Point Prevalence Survey of Benzodiazepine and Sedative-Hypnotic Drug Use in Hospitalized Adult Patients.

BACKGROUND: Benzodiazepines and sedative-hypnotic drugs (BZD/SHDs), such as zopiclone and the antidepressant trazodone, pose risks such as falls, fractures, and confusion, especially for older adults. Use of these drugs in the acute care setting is poorly understood. OBJECTIVES: To determine the point prevalence and characteristics of use of BZD/SHDs in hospitals in Nova Scotia, Canada. METHODS: A point prevalence survey was conducted for adults admitted to all hospitals with at least 30 acute care beds between May and August 2016. Drugs administered intravenously, patients in long-term care, and patients receiving mental health services, addiction treatment, or critical care were excluded. The proportion of included patients who had received a BZD/SHD within the 24 h before the start of the survey was determined. A descriptive statistical analysis was performed. RESULTS: Overall BZD/SHD prevalence was 34.6% (487/1409) across the 16 eligible hospitals. The average age was 70.3 years, and 150 (30.8%) of the patients were 80 years or older. Among the 585 prescriptions for these patients, commonly used drugs were zopiclone (32.0%), lorazepam (21.9%), and trazodone (21.9%). The most common indications for use were bedtime/daytime sedation (60.0%) and anxiety (12.5%). More than half of the prescriptions (55.7%) had been initiated at home, 37.6% were started in hospital, and the place of initiation was unknown for 6.7%. Benzodiazepines were prescribed more frequently to patients under 65 years than those 80 years or older (41.3% versus 22.2%, p < 0.001) whereas trazodone was more frequently prescribed to the older of these 2 age groups (52.7% versus 14.3%, p < 0.001). CONCLUSIONS: BZD/SHDs were frequently used by hospitalized adult patients in Nova Scotia. Trazodone appears to have been substituted for benzodiazepines in the oldest age group. Pharmacists should direct their efforts toward preventing inappropriate initiation of BZD/SHDs in hospital, particularly for elderly patients.

CONTEXTE: Les benzodiazépines et les médicaments sédatifs-hypnotiques (BZD/MSH), comme la zopiclone et l'antidépresseur trazodone, comportent des risques de chute, de fracture et de confusion, particulièrement chez les personnes âgées. Il existe une mauvaise compréhension de l'utilisation de ces médicaments dans un contexte de soins intensifs. OBJECTIFS: Déterminer la prévalence ponctuelle et les caractéristiques de l'utilisation des BZD/MSH dans des hôpitaux en Nouvelle-Écosse, au Canada. MÉTHODES: Une enquête sur la prévalence ponctuelle a été menée entre mai et août 2016 auprès d'adultes admis dans les hôpitaux comptant au moins 30 lits en soins intensifs. Les patients recevant ces médicaments par voie intraveineuse, ceux en établissement de soins de longue durée, ceux recevant des services en santé mentale ou un traitement pour la toxicomanie ou encore ceux des soins intensifs ont été exclus de l'enquête. La détermination de la proportion des patients inclus dans l'étude portait sur ceux qui avaient reçu des BZD/MSH au cours des 24 h précédant le début de l'enquête, et elle a été suivie d'une analyse statistique descriptive. RÉSULTATS: e manière générale, l'usage des BZD/MSH s'élevait à 34,6 % (487/1409) dans les 16 hôpitaux participants. L'âge moyen des patients était de 70,3 ans et 150 (30,8 %) étaient âgés d'au moins 80 ans. Parmi les 585 prescriptions pour ces patients, les médicaments communément utilisés étaient la zopiclone (32,0 %), le lorazepam (21,9 %) et le trazodone (21,9 %). Les indications d'utilisation les plus répandues concernaient la sédation au coucher et en cours de journée (60 %) et l'anxiété (12,5 %). Plus de la moitié des prescriptions (55,7 %) ont commencé à domicile, 37,6 % ont commencé à l'hôpital, et le lieu du début de la prise de ces médicaments était inconnu dans 6,7 % des cas. La prescription des benzodiazépines s'adressait plus souvent aux patients de moins de 65 ans qu'à ceux d'au moins 80 ans (41,3 % par rapport à 22,2 %, p < 0,001), tandis que la prescription de trazodone s'adressait plus souvent aux personnes de la tranche d'âge plus avancée (52,7 % par rapport à 14,3 %, p < 0,001). CONCLUSIONS: Les BZD/MSH étaient fréquemment utilisés par les patients adultes hospitalisés en Nouvelle-Écosse. La trazodone semble avoir remplacé les benzodiazépines dans le groupe plus âgé. Les pharmaciens devraient orienter leurs efforts sur la prévention de la prise inappropriée des BZD/MSH en hôpital, particulièrement par les patients plus âgés.

Linezolid-associated serotonin toxicity after escitalopram discontinuation: concomitant drug considerations.

We report a case of a hospitalised patient who developed probable serotonin toxicity shortly after the initiation of linezolid in whom the selective serotonin reuptake inhibitor (SSRI) escitalopram had been recently discontinued. On day 2 of linezolid administration, the patient reported severe anxiety and was observed to have full body jerking and twitching motions without mental status change. Notably, the patient was concomitantly receiving the antidepressant, trazodone and the benzodiazepine, clonazepam possibly affecting the severity and manifestations of serotonin toxicity. Linezolid was discontinued after 5 days and the patient's symptoms resolved. Serotonin toxicity can present with an array of symptoms and be life threatening if left unrecognised. This report highlights the clinical lessons that discontinuation of an SSRI upon initiation of linezolid does not eliminate the risk of serotonin toxicity and that other concomitant medications may worsen or improve some of the symptoms lending delay and uncertainty to the diagnosis.

Guideline for the management of wounds in patients with lower-extremity neuropathic disease: an executive summary.

This article summarizes the WOCN Evidence-Based Clinical Practice Guideline for Management of Wounds in Patients with Lower Extremity Neuropathic Disease. It is intended for use by physicians, nurses, therapists, and other health care professionals who work with adults who have or are at risk for, lower-extremity neuropathic disease (LEND), and includes updated scientific literature available from January 2003 through February 2012. The full guideline contains definitions of lower extremity neuropathic disorders and disease, prevalence of the problem, relevance and significance of the disorders, as well as comprehensive information about etiology, the nervous system, pathogenesis, and the overall management goals for patients at risk for developing neuropathic foot ulcers. A detailed assessment section describes how to conduct a full clinical history and physical examination. The guideline also provides two approaches to interventions. The first focuses on prevention strategies to reduce the risk of developing LEND wounds or recurrence, including life-long foot offloading, routine dermal temperature surveillance, use of adjunctive therapies, medication management, and implementing lower extremity amputation prevention measures and patient self-care education. The second approach summarized LEND wound management strategies including wound cleansing, debridement, infection management, maintenance of intact peri-wound skin, nutrition considerations, pain and paresthesia management, edema management, offloading and management of gait and foot deformity, medication management, surgical options, adjunctive therapies, patient education, and health care provider follow-up. A comprehensive reference list, glossary of terms, and several appendices regarding an algorithm to determine wound etiology, pharmacology, Lower Extremity Amputation (LEAP) Program, diabetes foot screening and other information is available at the end of the guideline.

All neuropathies great and small.

Autosomal-dominant pure hereditary spastic paraplegia (AD-HSP) is characterized by the degeneration of long axons in corticospinal tracts and dorsal columns, resulting in spasticity and difficulty walking. Mutations in the SPG4 gene product spastin are the predominant genetic lesions associated with this inherited disease. In this issue, Orso et al. examine and reconcile existing Drosophila mutants of spastin and generate a new model for HSP by overexpression of a fly spastin transgene that carries a mutation prevalent in human AD-HSP (see the related article beginning on page 3026). Expression of this mutant spastin protein produces pathology in flies reminiscent of the human disease, including adult locomotion defects, in addition to causing aberrant synaptic morphology and altered microtubule stability. Both movement and synaptic defects in fly mutants were ameliorated by treatment with the microtubule-modifying agent vinblastine. The results are consistent with disease-causing mutations in human spastin producing dominant-negative proteins and confirm the usefulness of Drosophila genetic techniques to understand HSP and other neurodegenerative diseases.