The Impact of a Pharmacist Intervention on Post-discharge Hypnotic Drug Discontinuation in Geriatric Inpatients

Study Overview
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Brief Summary
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This study investigated whether a multifaceted approach was associated with hypnotic drug discontinuation at one month after discharge

Detailed Description
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Chronic use of hypnotic agents is prevalent in older adults, who as a result are at increased risk for certain adverse events, such as day-time drowsiness and falls. Multiple strategies to discontinue hypnotics have been tested in geriatric patients, but evidence remains scarce. Hence, we aimed to investigate a multicomponent intervention to reduce hypnotic drug use in geriatric inpatients. A before-after study was performed on the acute geriatric wards of a teaching hospital. The before cohort received usual care while intervention patients were exposed to a pharmacist-led deprescribing intervention, comprising education of health care personnel, access to standardized discontinuation regimens, active patient involvement and support of transitional care. The primary outcome was hypnotic drug discontinuation at one month after discharge.

Official Title
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The Impact of a Pharmacist Intervention on Post-discharge Hypnotic Drug Discontinuation in Geriatric Inpatients: a Before-after Study

Conditions
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Hypnotic Withdrawal

Intervention / Treatment
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* Other: multifaceted pharmacist-led intervention
* Other: Usual care group


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients aged ≥ 75 years Admitted to an acute geriatric ward of UZ Leuven Documented chronic use of a hypnotic drug (hypnotics were defined as benzodiazepines and Z-drugs and chronic hypnotic drug use was defined as hypnotic use for at least five days a week during a minimum of four consecutive weeks. Indication: insomnia, anxiety or an undefined reason Exclusion Criteria: Concomitant use of multiple benzodiazepines and/or Z-drugs Discontinuation of the hypnotic drug prior to enrollment Estimated discharge from the hospital within 72 hours of admission No command of the Dutch language Severe psychiatric or neurological disease (e.g. bipolar disorder, epilepsy or dystonia) or a severe acute medication condition in the opinion of the treating physician End-of-life care. Study participants who died during their hospital stay were excluded from the analysis as their medication at discharge could not be evaluated. In case of any readmission, only the first admission was included in the analysis.

Ages Eligible for Study
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Minimum Age: 75 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Non-Randomized
Intervention Model: Sequential Assignment
Interventional Model Description: before-after study
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Other: Before group<br>In the usual care cohort, there was no systematic clinical pharmacist involvement regarding deprescribing of hypnotics. | Other: Usual care group<br>* all patients received comprehensive geriatric care without any systematic clinical pharmacist involvement regarding deprescribing of hypnotics. Treating physicians were not actively informed on the patient's participation in this particular study.<br>|
| Experimental: After group<br>In the intervention cohort a pharmacist-led intervention was implemented comprising the four following components: 1) education of health care personnel; 2) access to standardized discontinuation regimens; 3) patient education; 4) support of transitional care. | Other: multifaceted pharmacist-led intervention<br>* Educational sessions were provided to the physicians and nursing staff. Discontinuation regimens were developed. Prescribers were free to choose whether or not to actually use them. The regimens were derived from the regimen used by Petrovic et al. and encouraged a switch from any benzodiazepine to lorazepam 1 mg OD for one week followed by drug stop. Z-drugs were switched to zolpidem 5 mg OD for one week followed by drug stop. If deemed necessary, a pro re nata regimen of lorazepam 1 mg or zolpidem 5 mg for one additional week was prescribed respectively. The discontinuation regimens were incorporated into the hospital's electronic prescribing system. Furthermore, a clinical decision support system provided additional support. Patient education sessions were provided upon enrolment and at discharge. Specific patient leaflets were used to facilitate patient education. The patient's primary care physician and, if applicable, the nursing home were informed by phone.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Hypnotic drug discontinuation at one month after discharge | Difference in hypnotic discontinuation rate between before and after group | 1 month after discharge | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Hypnotic drug use | Description of type and dose of hypnotic drug use | 1 and 2 weeks after enrollment and at discharge (the end of the hospital stay, on average 12 days after admission) | 
| Restart of hypnotics during hospital stay | The emergency use of hypnotics after any discontinuation attempt during hospital stay. | From enrollment until discharge (the end of the hospital stay, on average 12 days after admission) | 
| Safety - incidence of delirium occurence during hospital stay | During hospital stay the incidence of physician-identified delirium was assessed together with emergency use of antipsychotics | From enrollment until discharge (the end of the hospital stay, on average 12 days after admission) | 
| Sleep quality | Sleep quality was determined during a patient interview using the Pittsburgh Sleep Quality Index (PSQI). The PSQI concerns a validated questionnaire where a higher score signifies a worse sleep quality; a total score of 5 or more indicates poor sleep quality | Upon inclusion, fourteen days after enrollment and one month after discharge | 
| Fall risk | The occurrence of falls | 1 month after discharge | 
| Determinants for post-discharge hypnotic discontinuation | Factors associated with hypnotic discontinuation | 1 month after discharge | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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deprescribing, tapering, adverse events, hypnotics, benzodiazepines, z-drugs, geriatrics