Hypnotic Withdrawal
Conditions
Keywords
deprescribing, tapering, adverse events, hypnotics, benzodiazepines, z-drugs, geriatrics
Brief summary
This study investigated whether a multifaceted approach was associated with hypnotic drug discontinuation at one month after discharge
Detailed description
Chronic use of hypnotic agents is prevalent in older adults, who as a result are at increased risk for certain adverse events, such as day-time drowsiness and falls. Multiple strategies to discontinue hypnotics have been tested in geriatric patients, but evidence remains scarce. Hence, we aimed to investigate a multicomponent intervention to reduce hypnotic drug use in geriatric inpatients. A before-after study was performed on the acute geriatric wards of a teaching hospital. The before cohort received usual care while intervention patients were exposed to a pharmacist-led deprescribing intervention, comprising education of health care personnel, access to standardized discontinuation regimens, active patient involvement and support of transitional care. The primary outcome was hypnotic drug discontinuation at one month after discharge.
Interventions
OTHERmultifaceted pharmacist-led intervention
* Educational sessions were provided to the physicians and nursing staff. * Discontinuation regimens were developed. Prescribers were free to choose whether or not to actually use them. The regimens were derived from the regimen used by Petrovic et al. and encouraged a switch from any benzodiazepine to lorazepam 1 mg OD for one week followed by drug stop. Z-drugs were switched to zolpidem 5 mg OD for one week followed by drug stop. If deemed necessary, a pro re nata regimen of lorazepam 1 mg or zolpidem 5 mg for one additional week was prescribed respectively. The discontinuation regimens were incorporated into the hospital's electronic prescribing system. Furthermore, a clinical decision support system provided additional support. * Patient education sessions were provided upon enrolment and at discharge. Specific patient leaflets were used to facilitate patient education. * The patient's primary care physician and, if applicable, the nursing home were informed by phone.
OTHERUsual care group
all patients received comprehensive geriatric care without any systematic clinical pharmacist involvement regarding deprescribing of hypnotics. Treating physicians were not actively informed on the patient's participation in this particular study.
Sponsors
Universitaire Ziekenhuizen KU Leuven
Study design
Allocation
NON_RANDOMIZED
Intervention model
SEQUENTIAL
Primary purpose
PREVENTION
Masking
NONE
Intervention model description
before-after study
Eligibility
Sex/Gender
ALL
Age
75 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Patients aged ≥ 75 years * Admitted to an acute geriatric ward of UZ Leuven * Documented chronic use of a hypnotic drug (hypnotics were defined as benzodiazepines and Z-drugs and chronic hypnotic drug use was defined as hypnotic use for at least five days a week during a minimum of four consecutive weeks. * Indication: insomnia, anxiety or an undefined reason
Exclusion criteria
* Concomitant use of multiple benzodiazepines and/or Z-drugs * Discontinuation of the hypnotic drug prior to enrollment * Estimated discharge from the hospital within 72 hours of admission * No command of the Dutch language * Severe psychiatric or neurological disease (e.g. bipolar disorder, epilepsy or dystonia) or a severe acute medication condition in the opinion of the treating physician * End-of-life care. Study participants who died during their hospital stay were excluded from the analysis as their medication at discharge could not be evaluated. In case of any readmission, only the first admission was included in the analysis.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Hypnotic drug discontinuation at one month after discharge | 1 month after discharge | Difference in hypnotic discontinuation rate between before and after group |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Restart of hypnotics during hospital stay | From enrollment until discharge (the end of the hospital stay, on average 12 days after admission) | The emergency use of hypnotics after any discontinuation attempt during hospital stay. |
| Safety - incidence of delirium occurence during hospital stay | From enrollment until discharge (the end of the hospital stay, on average 12 days after admission) | During hospital stay the incidence of physician-identified delirium was assessed together with emergency use of antipsychotics |
| Hypnotic drug use | 1 and 2 weeks after enrollment and at discharge (the end of the hospital stay, on average 12 days after admission) | Description of type and dose of hypnotic drug use |
| Fall risk | 1 month after discharge | The occurrence of falls |
| Determinants for post-discharge hypnotic discontinuation | 1 month after discharge | Factors associated with hypnotic discontinuation |
| Sleep quality | Upon inclusion, fourteen days after enrollment and one month after discharge | Sleep quality was determined during a patient interview using the Pittsburgh Sleep Quality Index (PSQI). The PSQI concerns a validated questionnaire where a higher score signifies a worse sleep quality; a total score of 5 or more indicates poor sleep quality |
Outcome results
None listed