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Evaluation of Benzodiazepine use for insomnia at Barossa Village


									Evaluation of Benzodiazepine use for insomnia at Barossa Village residency:
A comparison between criteria of best practice adherence in 2008 and 2009
Erin Kelly, Annabel Hoile, Georgia Kaidonis, Anne Durdin and Sameer Thakur, School of Medicine
Introduction:                                                                                      Results and discussion:
Benzodiazepine (BZD) use amongst the elderly is widespread. One of the common reasons              Within our study, no significant differences were noted for BZD prescriptions between males
for their prescription, particularly in aged care, is for sleep difficulties. This is despite      and females, or between residents with and without risk factors. The number of residents on
evidence that BZD are not effective in long-term management of sleep difficulties1.                BZDs was significantly higher than in February 2008 (χ2= 5.448; P=0.02).
Furthermore, the use of BZD in the elderly is associated with adverse effects, such as
increased risk of falls, incontinence and confusion1. In light of this, the National Prescribing         Table 1: Comparison of findings:
Service (NPS) has developed six criteria which describe best practice guidelines for the use
of benzodiazepines in insomnia in aged care homes3:                                                      Overall Findings:                                            Feb-08   Sep-09

1.BZD should not be first-line treatment for insomnia                                                    Residents prescribed BZD                                     26%      45%
2.BZD use in residents with risk factors (sleep apnoea, severe respiratory disease, history of
falls, impaired cognition) should be avoided                                                             Prescribed BZD for insomnia                                  20%      31%
3.A medication order for BZD should not be valid for more than 2 weeks
4.If required for insomnia, a shorter-acting BZD (such as temazepam) is preferred                        Residents prescribed > 1 BZD                                 4%       5%
5.If required for insomnia, BZD should be prescribed to be taken as required “prn”
                                                                                                         Measures of Best Practice Criteria:
6.Only low doses should be prescribed (e.g. temazepam <10mg)
                                                                                                         1. Non-drug sleep measures documented*                       53%      96%
In February 2008 the National Prescribing Service conducted an audit of BZD usage at the                                                                                                             4. Use of shorter acting BZDs: The number of shorter acting BZDs used to treat insomnia
Barossa Village Residency. This audit re-examined the use of BZD in managing insomnia at                                                                                                             increased from 2008 to 2009, however this change was not statistically significant. The
                                                                                                         2. Residents on BZDs with risk factors for adverse effects   87%      74%
Barossa Village residency to assess the effectiveness of changes made at Barossa Village                                                                                                             potential for accumulation of long-acting BZD in elderly patients is well recognised and for this
following the previous audit.                                                                            3.1 BZD prescription < 4 weeks (all indications)             5%       14%                   reason it is recommended that temazepam be prescribed in preference to oxazepam, as it has
                                                                                                                                                                                                     a more rapid onset of action.
                                                                                                         3.2 BZD prescription > 6 months (all indications)*           95%      21%
                                                                                                                                                                                                     5. Use of ‘prn’ prescription: In both 2008 and 2009, 26% of residents on BZDs for insomnia
                                                                                                         4. BZD orders for temazepam                                  53%      44%                   were on ‘prn’ doses. It is important that ‘prn’ prescriptions are issued where possible at
                                                             Study dates: 1-3 September,                                                                                                             Barossa Village Residency as intermittent use of BZDs has been shown to reduce both
                                                             2009.                                       5.1 BZD prescriptions as ‘prn’ orders                        26%      26%                   tolerance and dependence of BZDs amongst the elderly.
                                                             Location:       Barossa    Village
                                                             Residency, a high-dependency                5.2 ‘Prn’ patients taking BZD in previous 7 days             0%       67%                   6. Use of lower doses of BZDs: Both audits found that only a few residents were prescribed
                                                             care facility in Nuriootpa, South                                                                                                       temazepam greater than 10mg. This finding is in accordance with the Criteria of Best Practice.
                                                             Australia.                                  6. Temazepam dose greater than 10mg                          0%       13%

                                                                                                         *statistically significant                                                                  Conclusion:
                                                             Participants: Participants were                                                                                                         This project confirmed the efficacy of implementations put in place following the 2008 audit.
                                                             seventy four residents from           1. Non-drug sleep measures: Currently, 96% of the residents being prescribed BZDs for             Specifically, changes to sleep care plan implementation as well as reducing length of BZD
                                                             Barossa Village Residency (20         insomnia had sleep care plans in place. A Fisher exact Test found this to be significantly        prescription were successful. In order to further improve BZD prescribing at Barossa Village
                                                             male, 54 female). Five new            greater than the number with sleep care plans in 2008 (P = 0.003). This result suggests that      Residency, regular medication reviews with a particular focus on BZDs in terms of the NPS best
                                                             residents were excluded from          information given to Barossa Village staff at the end of 2008 resulted in effective changes to    practice guidelines is recommended. This will ensure that Barossa Village Residency continues
                                                             the study due to lack of              sleep management.                                                                                 to successfully work towards a safer and more efficacious use of BZDs for insomnia for their
                                                             assessment.                                                                                                                             residents.
                                                                                                   2. Use of BZD with risk factors for adverse effects: No significant difference in the number of
                                                                                                   people on BZD with risk factors was found. Unfortunately, many elderly patients have risk         Acknowledgement:
                                                                                                   factors for adverse effects. A medication review for current residents involving a careful        The research team would like to thank Lyn Helbig, Neil Piller and the Staff at Barossa Village
                                                                                                   decision making process weighting the costs and benefits of BZDs may help to improve this         Residency for their help and support in completing this audit.
                                                                                                   figure in future.
Methods:                                                                                                                                                                                             1.     NPS    Limited,     National    Prescribing   Service    Newsletter     24,     Oct     2002.      Cited    at
                                                                                                   3. Length of BZD prescription: In 2008, 95% of residents taking BZDs for insomnia had been        <>, 2009
The NPS Drug Use Evaluation protocol3 was used to collect data from residents’ case notes          prescribed BZDs for greater than 6 months, compared to 21% in 2009. This difference is            2. Van der Hooft et al, Inappropriate benzodiazepine use in older adults and the risk of fracture, British Journal of
and medical charts. Patients currently prescribed BZD, were further reviewed. Information          statistically significant (χ2=23.998; P<0.001). This result suggests that there has been an       Clinical Pharmacology, 2008
collected from these patients included: Indication for use; dose and frequency; falls history;     effective change implemented to reduce the amount of time patients are prescribed BZDs in         3. NPS Limited, Drug use evaluation: Benzodiazepine and non-benzodiazepine hypnotics for insomnia in aged
cognitive impairment (psycho-geriatric assessment scale) and alternative sleep strategies.         accordance with the criteria of best practice. This was an encouraging finding, but 94% of        care homes, cited at <>, 2009
                                                                                                                                                                                                     4. Allin R/DATIS, Benzodiazepine Audit February 2008: Barossa Village Homes, 2008
The SPSS package Sigmastat 3.0 was used for all Chi-squared and Fischer exact tests to             prescriptions still exceeded the recommended two weeks3. Thus further consideration of this
compare the data to the February 2008 audit.                                                       criterion is needed to reduce the likelihood of tolerance, dependence and associated
                                                                                                   withdrawal symptoms associated with continued BDZ use.

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