 Spanish National Health Surveys (ENSS). A total of 9570 interviews were analysed (3436 from 1993 and 6134 from 2003). The independent variables were sociodemographic and health-related, and the dependent variable was total consumption of psychotropic medication. Using logistic multivariate regression models, we have analysed the temporal evolution of psychotropic medication consumption between 1993 and 2003.

RESULTS

The prevalence of consumption was significantly higher in women (6.7% from 1993 and 26.4 % from 2003) versus men (2.4% from 1993 and 10.6% from 2003) (p < 0.001). Multivariate analysis, highlighted the association between increased psychoactive drug intake and sex, nervous, depressive, sleep disorders and negative perception of health, displayed a strong association with consumption of psychoactive drugs across the 2 years.

CONCLUSIONS

In Spain, the prevalence of psychoactive drug consumption is higher among elderly women than men, and increases with negative perception of health. The prevalence of consumption was significantly higher in the year 2003.

Factors influencing psychotropic prescription by non-psychiatrist physicians in a nursing home for the elderly in Brazil

CONTEXT AND OBJECTIVE

Although psychotropics are one of the classes of medications most prescribed in nursing homes for the elderly, studies examining prescribing patterns are limited in both number and scope. The present study was undertaken to investigate factors associated with general psychotropic use in a nursing home in Brazil.

DESIGN AND SETTING

Retrospective observational study at the Nursing Home for the Elderly, Institute of Biosciences, Universidade Estadual Paulista.

METHODS

Information on prescriptions was retrieved from the medical records of 108 elderly residents in a nursing home. Sixty-five of these patients, with mean age 74.5 years (+/-standard deviation 9.4 years), who were taking medications on a regular basis, comprised the sample. The effects of demographic and clinical variables on the psychotropic prescription pattern were examined.

RESULTS

Females were more likely to receive psychotropics (p = 0.038). Individuals on medicines for cardiovascular diseases received psychotropics less frequently (p = 0.001). The number of prescribed psychotropics correlated negatively with both age (p = 0.009) and number of non-psychotropic drugs (p = 0.009).

CONCLUSIONS

Although preliminary, the present results indicated that cardiovascular disease was the clinical variable that most influenced psychotropic prescription. Physicians' overconcern regarding drug interactions might at least partially explain this result. Further investigations involving larger sample sizes from different regions are warranted to confirm these findings.

Neugebrauch von Benzodiazepinen und das Risiko einer proximalen Femurfraktur

Benzodiazepines appear to increase the incidence of hip fractures. Their role as a time-dependent risk factor remains unclear. We therefore conducted a case-crossover study to determine whether the new use of benzodiazepines is associated with a rise in hip fractures. We analysed 49 months of the statutory health insurance Gmünder Ersatzkasse (GEK) and enrolled all first hip fractures. The index date was the day of hospital admission. Exposure to new use of benzodiazepines was compared within the five periods preceding the index date. Out of 1630 subjects, 223 (13.7%) had at least one prescription of benzodiazepines in the preceding 150 days before the index date, 74 (4.5%) of them as a first prescription. The average age of the population was 79.8 years (SD: 7.7). Odds ratio (OR) of hip fracture was highest during the initial 5 days of new use (OR: 3.43; 95% CI 1.15-10.20) and then declined to a non-significant OR of 1.59 (95% CI 0.96-2.63) after 30 days. In conclusion, the start of a new benzodiazepine is associated with an increased risk of hip fractures. However, the population attributable risk (PAR) and, therefore, the percentage of preventable events is small (PAR: 0.55%; 95% CI 0.05-1.06%).

Mental health for older adults and benzodiazpine use

Benzodiazepine (BZD) drug use among community-dwelling seniors is a significant health issue. Although long-term use of BZDs by seniors is a recognized problem, little is known about the mental health of the consumers. Better knowledge of their mental health would help nurses in identifying the psychological needs of this population. The goals of this longitudinal study1 (n = 138) were to describe the mental health status of long-term users of BZDs and to compare it with the mental health of seniors who have either begun or stopped consuming BZDs over a 1-year period (from Phase 1 to Phase 2). Results showed that one third of long-term users of BZDs do not present any mental health problem. Furthermore, no differences were observed between the mental health statuses of new users of BZDs, individuals who stopped using BZDs, and long-term users of BZDs. In conclusion, at least one third of long-term users of BZDs should stop using these drugs, and nurses should play a leading role in helping these seniors withdraw from BZD consumption.

Community pharmacy services to optimise the use of medications for mental illness: a systematic review

The objective of this systematic review was to evaluate the impact of pharmacist delivered community-based services to optimise the use of medications for mental illness. Twenty-two controlled (randomised and non-randomised) studies of pharmacists' interventions in community and residential aged care settings identified in international scientific literature were included for review. Papers were assessed for study design, service recipient, country of origin, intervention type, number of participating pharmacists, methodological quality and outcome measurement. Three studies showed that pharmacists' medication counselling and treatment monitoring can improve adherence to antidepressant medications among those commencing treatment when calculated using an intention-to-treat analysis. Four trials demonstrated that pharmacist conducted medication reviews may reduce the number of potentially inappropriate medications prescribed to those at high risk of medication misadventure. The results of this review provide some evidence that pharmacists can contribute to optimising the use of medications for mental illness in the community setting. However, more well designed studies are needed to assess the impact of pharmacists as members of community mental health teams and as providers of comprehensive medicines information to people with schizophrenia and bipolar disorder

Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits

OBJECTIVES

To quantify and compare potential benefits (subjective reports of sleep variables) and risks (adverse events and morning-after psychomotor impairment) of short term treatment with sedative hypnotics in older people with insomnia.

DATA SOURCES

Medline, Embase, the Cochrane clinical trials database, PubMed, and PsychLit, 1966 to 2003; bibliographies of published reviews and meta-analyses; manufacturers of newer sedative hypnotics (zaleplon, zolpidem, zopiclone) regarding unpublished studies.

SELECTION CRITERIA

Randomised controlled trials of any pharmacological treatment for insomnia for at least five consecutive nights in people aged 60 or over with insomnia and otherwise free of psychiatric or psychological disorders.

RESULTS

24 studies (involving 2417 participants) with extractable data met inclusion and exclusion criteria. Sleep quality improved (effect size 0.14, P < 0.05), total sleep time increased (mean 25.2 minutes, P < 0.001), and the number of night time awakenings decreased (0.63, P < 0.001) with sedative use compared with placebo. Adverse events were more common with sedatives than with placebo: adverse cognitive events were 4.78 times more common (95% confidence interval 1.47 to 15.47, P < 0.01); adverse psychomotor events were 2.61 times more common (1.12 to 6.09, P > 0.05), and reports of daytime fatigue were 3.82 times more common (1.88 to 7.80, P < 0.001) in people using any sedative compared with placebo.

CONCLUSIONS

Improvements in sleep with sedative use are statistically significant, but the magnitude of effect is small. The increased risk of adverse events is statistically significant and potentially clinically relevant in older people at risk of falls and cognitive impairment. In people over 60, the benefits of these drugs may not justify the increased risk, particularly if the patient has additional risk factors for cognitive or psychomotor adverse events.

Drug related falls: a study in the French Pharmacovigilance database

OBJECTIVE

To investigate the risk of falls associated with drugs among the French population using data reported to the French spontaneous reporting system and recorded in the French Pharmacovigilance database.

METHODS

All cases including a fall were searched in the French Pharmacovigilance database between 1995 and 1999. Drugs involved and characteristics of patients were investigated. In a second step, we estimated the risk associated with psychotropic and cardiovascular drugs in a case/non case comparison, where cases were reports including a fall and non cases all other reports. This risk was estimated by calculation of crude and age and gender adjusted reporting odds ratios (ROR).

RESULTS

During this period, 328 reports including a fall were reported (0.4% of the database). Patients were female in 70%. Mean age was 76 +/- 18 years. Comparisons between cases and non cases showed that cases were more likely to be women (OR: 1.9; 95% confidence interval (CI) [1.5-2.4]) and older. After adjustment on age and gender, falls remained significantly associated with exposure to benzodiazepines (4.7 [3.7-5.9]), imipraminic antidepressants (3.6 [2.5-5.1]), serotonin reuptake inhibitor (SRI) antidepressants (2.2 [1.5-3.1]) or nitrates (1.9 [1.2-2.8]).

CONCLUSION

This study confirms that taking psychotropic drugs strongly increases the risk of falls. The role of cardiovascular drugs (except nitrates) remains not significant when confounding factors are taken into account. According to the very high prevalence of psychotropic drug use in the French elderly, further study are needed to investigate the relative effect of some drugs on falls, like for example SRIs or short acting benzodiazepines.

Mental disorders associated with benzodiazepine use among older primary care attenders--a regional survey

BACKGROUND

Benzodiazepines (BDZs) are among the most commonly prescribed drugs in the elderly and their use is often too prolonged according to current international guidelines.

METHODS

We investigated the pattern of use of BDZs among 65- to 84-year-old attenders at 40 Italian primary care practices who answered positively in a questionnaire on the use of anxiolytic/hypnotic drugs and successfully completed the PRIME-MD questionnaire. The survey lasted 6 months, from February to July 2001.

RESULTS

Of the 1,156 subjects who completed the PRIME-MD, 748 subjects were positive for at least one psychiatric diagnosis. A depressive disorder was present in 36.5% of all PRIME-MD completers and in about one-third of cases represented by major depression, whereas anxiety disorders, somatoform disorders and alcohol abuse accounted for 18.2%, 8.1% and 1.7% of all PRIME-MD completers, respectively. Most patients were first prescribed BDZs by their General Practitioners (GPs) for each diagnostic group. However, patients with pure anxiety started BDZ treatment during hospitalisation more often (19.7%) than patients with depressive disorders (13.7 %). Moreover, patients with comorbid anxiety and depressive disorders (CADD) were most likely to receive their first BDZ prescription from a psychiatrist (15.7 %). Sleep disturbances were present in at least 50% of cases (and up to 86 %) in each diagnostic group. About 75% of prescriptions concerned anxiolytic BDZ or medium/long-acting BDZ. Most patients with anxiety, CADD and depression used night-time BDZ (65.2%, 56.9 % and 60.5%, respectively). The prevalence of chronic use of BDZs was equally high in all categories of psychiatric disorder (about 90 % for each), showing that the vast majority of patients, irrespective of the diagnosis, had been using BDZs for years.

CONCLUSIONS

BDZs are widely prescribed for elderly people by their GPs, often for a considerable length of time. The evidence that many BDZ consumers suffer from a depressive or an anxiety disorder, or both, could be a starting point for encouraging a rational prescription in accordance with international guidelines.

Potentially inappropriate prescriptions for older patients in long-term care

Background

Inappropriate medication use is a major healthcare issue for the elderly population. This study explored the prevalence of potentially inappropriate prescriptions (PIPs) in long-term care in metropolitan Quebec.

Methods

A cross sectional chart review of 2,633 long-term care older patients of the Quebec City area was performed. An explicit criteria list for PIPs was developed based on the literature and validated by a modified Delphi method. Medication orders were reviewed to describe prescribing patterns and to determine the prevalence of PIPs. A multivariate analysis was performed to identify predictors of PIPs.

Results

Almost all residents (94.0%) were receiving one or more prescribed medication; on average patients had 4.8 prescribed medications. A majority (54.7%) of treated patients had a potentially inappropriate prescription (PIP). Most common PIPs were drug interactions (33.9% of treated patients), followed by potentially inappropriate duration (23.6%), potentially inappropriate medication (14.7%) and potentially inappropriate dosage (9.6%). PIPs were most frequent for medications of the central nervous system (10.8% of prescribed medication). The likelihood of PIP increased significantly as the number of drugs prescribed increased (odds ratio [OR]: 1.38, 95% confidence interval [CI]: 1.33 – 1.43) and with the length of stay (OR: 1.78, CI: 1.43 – 2.20). On the other hand, the risk of receiving a PIP decreased with age.

Conclusion

Potentially inappropriate prescribing is a serious problem in the highly medicated long-term care population in metropolitan Quebec. Use of explicit criteria lists may help identify the most critical issues and prioritize interventions to improve quality of care and patient safety.

Aging alters dendritic morphology, input resistance, and inhibitory signaling in dentate granule cells of the rhesus monkey

The neural substrates of age-related hippocampal dysfunction in primates are poorly understood. This issue was addressed with combined intracellular biocytin filling and whole-cell patch clamp recordings of intrinsic membrane properties and inhibitory postsynaptic currents (IPSCs) in dentate granule cells in in vitro slices prepared from behaviorally characterized young (<11 years old) and aged (>24 years old) rhesus monkeys. Six of nine aged monkeys were significantly impaired in performance on the hippocampally mediated delayed nonmatch to sample (DNMS) task at a 2-minute delay. Morphometric analyses showed that cells from aged monkeys had significantly reduced vertical dendritic extents and distal dendritic branching but increased proximal dendritic branching. Intrinsic membrane and action potential properties did not differ between cells from young and aged monkeys with the exception of a small but significant increase in input resistance with age. The frequency, amplitude, and rise time of gamma-aminobutyric acid (GABA)(A) receptor-mediated miniature IPSCs were not significantly different in cells from young vs. aged monkeys. However, the miniature IPSC decay time constant and the benzodiazepine potentiation of this decay time constant were both significantly increased in cells from aged monkeys. These differences in the properties of dentate granule cells correlated positively with age but not specifically with impairment on the DNMS 2-minute delay task. Nevertheless, these changes in dendritic morphology, input resistance, and inhibitory signaling properties may be part of a constellation of subtle functional changes contributing to age-associated cognitive impairment.

Treatment and prevention of postherpetic neuralgia

There have been 4 recent major advances in the treatment of postherpetic neuralgia (PHN) that are based on the results of randomized, controlled trials. These advances are the demonstrations that gabapentin, the lidocaine patch 5%, and opioid analgesics are efficacious in patients with PHN, and the report that nortriptyline and amitriptyline provide equivalent analgesic benefits for patients with PHN but that nortriptyline is better tolerated. The results of these clinical trials are briefly reviewed, and their implications for the treatment of patients with PHN are discussed. Despite these treatment advances, many patients remain refractory to current therapy, and the prevention of PHN has therefore become an important focus of current research. Research on administration of the varicella-zoster vaccine to prevent herpes zoster and on treatment of patients who have herpes zoster with combined antiviral and analgesic therapy to prevent PHN is discussed.