Monique Elseviers

Systematic appraisal of dementia guidelines for the management of behavioural and psychological symptoms

BACKGROUNDnWithin the treatment of dementia, management of behavioural and psychological symptoms (BPSD) is a complex component.nnnPURPOSEnWe wanted to offer a pragmatic synthesis of existing specific practice recommendations for managing BPSD, based on agreement among systematically appraised dementia guidelines.nnnDATA SOURCESnWe conducted a systematic search in MEDLINE and guideline organisation databases, supplemented by a hand search of web sites.nnnSTUDY SELECTIONnFifteen retrieved guidelines were eligible for quality appraisal by the Appraisal of Guidelines Research and Evaluation instrument (AGREE), performed by 2 independent reviewers.nnnDATA EXTRACTIONnFrom the 5 included guidelines, 18 specific practice recommendations for BPSD were extracted and compared for their level of evidence and strength.nnnDATA SYNTHESISnNo agreement was found among dementia guidelines for the majority of specific practice recommendations with regard to non-pharmacological interventions, although these were recommended as first-line treatment. Pharmacological specific practice recommendations were proposed as second-line treatment, with agreement for the use of a selection of antipsychotics based on strong supporting evidence, but with guidance for timely discontinuation.nnnLIMITATIONSnThe appraisal of the level of agreement between guidelines for each specific practice recommendation was complicated by variation in grading systems, and was performed with criteria developed a posteriori.nnnCONCLUSIONnDespite the limited number of recommendations for which agreement was found, guidelines did agree on careful antipsychotic use for BPSD. Adverse events might outweigh the supporting evidence of efficacy, weakening the recommendation. More pivotal trials on the effectiveness of non-pharmacological interventions, as well as guidelines specifically focusing on BPSD, are needed.

Risk Factors for Poststroke Depression: Identification of Inconsistencies Based on a Systematic Review

Objective: Depression after stroke or poststroke depression (PSD) has a negative impact on the rehabilitation process and the associated rehabilitation outcome. Consequently, defining risk factors for development of PSD is important. The relationship between stroke and depression is described extensively in the available literature, but the results are inconsistent. The aim of this systematic review is to outline conflicting evidence on risk factors for PSD. Methods: PubMed, Medline, and Web of Knowledge were searched using the keywords “stroke,” “depression,” and “risk factor” for articles published between January 01, 1995, and September 30, 2012. Additional articles were identified and obtained from a hand search in related articles and reference lists. Results: A total of 66 article abstracts were identified by the search strategy and 24 articles were eligible for inclusion based on predefined quality criteria. The methodology varies greatly between the various studies, which is probably responsible for major differences in risk factors for PSD reported in the literature. The most frequently cited risk factors for PSD in the literature are sex (female), history of depression, stroke severity, functional impairments or level of handicap, level of independence, and family and social support. Conclusions: Many risk factors are investigated over the last 2 decades and large controversy exists concerning risk factors for development of PSD. These contradictions may largely be reduced to major differences in clinical data, study population, and methodology, which underline the need for more synchronized studies.

Benzodiazepine use in Belgian nursing homes: a closer look into indications and dosages

Aim(1) To describe the prevalence of benzodiazepine use in Belgian nursing homes, with specific attention to indications and dosages. (2) To compare actual and recommended dosages of benzodiazepines for anxiety and insomnia. (3) To explore the risk profile for chronic benzodiazepine use in institutionalised older adults.MethodsMedication charts of 1,730 residents from 76 nursing homes in Belgium were collected and analysed, using the ATC classification. Drug name, indication and daily dosage were recorded. From authoritative international sources, we extracted for each drug and each indication a daily dosage recommended not to be exceeded in older adults for comparison with observed actual dosages.ResultsAmong the chronic benzodiazepine or z-drug (BZD/Z) users (50% of the residents), the leading indication was ‘insomnia’ (59% of the users) followed by ‘anxiety’ (17%) and ‘unrest’ (10%). In the chronic prescriptions of BZD/Zs indicated for insomnia, the actual daily dose exceeded the geriatric upper limit in 95% of lormetazepam prescriptions, 82% of zolpidem, 78% of zopiclone and 35% of lorazepam prescriptions. For anxiety, daily doses also exceeded the limit but not to the same extent. Multivariate analysis showed BZD/Z use was positively associated with pain (OR 1.58, 95% CI 1.27–1.97), constipation (OR 1.43, 95% CI 1.16–1.76) and depression (OR 1.68, 95% CI 1.35–2.08). Residents with dementia were less likely to receive a BZD/Z (OR 0.60, 95% CI 0.48–0.74).ConclusionEfforts to reduce the use of BZD/Zs in nursing homes should concentrate on insomnia, with interventions aimed at reducing too high prevalence of chronic use and too high daily dosages in this indication.

Assessment of antipsychotic prescribing in Belgian nursing homes

BACKGROUNDnGiven the potential adverse effects of antipsychotics, high use in nursing homes creates concern. Our study goal was to explore the use of antipsychotics in relation to resident characteristics, and to assess the appropriateness of antipsychotic prescribing in Belgian nursing homes.nnnMETHODSnData were used from a cross-sectional study (Prescribing in Homes for the Elderly; PHEBE) conducted in 76 nursing homes in Belgium. Antipsychotics were classified into typical and atypical, using the anatomical therapeutic and chemical classification. Ten inappropriate antipsychotic prescribing indicators were selected from the updated Beers criteria (2003), Bergen District Nursing Home Study (BEDNURS) indicators, and Screening Tool of Older Peoples Prescriptions criteria (STOPP).nnnRESULTSnThe residents mean age was 84.8 years, 78.1% of whom were female. The prevalence of antipsychotic utilization was 32.9%. Antipsychotics were mainly indicated for dementia-related agitation, and psychosis with/without dementia. Higher use of antipsychotics was found for dementia (OR: 3.27; 95% CI: 2.61-4.09), insomnia (OR: 1.38; 95% CI: 1.10-1.73), depression (OR: 1.30; 95% CI: 1.03-1.65), and age <80 years (OR: 1.79; 95% CI: 1.38-2.33). Inappropriate antipsychotic prescribing indicators scoring the highest among users were: long-term use (92.6%), use despite risk of falling (45.6%), combined use with other psychotropics (31.8%), and duplicate use (15.1%). Inappropriate prescribing was associated with depression (OR: 3.41) and insomnia (OR: 2.17).nnnCONCLUSIONnThe indicator-driven analysis of antipsychotic prescribing quality revealed a need for improvement, with the main prescribing problems relating to duration and combination of therapies. Risks/benefits of off-label use need to be evaluated more consciously at the start of therapy, and at periodic re-evaluations.

Too many, too few, or too unsafe? Impact of inappropriate prescribing on mortality, and hospitalization in a cohort of community‐dwelling oldest old

AIMSnLittle is known about the impact of inappropriate prescribing (IP) in community-dwelling adults, aged 80 years and older. The prevalence at baseline (November 2008September 2009) and impact of IP (misuse and underuse) after 18xa0months on mortality and hospitalization in a cohort of community-dwelling adults, aged 80xa0years and older (nxa0=xa0503) was studied.nnnMETHODSnScreening Tool of Older Peoples Prescriptions (STOPP-2, misuse) and Screening Tool to Alert to Right Treatment (START-2, underuse) criteria were cross-referenced and linked to the medication use (in Anatomical Therapeutic Chemical coding) and clinical problems. Survival analysis until death or first hospitalization was performed at 18xa0months after inclusion using Kaplan-Meier, with Cox regression to control for covariates.nnnRESULTSnMean age was 84.4xa0(range 80-102) years. Mean number of medications prescribed was 5 (range 0-16). Polypharmacy (≥5 medications, 58%), underuse (67%) and misuse (56%) were high. Underuse and misuse coexisted in 40% and were absent in 17% of the population. A higher number of prescribed medications was correlated with more misused medications (rs xa0=xa0.51, Pxa0<xa00.001) and underused medications (rs xa0=xa0.26, Pxa0<xa00.001). Mortality and hospitalization rate were 8.9%, and 31.0%, respectively. After adjustment for number of medications and misused medications, there was an increased risk of mortality (HR 1.39, 95%xa0CI 1.10, 1.76) and hospitalization (HR 1.26, 95%xa0CI 1.10, 1.45) for every additional underused medication. Associations with misuse were less clear.nnnCONCLUSIONnIP (polypharmacy, underuse and misuse) was highly prevalent in adults, aged 80xa0years and older. Surprisingly, underuse and not misuse had strong associations with mortality and hospitalization.

Quality of prescribing in Belgian nursing homes: an electronic assessment of the medication chart

OBJECTIVEnTo develop a computerized assessment tool for monitoring the quality of prescribing in Belgian nursing homes.nnnDESIGNnIn a observational cross-sectional study of the medication charts of nursing home residents, potentially inappropriate medication (PIM) was investigated using three scoring systems for the elderly (Beers, ACOVE, BEDNURS) complemented with a list of drug-drug interactions.nnnSETTINGnA representative stratified sample of Belgian nursing homes (n = 76).nnnPARTICIPANTSnA random sample of nursing home residents with a complete data set (n = 1730) excluding palliative care patients.nnnMAIN OUTCOME MEASUREnA combination of PIM scores to assess inappropriate, under- and overprescribing.nnnRESULTSnIncluded residents had a mean age of 85, 78% were female. They used a mean of 7.1 chronic medications. Most PIMs were detected by the application of the ACOVE criteria for underprescribing with 58% of patients having at least one PIM. Using the BEDNURS and the Beers criteria, at least one PIM was noticed in 56 and 27% of patients, respectively. Patients characteristics showing a positive relationship with the PIM score were age, female gender, amount of clinical and nursing care problems, number of prescriptions and the use of psychotropic drugs (multiple regression analysis R(2) = 0.332).nnnCONCLUSIONSnIn Belgian nursing homes, the observed high level of drug utilization was associated with potentially inappropriate prescribing. The development of a combined assessment tool and the implementation of a computerized monitoring system of PIMs is highly recommended to improve the quality of prescribing.

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

OBJECTIVESnWe 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.nnnMETHODSnAll 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.nnnRESULTSnOf 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).nnnCONCLUSIONnOur 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.

Polypharmacy in a Belgian cohort of community-dwelling oldest old (80+)

Abstract Objectives: Polypharmacy is highly prevalent among older people (65+), but little is known on the medication use of the oldest old (80+). This study explores the medication use of the Belgian community-dwelling oldest old in relation to their demographic, clinical and functional characteristics. Methods: Baseline data was used from the BELFRAIL study; a prospective, observational population-based cohort of Belgian community-dwelling patients (80+). General practitioners recorded clinical problems and medications. Medications were coded by the Anatomic Therapeutic Chemical classification. Results: Participants’ (n = 503) mean age was 84.4 years (range 80–102) and 61.2% was female. Median chronic medication use was 5 (range 0–16). Polypharmacy (≥5 medications) was high (57.7%), with excessive polypharmacy (≥10 medications) in 9.1%. Most commonly used medication group were antithrombotics, but also benzodiazepines and antidepressants were frequently consumed. Demographics related to polypharmacy (univariate analysis) were female gender, low education and moderate alcohol use. Age, care dependency and cognitive impairment showed no association with polypharmacy. In multivariate analysis, the predominant association with polypharmacy was found for multimorbidity (OR 1.78, 95% CI 1.5–2.1), followed by depression (OR 3.7, 95% CI 4.4–9.7) and physical activity (OR 0.8, 95% CI 0.7–0.9). Conclusions: Polypharmacy was high among Belgian community-dwelling oldest old (80+). Determinants of polypharmacy were interrelated, but dominated by multimorbidity. On top of the burden of multimorbidity, polypharmacy was independently associated with less physical activity, and with depressive symptoms.

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

BackgroundSince antidepressants are prescribed for multiple indications, the use of an antidepressant cannot be equated with a diagnosis of depression.ObjectiveThe 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.MethodsThis 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.ResultsThe overall use of antidepressants in nursing homes was 39.5xa0% (95xa0% CI 37.2, 41.8). The physicians classified 34.2xa0% (95xa0% CI 32.0, 36.4) of the residents as having depression, and 80.9xa0% of these patients were treated with an antidepressant. Indications among the single antidepressant users (nxa0=xa0551) were depression (66.2xa0%), insomnia (13.4xa0%), anxiety (6.2xa0%) and neuropathic pain (1.6xa0%). In the indication of depression, 74.8xa0% used a selective serotonin reuptake inhibitor (SSRI), predominantly citalopram, sertraline and escitalopram. Venlafaxine was used by 10.7xa0% 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 44.5xa0% of prescribed dosages were below the MED. In the indication of insomnia, most of the time, trazodone (90.5xa0%) or mirtazapine (5.4xa0%) 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 13.9xa0% received an antidepressant (mostly an SSRI), and the remaining received a benzodiazepine.ConclusionsThe 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.

Prevalence and management of antibiotic associated diarrhea in general hospitals

BackgroundAntibiotic-associated diarrhea (AAD) is a common adverse effect of antibiotic (AB) treatment. This study aimed to measure the overall prevalence of AAD (including mild to moderate diarrhea) in hospitalized AB treated patients, to investigate associated risk factors and to document AAD associated diagnostic investigations, contamination control and treatment.MethodsDuring 8 observation days (with time delay of 10–14 days between each observation day), all adult patients hospitalized at an internal medicine ward of 4 Belgian participating hospitals were screened for AB use. Patients receiving AB on the observation day were included in the study and screened for signs and symptoms of AAD using a period prevalence methodology. Clinical data were collected for all AB users and AAD related investigations and treatment were collected for the entire duration of AAD. Additionally, nurses noted daily the frequency of all extra care associated to the treatment of the diarrhea.ResultsA total of 2543 hospitalized patients were screened of which 743 were treated with AB (29.2%). Included AB users had a mean age of 68 yr (range 16–99) and 52% were male. Penicillins were mostly used (63%) and 19% received more than one AB. AAD was observed in 9.6% of AB users including 4 with confirmed Clostridium difficile infection. AAD started between 1 and 16 days after AB start (median 5) and had a duration of 2 to 41 days (median 4). AAD was significantly associated with higher age and the use of double AB and proton pump inhibitors. AAD patients had extra laboratory investigations (79%), received extra pharmacological treatment (42%) and 10 of them were isolated (14%). AAD related extra nursing time amounted to 51 minutes per day for the treatment of diarrhea.ConclusionsIn this observational study, with one third of hospitalized patients receiving AB, an AAD period prevalence of 9.6% in AB users was found. AAD caused extra investigations and treatment and an estimated extra nursing care of almost one hour per day. Preventive action are highly recommended to reduce the prevalence of AAD and associated health care costs.