Polypharmacy and potentially inappropriate prescribing of benzodiazepines in older nursing home residents

Figures & data

Figure 1. The strength of association between a higher number of drugs and potentially predictive factors (POR, proportional odds ratio^a).

Table 1. Main characteristics of nursing home residents.

Characteristic	Number of medications
	Total (n = 226)		No polypharmacy 1–4 (n = 56)		Polypharmacy 5–9 (n = 112)		Hyperpolypharmacy ≥10 (n = 58)		p-value
Region
City of Zagreb	33.2%	(75)	19.6%	(11)	41.1%	(46)	31.0%	(18)	<.001
Dalmatia	33.6%	(76)	23.2%	(13)	28.6%	(32)	53.4%	(31)
Slavonia	33.2%	(75)	57.1%	(32)	30.4%	(34)	15.5%	(9)
Age, years mean ± SD	82.5 ± 6.2		82.1 ± 6.0		82.8 ± 6.5		82.2 ± 5.8		.732
Age categories
65–74	10.2%	(23)	8.9%	(5)	10.7%	(12)	10.3%	(6)	.367
75–84	49.6%	(112)	55.4%	(31)	42.9%	(48)	56.9%	(33)
≥85	40.3%	(91)	35.7%	(20)	46.4%	(52)	32.8%	(19)
Gender (female)	76.5%	(173)	71.4%	(40)	80.4%	(90)	74.1%	(43)	.385
Number of diseases, median (IQR)	6 (4–8)		3 (2–5)		6 (5–8)		9 (7–13)		<.001
Number of diseases^a
0–3	18.4%	(40)	58.5%	(31)	8.2%	(9)	0.0%	(0)	<.001
4–5	27.2%	(59)	35.8%	(19)	30.9%	(34)	11.1%	(6)
≥6	54.4%	(118)	5.7%	(3)	60.9%	(67)	88.9%	(48)
Psychiatric disorders
Sleeping problem	61.9%	(140)	33.9%	(19)	67.9%	(76)	77.6%	(45)	<.001
Anxiety	31.1%	(70)	7.1%	(4)	35.7%	(40)	45.6%	(26)	<.001
Depression	23.0%	(52)	14.3%	(8)	25.0%	(28)	27.6%	(16)	.188
Neurological diseases^b	15.0%	(34)	7.1%	(4)	14.3%	(16)	24.1%	(14)	.038
Dementia	4.0%	(9)	1.8%	(1)	4.5%	(5)	5.2%	(3)	.745
Panic disorders	1.8%	(4)	0.0%	(0)	1.8%	(2)	3.4%	(2)	.466
Geriatric scales
Depression Rating Scale (DRS)^c ≥3	37.6%	(85)	25.0%	(14)	35.7%	(40)	53.4%	(31)	.006
Cognitive Performance Scale (CPS)^d ≥2	27.9%	(63)	26.8%	(15)	27.7%	(31)	29.3%	(17)	.954
Pain Scale^e ≥1	63.3%	(143)	48.2%	(27)	62.5%	(70)	79.3%	(46)	.003
Clinical Frailty Scale (CFS)^f ≥5	19.9%	(45)	7.1%	(4)	16.1%	(18)	39.7%	(23)	<.001
Symptoms
Chronic pain	54.9%	(117)	41.5%	(22)	56.2%	(59)	65.5%	(36)	.041
Fatigue	51.8%	(117)	44.6%	(25)	50.9%	(57)	60.3%	(35)	.237
Unsteady gait (in last 3 days)	38.1%	(86)	21.4%	(12)	40.2%	(45)	50.0%	(29)	.006
Headache (in last 7 days)	24.3%	(55)	12.5%	(7)	22.3%	(25)	39.7%	(23)	.003
Dyspnoea	23.0%	(52)	16.1%	(9)	23.2%	(26)	29.3%	(17)	.244
Dizziness (in last 3 days)	19.9%	(45)	10.7%	(6)	19.6%	(22)	29.3%	(17)	.045
Loss of appetite (in last 7 days)	15.0%	(34)	8.9%	(5)	10.7%	(12)	29.3%	(17)	.002
Hypotension (in last 7 days)	11.1%	(25)	10.7%	(6)	10.7%	(12)	12.1%	(7)	.961
Abnormal thought process (in last 3 days)	5.8%	(13)	3.6%	(2)	7.1%	(8)	5.2%	(3)	.758
Bradycardia (in last 7 days)	3.5%	(8)	0.0%	(0)	3.6%	(4)	6.9%	(4)	.134
Syncope (in last 7 days)	0.4%	(1)	0.0%	(0)	0.0%	(0)	1.7%	(1)	.504
Prevalence of drugs
Psychotropic meds 1+ (incl. BZD)	72.1%	(163)	37.5%	(21)	77.7%	(87)	94.8%	(55)	<.001
BZDs	55.8%	(126)	23.2%	(13)	60.7%	(68)	77.6%	(45)	<.001
Opioids	31.0%	(70)	7.1%	(4)	31.2%	(35)	53.4%	(31)	<.001
Hypnotics (excl. BZD)	17.7%	(40)	8.9%	(5)	12.5%	(14)	36.2%	(21)	<.001
Antidepressants	13.7%	(31)	5.4%	(3)	15.2%	(17)	19.0%	(11)	.088
Antipsychotics	10.6%	(24)	0.0%	(0)	9.8%	(11)	22.4%	(13)	<.001
Antiparkinsonics	1.8%	(4)	0.0%	(0)	2.7%	(3)	1.7%	(1)	.809
Antidementia medications	0.9%	(2)	0.0%	(0)	0.0%	(0)	3.4%	(2)	.126
Anticholinergic medications	80.1%	(181)	44.6%	(25)	87.5%	(98)	100.0%	(58)	<.001
Medications with sedative properties	32.7%	(74)	12.5%	(7)	28.6%	(32)	60.3%	(35)	<.001

Percentages calculated from non-missing values: missing values were found in number of diseases (n = 217), particularly for anxiety (n = 225) and chronic pain (n = 213).

^a Ninety-one diseases analysed.

^b Neurological diseases include Alzheimer’s disease, vascular dementia, Lewy body dementia, other dementia, multiple sclerosis, traumatic brain injury (TBI), Parkinson’s disease, stroke (CVA), quadriplegia, paraplegia and hemiplegia.

^c DRS [26] is calculated from seven items: (1) made negative statements, (2) angry with yourself or others, (3) anxious, restless or uneasy, (4) expressions, including nonverbal, of a lack of pleasure in life (anhedonia), (5) repetitive anxious complaints/concerns (non-health related), (6) sad, pained or worried facial expression and (7) sad, depressed or hopeless. DRS score ranges from 0 (no mood symptoms) to 14 (all mood symptoms present in the last three days), where a score of 3 or higher indicates a NH resident with clinically relevant depression.

^d CPS [27] is calculated from six items: (1) cognitive skills for daily decision making, (2) short-term memory problems, (3) making self-understood, (4) managing finance – capacity, (5) managing medications – capacity and (6) walking ability. CPS ranges from 0 to 8, and a score value of 0–1 means cognition intact, 2–5 cognition impaired, while 6–8 signifies severe/very severe cognitive impairment.

^e Pain Scale [29] ranges from 0 (no pain) to 4 (daily excruciating pain).

^f Rockwood’s CFS score ranges from 1 (the lowest level of geriatric frailty) to 9 (the highest level of geriatric frailty) and can be classified into robust (CFS 1–3), pre-frail (CFS 4) and frail (CFS ≥5) [28]. Patients with scores 9 (terminally ill patients) and 8 (very severely frail, approaching end of life) were excluded from the study, see ‘Materials and methods’ section.

Figure 2. Prevalence of benzodiazepine use in nursing home residents^a.

Figure 3. Potentially inappropriate benzodiazepine prescribing in nursing home residents.

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Data availability statement

The datasets used and/or analysed during the current study are available from the corresponding author as the chair of the research works in the START/MED/093 project called ‘Grant Schemes at Charles University’ (Reg. No. CZ.02.2.69/0.0/0.0/19_073/0016935) and the NETPHARM project/New Technologies for Translational Research in Pharmaceutical Sciences (project ID CZ.02.01.01/00/22_008/0004607).