Appropriate and safe prescribing for older adults is rendered difficult by the increased risk of side effects, drug-drug interactions and adverse events, due to associated comorbidities and high prevalence polypharmacy in this population [1, 2]. Prescriptions are considered inappropriate when potential risks outweigh potential benefits, and safer therapeutic alternatives exist that have similar or superior efficacy [3–5]. Avoiding the use of inappropriate and high-risk drugs is an important, simple and effective strategy in reducing medication-related problems and adverse drug events in older adults . The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults identifies, grades and qualifies potentially inappropriate medications. The criteria were developed by a panel of geriatric pharmacy experts who applied a modified Delphi method to a systematic review of all medications and graded the evidence to reach a consensus on a recommended list of drugs to avoid in older people [5–7].
Currently, far too many older adults are taking inappropriate prescriptions, which further increases the risk of adverse drug reactions and unnecessary hospitalizations [5, 8–11]. Inappropriate prescribing has been estimated to occur in 12 to 40% of community-dwelling non-hospitalized older adults aged over 60 years, depending on the criteria used and the country studied [3, 5, 9–14]. A conservative estimate of the incremental healthcare expenditures related to inappropriate prescribing among community-dwelling older adults is $7.2 billion in the United States .
Benzodiazepines represent one of the most prevalent inappropriate prescriptions, consumed by 19% of older adults (range 10 to 42%) . The new Beers list, released in 2012, recommends that all short- and long-acting benzodiazepine sedative-hypnotic drugs used for the treatment of anxiety and insomnia should be avoided in older adults, due to an excessive risk of delirium, falls, fractures and motor vehicle accidents [5, 16–19]. Benzodiazepines have also been shown to increase the risk of amnestic and non-amnestic cognitive impairment and may lead to incident dementia [20, 21].
Previous research has attempted to define the best strategy to inform and educate relevant parties, to try and implement safer prescribing practices, and to eliminate benzodiazepine use. The problem is that chronic benzodiazepine users develop a psychological dependence to benzodiazepines, and both physicians and consumers have difficulty implementing tapering protocols . Many patients deny or minimize side effects, or express reluctance to risk suffering without these medications . For these reasons physicians are hesitant about insisting on benzodiazepine discontinuation for fear of upsetting the doctor-patient relationship or because they believe that the patient tolerates the medication with minimal side effects .
Interventions to reduce benzodiazepine use in older people have been tested [24–47]. Several approaches have yielded insignificant results; other approaches, such as physician-targeted online drug audits, didactic educational activities and letters from physicians advising on risks associated with benzodiazepine use, have resulted in discontinuation rates ranging from 16 to 25% [43–47]. Despite achieving mild success in benzodiazepine discontinuation, these approaches are rarely feasible on a large scale and can be linked to extensive fees.
Targeting consumers directly as catalysts for engaging physicians and pharmacists in collaborative discontinuation of benzodiazepine drugs is a novel approach to reduce inappropriate prescriptions that has never been tested. Studies have shown that collaborative efforts to taper benzodiazepine use do not result in an increased workload for family physicians . This type of approach could empower patients to participate in medication safety, diminish physician workload and do so at lower costs than current approaches in changing medical practice.
The aim of the current cluster randomized controlled trial is to determine the effectiveness of an educational tool directed at older adults on subsequent cessation of benzodiazepine use.