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A Drug Use Evaluation of Bedtime Sedation in Geriatric Patients

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A Drug Use Evaluation of Bedtime Sedation in Geriatric Patients The Canadian Journal of Hospital Pharmacy- Volume 47, No. 5, October, 1994 197 A Drug Use Evaluation of Bedtime Sedation in Geriatric Patients Janet W. Demsey ABSTRACT RESUME A pilot study was designed to assess the feasibility of On a effectue un projet pilote pour voir si on pouvait a shared regional drug use evaluation (DUE) program implanter un programme regional d'evaluation de involving patients. A retrospective DUE on the use of ! 'utilisation des medicaments par !es patients ages. benzadiazepines, chloral hydrate and neuroleptics On a procede pour cela a une analyse retrospective for bedtime sedation was performed on geriatric de !'utilisation des benzadiazepines, de !'hydrate de patient populations from two hospitals. Regional chloral et des neuroleptiques par des patients ages de program staff coordinated the DUE, including deux hopitaux, au coucher, en guise d'hypnotique. Le development of the criteria and chart review. The personnel du programme regional a coordonne participating Pharmacy departments performed the l'exercice, etabli les criteres d'evaluation et.revu Les internal administrative and Pharmacy and dossiers. Les departements de pharmacie participants Therapeutics committee communications. se sont occupes des communications entre Forty patient charts from two sites were reviewed. !'administration et le Comite de pharmacologie. The DUE results indicated different rates ofdrug use Les dossiers de 40 patients ant ete examines aux and discontinuation of therapy between the two deux endroits. Les resultats revelent des taux geriatric patient populations. The overall rates of differents d'utilisaton des medicaments et d' abandon inappropriate drug use were similar. One undesirable du traitement pour Les deux populations de patients clinical outcome occurred. Benzadiazepine use for ages. Le taux global d'utilisation inappropriee des more than 30 days was high in both groups. medicaments etait similaire dans Les deux hopitaux. Identification ofthe justification for drug use, dosage Un seul denouement clinique indesirable a ete re/eve. reduction and drug discontinuation did not occur in L'utilisation de benzadiazepine pendant plus de 30 the majority of patients. The pilot study identified jours etait relativement elevee pour les deux groupes. areas where use of bedtime sedation could be On n'a pas justifie ['indication du medicament, la improved, and allowed development of DUE criteria diminution de la posologie et ['abandon du traite­ for future evaluation. ment dans la majorite des cas. Le projet pilote a cerne Key Words: bedtime sedation, benzodiazepines, dans quelles situations il conviendrait d'ameliorer drug use evaluation, geriatrics !'utilisation des hypnotiques au coucher et a permis l'etablissement de criteres en vue d'une evaluation ulterieure de !'utilisation des medicaments. Mots cles: benzodiazepines, evaluation de I 'utilisation Can J Hosp Pharm 1994;47:197-202 des medicaments, geriatrie, hypnotique INTRODUCTION patient incidents in hospital. To from the literature concerning Quality assurance for pharmacy facilitate DUE in geriatric patients, adverse drug reactions and the departments includes drug use a pilot study was designed to assess prevalence of psychoactive drug use evaluation (DUE). Since accredi­ the feasibility of a shared program in geriatric patients. These concerns tation reviews for hospitals examine between two hospitals. This was have led to national health care quality assurance activities, DUE is done as part of a larger regional regulations in the United States a significant responsibility of formulary review and DUE project (Omnibus Budget Reconciliation pharmacists, physicians, and in which members of the program Act, 1990) which attempt to limit hospital administrators. With the staff coordinated and assisted in the psychoactive drug use in geriatric growth of the geriatric population completion of DUE within the nursing home patients. The use of has come the recognition of adverse participating hospitals. benzodiazepines with long drug reactions as a reason for The reasons for selection of a elimination half-lives has been hospital admission. Adverse drug DUE on bedtime sedation in the associated with hip fractures. 1 The reactions are also associated with geriatric patient group stemmed literature also includes documen- Janet W. Demsey, Pharm.D., was Formulary/DUE Coordinator, Ottawa Valley Regional Drug Information Service, Ottawa General Hospital, Ottawa, Ontario. She is currently working at the Stratford General Hospital. Acknowledgements: The author would like to acknowledge the contributions of Michael Tierney and Carol Repchinsky in the Department of Pharmacy at Ottawa General Hospital, and Shirley Mack for data collection. Funding was provided by a Hospital Incentive Grant, Ministry of Health, Ontario. 198 The Canadian Journal of Hospital Pharmacy - Volume 47, No. 5, October, 1994 tation of adverse drug reactions (e.g., number of measures to encourage Patient identification occurred early falls, confusion, and bizarre appropriate drug use.6 First, in 1993. This was done by the behaviour) related to triazolam use treatment of underlying medical or Pharmacy contact in each hospital in geriatric patients. 2 Indeed, psychiatric disorders should occur (Director of Pharmacy). The criteria specific recommendations to limit since insomnia is a common were submitted by the Directors to the dosage and duration of use for symptom of many conditions. the hospitals' Pharmacy and triazolam were developed by the Second, insomnia should be Therapeutics (P & T) committees in Health Protection Branch (Health classified as transient, short-term or April - June, 1993. The forms used and Welfare Canada) in 1991 and in long-term. Transient or short-term for data collection were tested and 1992. 3.4 In the United Kingdom, insomnia may require drug use of revised by the program staff during the drug was withdrawn from the several days or three weeks duration, the summerof 1993. Data collection market. Avorn et al5 reported a respectively. Drug use for long-term for the DUE occurred between reduction in the use of benzodi­ insomnia is controversial since the August 23 and September 23, 1993. azepines of 20% in the study group drugs are not considered effective All data collection was performed compared to 9% in the control group for long-term use. Third, drug selec­ by one program staff member. A after implementation of an edu­ tion, when indicated, should report of each hospital's results was cational program targeted at consider the elimination half-life prepared by the program staff and physicians, nurses, and aides. They and presence of active metabolites discussed with the Director of noted reduced psychoactive drug of the benzodiazepine chosen. Pharmacy in October, 1993. The use without adverse effects on Fourth, duration of use should be report was discussed with the behaviour or level of functioning. related to the degree to which the participating hospitals' medical staff Bedtime sedative use of selected patient is troubled by the insomnia, and/or P & T committee by the psychoactive agents was chosen for and patient education and non-drug Directors of Pharmacy. the DUE. The prevalent agents in measures should accompany Patients eligible for inclusion in the participating hospitals were intermittent benzodiazepine use. the DUE were identified. Geriatric benzodiazepines, chloral hydrate, Fifth, the risks of drug use are not patients were defined as over the and neuroleptics. insignificant (e.g., decreased day­ age of 60 years. Hospital A was a DUE criteria for appropriate use time performance, drug dependence, 202-bed long-term care facility with of any drug for bedtime sedation rebound exacerbation of sleep a pharmacy staff of 3.0 full-time have not been published. Benzo­ disturbance upon withdrawal). The equivalents (FTE). For Hospital A, diazepines are first line drugs for population at increased risk for patients admitted to the chronic or bedtime sedation. 6 However, adverse effects is geriatric patients. rehabilitation beds, for whom a neuroleptics and chloral hydrate Hence, benzodiazepine, neuro­ benzodiazepine, neuroleptic or remain in use in geriatrics. When a leptic, and chloral hydrate use for chloral hydrate for bedtime sedation neuroleptic is used for bedtime bedtime sedation was chosen as a was prescribed, were eligible. sedation, haloperidol has his­ regional DUE pilot study to describe Patient admissions, over a six-month torically been chosen. 7 The choice the characteristics of drug use in an period from October 1991 to March of drug may be considered attempt to improve geriatric patient 1992, were used to identify potential somewhat controversial. Dosing care. charts for review. Hospital B was a recommendations for geriatric 200-bed psychiatric facility with patients are also problematic. METHODS pharmacy staff of 5.0 FTE. For Typical geriatric drug dosing A retrospective DUE was carried Hospital B, patients admitted to the references suggest the reduction of out in two hospitals. Consent was acute psychogeriatric ward, for drug doses by 50%.7 Some required from Pharmacy, hospital whom one of the above drugs for recommend use of 25% to 50% of administration, and medical staff bedtime sedation was prescribed, the standard dose of hypnotics and for participation in the program to were eligible. Patient admissions, anxiolytics for patients over 80 years ensure access to patient charts and over a six-month period from of age because of altered to address the issue
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