Older adults and high-risk medication administration in the emergency department

Abstract

BackgroundOlder adults are susceptible to adverse effects from opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and benzodiazepines (BZDs). We investigated factors associated with the administration of elevated doses of these medications of interest to older adults (≥65 years old) in the emergency department (ED).Patients and methodsED records were queried for the administration of medications of interest to older adults at two academic medical center EDs over a 6-month period. Frequency of recommended versus elevated (“High doses” were defined as doses that ranged between 1.5 and 3 times higher than the recommended starting doses; “very high doses” were defined as higher than high doses) starting doses of medications, as determined by geriatric pharmacy/medicine guidelines and expert consensus, was compared by age groups (65–69, 70–74, 75–79, 80–84, and ≥85 years), gender, and hospital.ResultsThere were 17896 visits representing 11374 unique patients >65 years of age (55.3% men, 44.7% women). A total of 3394 doses of medications of interest including 1678 high doses and 684 very high doses were administered to 1364 different patients. Administration of elevated doses of medications was more common than that of recommended doses. Focusing on opioids and BZDs, the 65–69-year age group was much more likely to receive very high doses (1481 and 412 doses, respectively) than the ≥85-year age groups (relative risk [RR] 5.52, 95% CI 2.56–11.90), mainly reflecting elevated opioid dosing (RR 8.28, 95% CI 3.69–18.57). Men were more likely than women to receive very high doses (RR 1.47, 95% CI 1.26–1.72), primarily due to BZDs (RR 2.12, 95% CI 2.07–2.16).ConclusionAdministration of elevated doses of opioids and BZDs in the older population occurs frequently in the ED, especially to the 65–69-year age group and men. Further attention to potentially unsafe dosing of high-risk medications to older adults in the ED is warranted.

Concurrent Use of Opioids with Other Central Nervous System-Active Medications Among Older Adults

“…[5][6][7][8]10,13,[15][16][17][18][19] As in other studies, those who used opioids and other CNS medications concurrently often were taking other medications to manage mental health problems of anxiety, insomnia, or depression associated with their chronic pain management. [4][5][6][7][8][9][10][11] Not surprisingly, the most commonly used concurrent medications with opioids were gabapentinoids and benzodiazepines. 6,12,15,19,25 Use of gabapentinoids has increased dramatically in recent years to augment the analgesic effect of opioids, perhaps associated with pressure to use lower dosages of opioids.…”

“…These characteristics are generally consistent across research studies. [4][5][6][7][8][9][10][11]13,14,17 That concurrent use of medication increased with younger age groups is noteworthy as these individuals age into Medicareeligible coverage plans. Problems with anxiety, depression, and insomnia have been consistently associated with pain management but to date have few alternatives to pharmacological treatments.…”

“…3 Benzodiazepines and other CNS-active medications are often used in combination with opioids to augment analgesic effects and/or to manage insomnia, anxiety, and other mental health disorders frequently associated with chronic pain. [4][5][6][7][8][9][10][11][12] Yet, despite the contraindications and warnings, concurrent use of opioids with other CNS-active medications, especially benzodiazepines, remains common across age groups and within various patient settings. 8,9,13,14 To date, concurrent use has no consistent definition in the scientific literature and has been variously defined as an overlap of 1 day, [15][16][17] 30 days, 18 or 90 days 7 when pharmaceutical claims were available or, more commonly, as during the same time period on surveys such as the National Ambulatory Medical Care Survey.…”

“…5,6,15,19 Such concomitant pharmaceutical solutions are frequently offered as first-line treatment options whether patients present in a provider's office or in the emergency room (ER) for the treatment of chronic pain complicated with anxiety, insomnia, or other mental health issues. 5,6,8,11,14,18,19,22,25 The providers prescribing concurrent opioids and other CNS-active medications have been characterized primarily as primary care providers (PCPs) who manage the regular care of their patients. 5,6,8,14,18,19 However, the Veteran's Administration (VA), with a designed specialist referral system and computerized drug monitoring, has reported opioids to be more often prescribed by PCPs, with benzodiazepines and other mental health medications more often prescribed by mental health providers.…”

Consideraciones respecto al uso de dosis de carga de diazepam para el tratamiento de la dependencia a benzodiacepinas

“…La duración y evolución de los posibles síntomas también es variable, tal y como queda reflejado en un estudio prospectivo (Vikander, Koechling, Borg, Tönne y Hiltunen, A su vez los datos recogidos en España reflejan la elevada prevalencia de benzodiacepinas en la población mayor de 75 años, siendo esta franja de edad la que recibe mayor tasa de prescripciones (Bejarano-Romero et al, 2008) y con ello el riesgo inherente al abuso y dependencia a los mismos. En esta población donde son características la pluripatología y polifarmacia, la sobredosificación con diacepam sería contraproducente dada la mayor vulnerabilidad a la aparición de efectos secundarios, tanto paradójicos como esperables por la sedación, favoreciendo un aumento de la estancia hospitalaria (Kim et al, 2017).…”