Risk of Falls Associated with Long-Acting Benzodiazepines or Tricyclic Antidepressants Use in Community-Dwelling Older Adults: A Nationwide Population-Based Case–Crossover Study

Influence of Ageing on the Pharmacodynamics and Pharmacokinetics of Chronically Administered Medicines in Geriatric Patients: A Review

As people age, the efficiency of various regulatory processes that ensure proper communication between cells and organs tends to decline. This deterioration can lead to difficulties in maintaining homeostasis during physiological stress. This includes but is not limited to cognitive impairments, functional difficulties, and issues related to caregivers which contribute significantly to medication errors and non-adherence. These factors can lead to higher morbidity, extended hospital stays, reduced quality of life, and even mortality. The decrease in homeostatic capacity varies among individuals, contributing to the greater variability observed in geriatric populations. Significant pharmacokinetic and pharmacodynamic alterations accompany ageing. Pharmacokinetic changes include decreased renal and hepatic clearance and an increased volume of distribution for lipid-soluble drugs, which prolong their elimination half-life. Pharmacodynamic changes typically involve increased sensitivity to various drug classes, such as anticoagulants, antidiabetic and psychotropic medications. This review examines the primary age-related physiological changes in geriatrics and their impact on the pharmacokinetics and pharmacodynamics of medications.

Understanding polypharmacy for people receiving home care services: a scoping review of the evidence

BACKGROUND

Polypharmacy, defined as the concurrent use of five or more medications, is common amongst older adults receiving home care services. The relationship between home care and polypharmacy may be critical to older people's health, but there is little research on this topic.

OBJECTIVE

To understand the extent and type of evidence on individuals receiving home care services and experiencing polypharmacy.

METHODS

This review followed the Preferred Reporting of Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. Three databases (MEDLINE, Embase, CINAHL) were systematically searched (December 2023) to identify studies with adult participants experiencing polypharmacy and receiving home care.

RESULTS

Twenty-three studies were included. For individuals receiving home care services, the studies reported on the following: (i) prevalence of polypharmacy, (ii) interventions to reduce inappropriate polypharmacy, (iii) perceived role of home care workers, (iv) assessment of health literacy in individuals experiencing polypharmacy, and (v) factors associated with polypharmacy and potentially inappropriate medications (PIMs). Polypharmacy and PIMs were found to be associated with older age, female sex, increased frailty, living alone, poor economic situation and inaccuracies within medical records. Improved appropriateness of prescribing can be achieved through interprofessional interventions, efficient use of home care workers and improved health literacy.

CONCLUSION

This review highlights research on the extent of polypharmacy in home care and ways to address it. Whilst there are suggestions for enhancing medication quality, key gaps remain in research into the experiences of care staff and recipients in managing medications and polypharmacy, which should be addressed.

The association between falls and fall-risk-increasing drugs among older patients in out-patient clinics: A retrospective cohort, single center study

BACKGROUND

Falls among older adults are considered a significant global health concern, often leading to severe injuries and increased healthcare costs. Fall-risk-increasing drugs (FRIDs), such as opioids and benzodiazepines, have been identified as contributing factors, yet the causal relationship remains unclear. This study examined the association between FRIDs, identified using the STOPP version 2 and STOPP Fall criteria, and falls among older outpatients.

METHODS

This retrospective cohort study included 19,705 patients aged 65 and older who visited outpatient clinics at Thammasat University Hospital, Thailand, in 2021. Data were collected from electronic medical records, including demographics, public health insurance schemes, diagnoses, and prescribed medications. FRIDs were identified using section K of STOPP version 2 and STOPPFall criteria. The association between FRIDs and falls was analyzed using multiple logistic regression.

RESULTS

The prevalence of FRIDs was 33 %, with Lorazepam being the most common. The overall incidence of falls was 1.48 %. An adjusted relative risks (ARR) of falls in the participants with FRIDs was 1.35 (95 % CI: 1.03-1.76) and 1.31 (95 % CI: 1.03-1.66) according to STOPP version 2 and STOPPFall criteria, respectively. Females, patients over 70, and those with polypharmacy or frequent outpatient visits also had increased fall risks.

CONCLUSION

FRIDs are associated with an increased risk of falls among older adults in outpatient settings. These findings highlight the need for careful prescribing and monitoring of FRIDs, particularly in older patients with other fall risk factors.

Association between Central Nervous System Drugs and Femoral Fracture Risk in Japanese Individuals ≥80 Years Old: A Case-crossover Study

Objective To assess the association between concomitant use of central nervous system drugs and femoral fracture risk in individuals ≥80 years old in Japan. Methods A case-crossover design was used, defining the case period as 3 days before the fracture diagnosis and the control period as 31-33, 34-36, and 37-39 days prior. The association between the daily intake of central nervous system drugs (Anatomical Therapeutic Chemical codes) and fracture risk was analyzed using conditional logistic regression. Patients Using the Japanese administrative claims database, we examined elderly patients diagnosed with femoral neck fractures between January 1, 2009, and December 31, 2020. Results In 255,875 patients, the concomitant use of central nervous system drugs increased the odds ratios of femoral fracture [3.41 (95% confidence interval: 3.27-3.55), 3.69 (3.46-3.91), 3.76 (3.42-4.13), and 4.34 (3.86-4.86) for an intake of >0-1, >1-2, >2-3, and >3 central nervous system drugs, respectively]. Conclusion The concomitant use of central nervous system drugs is associated with an increased risk of femoral fractures in individuals ≥80 years old in Japan.

Association between Opioid-Benzodiazepine Trajectories and Injurious Fall Risk among US Medicare Beneficiaries

Background/Objectives: Concurrent opioid (OPI) and benzodiazepine (BZD) use may exacerbate injurious fall risk (e.g., falls and fractures) compared to no use or use alone. Yet, patients may need concurrent OPI-BZD use for co-occurring conditions (e.g., pain and anxiety). Therefore, we examined the association between longitudinal OPI-BZD dosing patterns and subsequent injurious fall risk. Methods: We conducted a retrospective cohort study including non-cancer fee-for-service Medicare beneficiaries initiating OPI and/or BZD in 2016-2018. We identified OPI-BZD use patterns during the 3 months following OPI and/or BZD initiation (i.e., trajectory period) using group-based multi-trajectory models. We estimated the time to first injurious falls within the 3-month post-trajectory period using inverse-probability-of-treatment-weighted Cox proportional hazards models. Results: Among 622,588 beneficiaries (age ≥ 65 = 84.6%, female = 58.1%, White = 82.7%; having injurious falls = 0.45%), we identified 13 distinct OPI-BZD trajectories: Group (A): Very-low OPI-only (early discontinuation) (44.9% of the cohort); (B): Low OPI-only (rapid decline) (15.1%); (C): Very-low OPI-only (late discontinuation) (7.7%); (D): Low OPI-only (gradual decline) (4.0%); (E): Moderate OPI-only (rapid decline) (2.3%); (F): Very-low BZD-only (late discontinuation) (11.5%); (G): Low BZD-only (rapid decline) (4.5%); (H): Low BZD-only (stable) (3.1%); (I): Moderate BZD-only (gradual decline) (2.1%); (J): Very-low OPI (rapid decline)/Very-low BZD (late discontinuation) (2.9%); (K): Very-low OPI (rapid decline)/Very-low BZD (increasing) (0.9%); (L): Very-low OPI (stable)/Low BZD (stable) (0.6%); and (M): Low OPI (gradual decline)/Low BZD (gradual decline) (0.6%). Compared with Group (A), six trajectories had an increased 3-month injurious falls risk: (C): HR = 1.78, 95% CI = 1.58-2.01; (D): HR = 2.24, 95% CI = 1.93-2.59; (E): HR = 2.60, 95% CI = 2.18-3.09; (H): HR = 2.02, 95% CI = 1.70-2.40; (L): HR = 2.73, 95% CI = 1.98-3.76; and (M): HR = 1.96, 95% CI = 1.32-2.91. Conclusions: Our findings suggest that 3-month injurious fall risk varied across OPI-BZD trajectories, highlighting the importance of considering both dose and duration when assessing injurious fall risk of OPI-BZD use among older adults.

Post-Stroke Depression in Older Adults: An Overview

Detailed data on post-stroke depression (PSD) in older adults are limited in spite of the high vulnerability of this population to stroke. In fact, PSD prevalence in older adults ranges from 16.0 to 43.9%; however, timing and instruments of evaluation often differ significantly across all available studies. The etiology, genetic and inflammatory factors, as well as structural brain alterations, are claimed as part of a multifaceted mechanism of action in PSD onset. Thus, the aim of this narrative review was to further elaborate on the prevalence, etiology, diagnosis, consequences and treatment of PSD in older adults. The consequences of PSD in older adults may be devastating, including a poor functional outcome after rehabilitation and lower medication adherence. In addition, lower quality of life and reduced social participation, higher risk of new stroke, rehospitalization, and mortality have been reported. In this scenario, treating PSD represents a crucial step to prevent these complications. Both pharmacological and non-pharmacological therapies are currently available. The pharmacological treatment utilizes antidepressant drugs, such as selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TAs) and new multimodal antidepressants (NMAs). Non-pharmacological therapies include psychological interventions and non-invasive brain stimulation techniques, while excluding drug administration. In the general population experiencing PSD, SSRIs (sertraline in particular) are the most prescribed, whereas the combination of antidepressants and psychotherapy is underused. Furthermore, about one-third of patients do not receive treatment for PSD. In regard to older adults with PSD, the possibility of more adverse effects or contraindications to antidepressant prescription due to comorbidities may limit the therapeutic window. Although drugs such as citalopram, escitalopram, sertraline, venlafaxine, and vortioxetine are usually well tolerated by older patients with PSD, the few randomized controlled trials (RCTs) specifically considering older adults with PSD have been conducted with fluoxetine, fluvoxamine, reboxetine, citalopram and nortriptyline, often with very small patient samples. Furthermore, data regarding the results of non-pharmacological therapies are scarce. High-quality RCTs recruiting large samples of older adults are needed in order to better manage PSD in this population. In addition, adequate screening and diagnosis instruments, with reliable timing of evaluation, should be applied.

Pharmacists' Counseling and Benzodiazepines Dispensing for Sleep Disorders: A Simulated Patient Study in Iran

Objective

Sleep is critical for good health and quality of life, but many people struggle with sleep disorders. Pharmacists are on the front lines, helping patients manage these problems. However, there is growing concern that some pharmacists are dispensing benzodiazepines over-the-counter and failing to provide proper counseling. This study examined how pharmacists in Iran performed in these areas.

Methods

Between January and April 2022, we conducted a cross-sectional study in three major Iranian cities, using a "simulated patient" to observe how pharmacists interacted with them. In total, 431 pharmacies participated, and we used detailed forms to record the pharmacists' behavior. We then analyzed the data using descriptive statistics and the Chi-square tests.

Findings

Of 549 visits, 78.5% were managed by pharmacists, whereas the remainder were managed by other pharmacy staff. 79.7% of pharmacists evaluated the patient before deciding whether or not to prescribe the medication and 58.9% provided a kind of counseling for their offered medication, but just 10.6% of pharmacies had a private counseling area. Despite regulations that require a valid prescription for benzodiazepines, 9.2% of pharmacies dispensed diazepam, and 13.2% dispensed alprazolam without requesting one, and when counseling was offered, it often lacked critical details.

Conclusion

These findings raise serious concerns. There are deficiencies in how pharmacists and patients interact, with many pharmacists spending minimal time assessing patient needs. The high rates of benzodiazepine dispensing without valid prescriptions and inadequate counseling point to a need for stricter protocols and more training. To address these issues, health-care professionals and policymakers must collaborate to improve the quality and safety of sleep disorder treatment in community pharmacies.

Drugs and the elderly: A complex interaction

Although it can be difficult to define who should be considered an elderly person, the population aged 65 and over is experiencing the fastest demographic expansion and will represent almost one billion inhabitants of the 2030 World. Drug use increases dramatically with age and the elderly population is, by far, the highest consumer of medicines, up to 10 times more than younger adults. This consumption is in many aspects inappropriate, unjustified or sub-optimal and associated with a huge number of adverse reactions, admissions in emergency units and attributable deaths. A good part of which could be prevented if basic rules of good prescription and ad-hoc guidelines were systematically used. Even if older adults are more likely to present an adverse drug reaction, available data tend to support that the main risk factor of iatrogenesis in the elderly is the number of drugs used. Moreover, it is often irrelevant to transpose to this population the conclusions concerning the benefit-risk balance of drugs assessed in younger adults; similarly, approaches and programs classically used in pharmacovigilance and pharmacoepidemiology should be tailored to this specific population.