Background Elderly patients admitted to intensive care units (ICU) are at risk of receiving potentially (PIMs) and actually inappropriate medications (AIMs). Objectives To determine types of PIMs and AIMs, which PIMs are most likely to be considered AIMs, and risk factors for PIMs and AIMs at hospital discharge in elderly ICU survivors. Design Prospective cohort study Setting Tertiary care, academic medical center Participants 120 patients ≥ 60 years old who survived an ICU hospitalization Measurements PIMs were defined according to published criteria; AIMs were adjudicated by a multidisciplinary panel. Medication lists were abstracted at the time of pre-admission, ward admission, Intensive Care Unit (ICU) admission, ICU discharge, and hospital discharge. Poisson regression was used to examine independent risk factors for hospital discharge PIMs and AIMs. Results Of 250 PIMs prescribed at discharge, the most common were opioids (28%), anticholinergics (24%), antidepressants (12%), and drugs causing orthostasis (8%). The three most common AIMs were anticholinergics (37%), non-benzodiazepine hypnotics (14%), and opioids (12%). Overall, 36% of discharge PIMs were classified as AIMs, but the percentage varied by drug type. Whereas only 16% of opioids, 23% of antidepressants, and 10% of drugs causing orthostasis were classified as AIMs; 55% of anticholinergics, 71% of atypical antipyschotics, 67% of non-benzodiazepine hypnotics and benzodiazepines, and 100% of muscle relaxants were deemed AIMs. The majority of PIMs and AIMs were first prescribed in the ICU. Pre-admission PIMs, discharge to somewhere other than home, and discharge from a surgical service predicted number of discharge PIMs, but none of the factors predicted AIMs at discharge. Conclusions Certain types of PIMs, which are commonly initiated in the ICU, are more frequently considered inappropriate upon clinical review. Efforts to reduce AIMs in elderly ICU survivors should target these specific classes of medications.

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Objective To determine whether benzodiazepine and propofol doses are increased at night and whether daytime and nighttime sedative doses are associated with delirium, coma, and delayed liberation from mechanical ventilation. Design Single-center, prospective cohort study nested within the Awakening and Breathing Controlled randomized trial Setting Saint Thomas Hospital in Nashville, TN from 2004–2006 Patients Adult patients receiving mechanical ventilation for greater than 12 hours with continuous recording of hourly sedation dosing Interventions We measured hourly doses of benzodiazepine and propofol exposure during the daytime (7am–11pm) and nighttime (11pm–7am) for five days. We quantified nighttime dose increases by subtracting the average hourly daytime dose on the preceding day from subsequent average hourly nighttime dose. We used multivariable logistic regression to determine if daytime and nighttime dose increases were independently associated with delirium, coma, and delayed liberation from mechanical ventilation. Measurements and main results Among 140 patients, the median APACHE II score was 27 [IQR: 22, 33]. Among those receiving the sedatives, benzodiazepine and propofol doses were increased at night on 40% and 41% of patient-days, respectively. Of 485 patient-days, delirium was present on 160 (33%) and coma on 206 (42%). In adjusted models, greater daytime benzodiazepine dose was independently associated with failed SBT and extubation, and subsequent delirium (p<0.02 for all). Nighttime increase in benzodiazepine dose was associated with failed SBT (p<0.01) and delirium (p=0.05). Daytime propofol dose was marginally associated with subsequent delirium (p=0.06). Conclusions Nearly half of mechanically ventilated ICU patients received greater doses of sedation at night, a practice associated with failed SBTs, coma, and delirium. Over the first five days in our study, patients spent 75% of their time in coma or delirium, outcomes that may be reduced by efforts to decrease sedative exposure during both daytime and nighttime hours in the ICU.