European Journal of Clinical Pharmacology

, Volume 74, Issue 2, pp 233–241 | Cite as

Can clinical practice indicator relating to long-acting benzodiazepine use in the elderly be easily generated in a hospital setting?

  • Badria Kadri
  • Antonio Teixeira
  • Christelle Duteil
  • Annabelle Tan
  • Hélène Barreteau
  • Christophe Segouin
  • Pénélope Troude
Pharmacoepidemiology and Prescription



To improve the appropriate use of long-acting benzodiazepine (la.bzd) prescriptions in the elderly, the Haute Autorité de Santé (HAS) has developed clinical practice indicators (CPI). The alert indicator (AI) evaluates the prevalence of la.bzd prescription among older people. The mastering indicator (MI) corresponds to the prevalence of elderly with a justified, i.e., appropriate, la.bzd prescription among all the elderly with la.bzd prescriptions.


The objective of this study was to test the feasibility of routine generation of CPI regarding la.bzd prescriptions among the elderly in the hospital setting.


This was a retrospective study.


The study was conducted in two university hospitals located in Paris.


Eligible cases were patients aged 65 years and older who were hospitalized in acute care units from January to June 2014.


The AI calculation was based on information extracted from medical databases from these hospitals. The appropriateness of la.bzd prescription was assessed by a physician and a pharmacist and was based on review of computerized patient records and prescriptions, using an ad hoc algorithm. The MI was then calculated. Variation in the level of indicators was explored according to the characteristics of patients and of their hospitalization using chi2 test. Factors associated with a potentially inappropriate prescription (PIP) of la.bzd were studied using univariate and multivariate logistic regression.


Among the 4167 patients included in the study, 362 had la.bzd prescriptions, i.e., the AI was 9%. Prescriptions were found to be appropriate for 83 patients, i.e., the MI was 23% and PIP was 77%. The MI varied between 13 and 31% according to characteristics of patients and of hospitalization. In multivariate analysis, factors associated with PIP were age, number of comorbidities, type of care unit, and concurrent prescription of a neuroleptic or hypnotic.


Generation of the AI was routinely possible but only for acute care units with computerized prescriptions, corresponding to 78% of patients. Production of the MI has required medical record review for all patients with a la.bzd prescription and cannot be automated. However, difficulties in generating the MI have identified areas for significant improvement. Moreover, strategies to improve the care of older people with a la.bzd prescription could be targeted using characteristics of patients and of hospitalization associated with PIP. The future deployment of a single electronic medical record in all care departments would make it easier to mine the data and make possible automated production of CPI.


Potentially inappropriate prescription Long acting benzodiazepine Clinical practice indicator Older people 



The authors want to thank Maria Ramanisamanana and Anne Guillard for their precious technical help in Phedra database extraction. We want to thank Dr. Juliette Oliary for her advices regarding structure and quality of data in Phedra. We also thank Judith Armbruster and Mary Alice Parsons for their skillful assistance in reviewing the language of this manuscript.

Supplementary material

228_2017_2371_MOESM1_ESM.docx (76 kb)
ESM 1 (DOCX 75.7 kb)


  1. 1.
    Fauchais A-L, Ploquin I, Ly K, Rhaïem K, Bezanahary H, Tarnaud T, Soria P, Liozon E, Loustaud-Ratti V, Vidal E (2006) Adverse drug related events in a postemergency unit: prospective cohort study with 6 months follow up. Rev Med Interne 27(5):375–381. CrossRefPubMedGoogle Scholar
  2. 2.
    Atiqi R, van Bommel E, Cleophas TJ, Zwinderman AH (2010) Prevalence of iatrogenic admissions to the departments of medicine/cardiology/ =pulmonology in a 1,250 bed general hospital. Int J Clin Pharmacol Ther 48(8):517–524. CrossRefPubMedGoogle Scholar
  3. 3.
    Davies EC, Green CF, Taylor S, Williamson PR, Mottram DR, Pirmohamed M (2009) Adverse drug reactions in hospital in-patients: a prospective analysis of 3695 patient-episodes. PLoS One 4(2):e4439. CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Passarelli MCG, Jacob-Filho W, Figueras A (2005) Adverse drug reactions in an elderly hospitalised population: inappropriate prescription is a leading cause. Drugs Aging 22(9):767–777. CrossRefPubMedGoogle Scholar
  5. 5.
    Lau DT, Kasper JD, Potter DEB, Lyles A, Bennett RG (2005) Hospitalization and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents. Arch Intern Med 165(1):68–74. CrossRefPubMedGoogle Scholar
  6. 6.
    Bradley MC, Fahey T, Cahir C, Bennett K, O’Reilly D, Parsons C, Hughes CM (2012) Potentially inappropriate prescribing and cost outcomes for older people: a cross-sectional study using the Northern Ireland Enhanced Prescribing Database. Eur J Clin Pharmacol 68(10):1425–1433. CrossRefPubMedGoogle Scholar
  7. 7.
    Hill-Taylor B, Sketris I, Hayden J, Byrne S, O'Sullivan D, Christie R (2013) Application of the STOPP/START criteria: a systematic review of the prevalence of potentially inappropriate prescribing in older adults, and evidence of clinical, humanistic and economic impact. J Clin Pharm Ther 38(5):360–372. CrossRefPubMedGoogle Scholar
  8. 8.
    Atkin PA, Veitch PC, Veitch EM, Ogle SJ (1999) The epidemiology of serious adverse drug reactions among the elderly. Drugs Aging 14(2):141–152. CrossRefPubMedGoogle Scholar
  9. 9.
    Bourin M (2010) The problems with the use of benzodiazepines in elderly patients. Encéphale 36(4):340–347. CrossRefPubMedGoogle Scholar
  10. 10.
    Zubenko GS, Sunderland T (2000) Geriatric psychopharmacology: why does age matter? Harv Rev Psychiatry 7(6):311–333. CrossRefPubMedGoogle Scholar
  11. 11.
    Hebert C, Delaney JAC, Hemmelgarn B, Lévesque LE, Suissa S (2007) Benzodiazepines and elderly drivers: a comparison of pharmacoepidemiological study designs. Pharmacoepidemiol Drug Saf 16(8):845–849. CrossRefPubMedGoogle Scholar
  12. 12.
    Billioti de Gage S, Moride Y, Ducruet T, Kurth T, Verdoux H, Tournier M, Pariente A, Begaud B (2014) Benzodiazepine use and risk of Alzheimer’s disease: case-control study. BMJ 349(sep09 2):g5205. CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Chang CM, Chen MJ, Tsai CY, Ho LH, Hsieh HL, Chau YL, Liu CY (2011) Medical conditions and medications as risk factors of falls in the inpatient older people: a case-control study. Int J Geriatr Psychiatry 26(6):602–607. CrossRefPubMedGoogle Scholar
  14. 14.
    Berdot S, Bertrand M, Dartigues JF, Fourrier A, Tavernier B, Ritchie K et al (2009) Inappropriate medication use and risk of falls—a prospective study in a large community-dwelling elderly cohort. BMC Geriatr:9–30Google Scholar
  15. 15.
    Leipzig RM, Cumming RG, Tinetti ME (1999) Drugs and falls in older people: a systematic review and meta-analysis: I. Psychotropic drugs. J Am Geriatr Soc 47(1):30–39. CrossRefPubMedGoogle Scholar
  16. 16.
    Wang PS, Bohn RL, Glynn RJ, Mogun H, Avorn J (2001) Hazardous benzodiazepine regimens in the elderly: effects of half-life, dosage, and duration on risk of hip fracture. Am J Psychiatry 158(6):892–898. CrossRefPubMedGoogle Scholar
  17. 17.
    By the American Geriatrics Society Beers Criteria Update Expert Panel (2015) American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 63(11):2227–2246. CrossRefGoogle Scholar
  18. 18.
    O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P (2015) STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing 44(2):213–218. CrossRefPubMedGoogle Scholar
  19. 19.
    HAS (2012) AMI n°3: Benzodiazépines à demi-vie longue chez le sujets âgéGoogle Scholar
  20. 20.
    Eliot RA, Woodward MC, Oborne CA (2001) Improving benzodiazepine prescribing for elderly hospital inpatients using audit and multidisciplinary feedback. Int Med J 31:529–535CrossRefGoogle Scholar
  21. 21.
    Laroche ML, Charmes JP, Nouaille Y, Fourrier A, Merle L (2006) Impact of hospitalisation in an acute medical geriatric unit on potentially inappropriate medication use. Drugs Aging 23(1):49–59. CrossRefPubMedGoogle Scholar
  22. 22.
    Batty GM, Oborne CA, Swift CG, Jackson SH (2000) Development of an indicator to identify inappropriate use of benzodiazepines in elderly medical in-patients. Int J Geriatr Psychiatry 15(10):892–896.<892::AID-GPS213>3.0.CO;2-X CrossRefPubMedGoogle Scholar
  23. 23.
    Gauthier AC, Mattson RH (2015) Clobazam: a safe, efficacious, and newly rediscovered therapeutic for epilepsy. CNS Neurosci Ther 21(7):543–548. CrossRefPubMedGoogle Scholar
  24. 24.
    Mayo-Smith MF, Beecher LH, Fischer TL, Gorelick DA, Guillaume JL, Hill A, Jara G, Kasser C, Melbourne J (2004) Management of alcohol withdrawal delirium: an evidence-based practice guideline. Arch Intern Med 164(13):1405–1412. CrossRefPubMedGoogle Scholar
  25. 25.
    Kraemer KL, Conigliaro J, Saitz R (1999) Managing alcohol withdrawal in the elderly. Drugs Aging 14(6):409–425. CrossRefPubMedGoogle Scholar
  26. 26.
    Ashton H (1994) Guidelines for the rational use of benzodiazepines. When and what to use. Drugs 48(1):25–40. CrossRefPubMedGoogle Scholar
  27. 27.
    Brett J, Murnion B (2015) Management of benzodiazepine misuse and dependence. Aust Prescr 38(5):152–155.  10.18773/austprescr.2015.055 CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Clay E, Falissard B, Moore N, Toumi M (2013) Contribution of prolonged-release melatonin and anti-benzodiazepine campaigns to the reduction of benzodiazepine and Z-drugs consumption in nine European countries. Eur J Clin Pharmacol 69(4):1–10. CrossRefPubMedGoogle Scholar
  29. 29.
    Wagner J, Wagner ML (2000) Non-benzodiazepines for the treatment of insomnia. Sleep Med Rev 4(6):551–581. CrossRefPubMedGoogle Scholar
  30. 30.
    Laroche ML, Charmes JP, Merle L (2007) Potentially inappropriate medications in the elderly: a French consensus panel list. Eur J Clin Pharmacol 63:725–731CrossRefPubMedGoogle Scholar
  31. 31.
    Quan H, Li B, Couris CM, Fushimi K, Graham P, Hider P, Januel J-M, Sundararajan V (2011) Updating and validating the Charlson Comorbidity Index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol 173(6):676–682. CrossRefPubMedGoogle Scholar
  32. 32.
    Sun GW, Shook TL, Kay GL (1996) Inappropriate use of bivariable analysis to screen risk factors for use in multivariable analysis. J Clin Epidemiol 49(8):907–916. CrossRefPubMedGoogle Scholar
  33. 33.
    Lechevallier N, Fourrier A, Berr C (2003) Benzodiazepine use in the elderly: the EVA Study. Rev Epidemiol Sante Publique 51(3):317–326PubMedGoogle Scholar
  34. 34.
    Fourrier A, Letenneur L, Dartigues J, Moore N, Bégaud B (2001) Benzodiazepine use in an elderly community-dwelling population. Characteristics of users and factors associated with subsequent use. Eur J Clin Pharmacol 57(5):419–425. CrossRefPubMedGoogle Scholar
  35. 35.
    Johnell K, Fastbom J (2009) The use of benzodiazpines and related drugs amongst older people in Sweden: associated factors and concomitant use of other psychotropics. Int J Geriatr Psychiatry 24(7):731–738. CrossRefPubMedGoogle Scholar
  36. 36.
    Gallagher P, O’Mahony D (2008) STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers’ criteria. Age Ageing 37(6):673–679. CrossRefPubMedGoogle Scholar
  37. 37.
    Onda M et al (2015) Identification and prevalence of adverse drug events caused by potentially inappropriate medication in homebound elderly patients: a retrospective study using a nationwide survey in Japan. BMJ Open 5(8):e007581CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Gallagher P, Lang PO, Cherubini A, Topinková E, Cruz-Jentoft A, Montero Errasquín B, Mádlová P, Gasperini B, Baeyens H, Baeyens JP, Michel JP, O’Mahony D (2011) Prevalence of potentially inappropriate prescribing in an acutely ill population of older patients admitted to six European hospitals. Eur J Clin Pharmacol 67(11):1175–1188. CrossRefPubMedGoogle Scholar
  39. 39.
    Mo L, Yang X, He J, Dong B (2014) Evaluation of potentially inappropriate medications in older inpatients in China. J Am Geriatr Soc 62(11):2216–2218. CrossRefPubMedGoogle Scholar
  40. 40.
    Nam YS, Han JS, Kim JY, Bae WK, Lee K (2016) Prescription of potentially inappropriate medication in Korean older adults based on 2012 Beers Criteria: a cross-sectional population based study. BMC Geriatr 16(1):118. CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Hudhra K, Beçi E, Petrela E, Xhafaj D, García-Caballos M, Bueno-Cavanillas A (2016) Prevalence and factors associated with potentially inappropriate prescriptions among older patients at hospital discharge. J Eval Clin Pract 22(5):707–713. CrossRefPubMedGoogle Scholar
  42. 42.
    Liu CL, Peng LN, Chen YT, Lin MH, Liu LK, Chen LK (2012) Potentially inappropriate prescribing (IP) for elderly medical inpatients in Taiwan: a hospital-based study. Arch Gerontol Geriatr 55(1):148–151. CrossRefPubMedGoogle Scholar
  43. 43.
    Niborg G et al (2012) Inappropriate prescribing for the elderly—a modern epidemic? Arch Gerontol 68(7):1085–1094Google Scholar
  44. 44.
    Maidment R, Livingston G, Katona C (2002) Just keep taking the tablets: adherence to antidepressant treatment in older people in primary care. Int J Geriatr Psychiatry 17(8):752–757. CrossRefPubMedGoogle Scholar
  45. 45.
    MacLaughlin EJ, Raehl CL, Treadway AK, Sterling TL, Zoller DP, Bond CA (2005) Assessing medication adherence in the elderly: which tools to use in clinical practice? Drugs Aging 22(3):231–255.
  46. 46.
    Sidorkiewicz S, Tran V-T, Cousyn C, Perrodeau E, Ravaud P (2016) Discordance between drug adherence as reported by patients and drug importance as assessed by physicians. Ann Fam Med 14(5):415–421. CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2017

Authors and Affiliations

  1. 1.Public Health and Health Economics DepartmentAP-HP, Saint-Louis-Lariboisière Fernand-Widal Hospital GroupParisFrance
  2. 2.PharmacyAP-HP, Saint-Louis-Lariboisière Fernand-Widal Hospital GroupParisFrance
  3. 3.Geriatric DepartmentAP-HP, Saint-Louis-Lariboisière Fernand-Widal Hospital GroupParisFrance
  4. 4.INSERM UMR-S942, PRES Sorbonne Paris CitéUniversity Paris DiderotParisFrance

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