Use of benzodiazepines, depressive symptoms and cognitive function in old age

Impact of psychotropic medications on cognition among older adults: a systematic review

OBJECTIVES

The aim of this systematic review is to examine the cognitive impact of psychotropic medications including benzodiazepines, antidepressants, mood stabilizers, antipsychotics, or a combination of these drugs on older adults.

DESIGN

Systematic review.

SETTING

We searched Medline, PsycINFO, and Embase through the Ovid platform, CINAHL through EBSCO, and Web of Science.

PARTICIPANTS AND INTERVENTIONS

Randomized control trials (RCTs) and cohort studies that used a validated scale to measure cognition with a follow-up period of at least six months were included.

MEASUREMENT

The primary outcome of interest was cognitive change associated with psychotropic medication use.

RESULTS

A total of 7551 articles were identified from the primary electronic literature search across the five databases after eliminating duplicates. Based on full-text analysis, 27 articles (two RCTs, 25 cohorts) met the inclusion criteria. Of these, nine each examined the impact of benzodiazepines and antidepressants, five examined psychotropic combinations, three on antipsychotic drugs, and one on the effects of mood stabilizers.

CONCLUSIONS

This is the first systematic review to examine the cognitive impact of multiple psychotropic drug classes in older adults over an extended follow-up period (six months or more) using robust sample sizes, drug-free control groups, and validated cognitive instruments. We found evidence to indicate cognitive decline with the cumulative use of benzodiazepines and the use of antidepressants, especially those with anticholinergic properties among older adults without cognitive impairment at baseline. Further, the use of antipsychotics and psychotropic combinations is also associated with cognitive decline in older adults.

Sex differences in the associations of non-medical use of prescription drugs with depressive and anxiety symptoms among undergraduates in China

BACKGROUND

Non-medical use of prescription drugs (NMUPD) and their association with depression and anxiety are becoming global concerns. Biological sex may introduce differential exposure to NMUPD or depressive/anxiety symptoms. However, few studies have investigated the potential sex differences in the associations of NMUPD with depressive/anxiety symptoms.

METHODS

Data were drawn from the 2019 School-based Chinese College Students Health Survey. A total of 30,039 undergraduates (mean age: 19.8 [SD: 1.3] years) from sixty universities/colleges in China completed standard questionnaires and were included in the study (response rate: 97.7 %).

RESULTS

In the final adjusted model, non-medical use of opioids (experimenters: β = 1.10, [95 % CI, 0.62 to 1.57]) or sedatives (frequent users: β = 2.98, [95 % CI, 0.70 to 5.26]) was associated with depressive symptoms, while non-medical use of opioids (frequent users: β = 1.37, [95 % CI, 0.32 to 2.42]) or sedatives (frequent users: β = 1.19, [95 % CI, 0.35 to 2.03]) was also associated with anxiety symptoms. Sex-stratified analyses indicated that lifetime opioids misuse was associated with depressive symptoms in both sexes but with anxiety symptoms only in males (β = 0.39, [95 % CI, 0.09 to 0.70]). The association of lifetime sedative misuse with depressive symptoms was greater in males, while the significant association with anxiety symptoms remained only in female (β = 0.52, [95 % CI, 0.14 to 0.91]).

LIMITATIONS

Causal inference cannot be made due to the cross-sectional nature of the data.

CONCLUSIONS

Our study suggests NMUPD is associated with depressive and anxiety symptoms among Chinese undergraduates, and the associations may differ by sex.

Predicting benzodiazepine prescriptions: A proof-of-concept machine learning approach

Introduction

Benzodiazepines are the most commonly prescribed psychotropic medications, but they may place users at risk of serious adverse effects. Developing a method to predict benzodiazepine prescriptions could assist in prevention efforts.

Methods

The present study applies machine learning methods to de-identified electronic health record data, in order to develop algorithms for predicting benzodiazepine prescription receipt (yes/no) and number of benzodiazepine prescriptions (0, 1, 2+) at a given encounter. Support-vector machine (SVM) and random forest (RF) approaches were applied to outpatient psychiatry, family medicine, and geriatric medicine data from a large academic medical center. The training sample comprised encounters taking place between January 2020 and December 2021 (N = 204,723 encounters); the testing sample comprised data from encounters taking place between January and March 2022 (N = 28,631 encounters). The following empirically-supported features were evaluated: anxiety and sleep disorders (primary anxiety diagnosis, any anxiety diagnosis, primary sleep diagnosis, any sleep diagnosis), demographic characteristics (age, gender, race), medications (opioid prescription, number of opioid prescriptions, antidepressant prescription, antipsychotic prescription), other clinical variables (mood disorder, psychotic disorder, neurocognitive disorder, prescriber specialty), and insurance status (any insurance, type of insurance). We took a step-wise approach to developing a prediction model, wherein Model 1 included only anxiety and sleep diagnoses, and each subsequent model included an additional group of features.

Results

For predicting benzodiazepine prescription receipt (yes/no), all models showed good to excellent overall accuracy and area under the receiver operating characteristic curve (AUC) for both SVM (Accuracy = 0.868-0.883; AUC = 0.864-0.924) and RF (Accuracy = 0.860-0.887; AUC = 0.877-0.953). Overall accuracy was also high for predicting number of benzodiazepine prescriptions (0, 1, 2+) for both SVM (Accuracy = 0.861-0.877) and RF (Accuracy = 0.846-0.878).

Discussion

Results suggest SVM and RF algorithms can accurately classify individuals who receive a benzodiazepine prescription and can separate patients by the number of benzodiazepine prescriptions received at a given encounter. If replicated, these predictive models could inform system-level interventions to reduce the public health burden of benzodiazepines.

A phase 2 trial of inhaled nitrous oxide for treatment-resistant major depression

Nitrous oxide at 50% inhaled concentration has been shown to improve depressive symptoms in patients with treatment-resistant major depression (TRMD). Whether a lower concentration of 25% nitrous oxide provides similar efficacy and persistence of antidepressant effects while reducing the risk of adverse side effects is unknown. In this phase 2 clinical trial (NCT03283670), 24 patients with severe TRMD were randomly assigned in a crossover fashion to three treatments consisting of a single 1-hour inhalation with (i) 50% nitrous oxide, (ii) 25% nitrous oxide, or (iii) placebo (air/oxygen). The primary outcome was the change on the Hamilton Depression Rating Scale (HDRS-21). Whereas nitrous oxide significantly improved depressive symptoms versus placebo (P = 0.01), there was no difference between 25 and 50% nitrous oxide (P = 0.58). The estimated differences between 25% and placebo were -0.75 points on the HDRS-21 at 2 hours (P = 0.73), -1.41 points at 24 hours (P = 0.52), -4.35 points at week 1 (P = 0.05), and -5.19 points at week 2 (P = 0.02), and the estimated differences between 50% and placebo were -0.87 points at 2 hours (P = 0.69), -1.93 points at 24 hours (P = 0.37), -2.44 points at week 1 (P = 0.25), and -7.00 points at week 2 (P = 0.001). Adverse events declined substantially with dose (P < 0.001). These results suggest that 25% nitrous oxide has comparable efficacy to 50% nitrous oxide in improving TRMD but with a markedly lower rate of adverse effects.

Using a machine learning approach to investigate factors associated with treatment-resistant depression among adults with chronic non-cancer pain conditions and major depressive disorder

OBJECTIVE

Presence of chronic non-cancer pain conditions (CNPC) among adults with major depressive disorder (MDD) may reduce benefits of antidepressant therapy, thereby increasing the possibility of treatment resistance. This study sought to investigate factors associated with treatment-resistant depression (TRD) among adults with MDD and CNPC using machine learning approaches.

METHODS

This retrospective cohort study was conducted using a US claims database which included adults with newly diagnosed MDD and CNPC (January 2007-June 2017). TRD was identified using a clinical staging algorithm for claims data. Random forest (RF), a machine learning method, and logistic regression was used to identify factors associated with TRD. Initial model development included 42 known and/or probable factors that may be associated with TRD. The final refined model included 20 factors.

RESULTS

Included in the sample were 23,645 patients (73% female mean age: 55 years; 78% with ≥2 CNPC, and 91% with joint pain/arthritis). Overall, 11.4% adults (N = 2684) met selected criteria for TRD. The five leading factors associated with TRD were the following: mental health specialist visits, polypharmacy (≥5 medications), psychotherapy use, anxiety, and age. Cross-validated logistic regression model indicated that those with TRD were younger, more likely to have anxiety, mental health specialist visits, polypharmacy, and psychotherapy use with adjusted odds ratios (AORs) ranging from 1.93 to 1.27 (all ps < .001).

CONCLUSION

Machine learning identified several factors that warrant further investigation and may serve as potential targets for clinical intervention to improve treatment outcomes in patients with TRD and CNPC.

Is Long-Term Benzodiazepine Use a Risk Factor for Cognitive Decline? Results of a Systematic Review

Background and Aims

Benzodiazepines have been widely used for long periods of time despite their adverse effects. The acute effects on cognition are well established. However, less is known about the long-term effects. This study critically reviewed existing evidence of the association between long-term exposure to benzodiazepines and risk of cognitive decline in adults.

Methods

A systematic review with narrative synthesis was conducted. PubMed and PsycINFO databases were searched using combinations of keywords related to “benzodiazepines” and “cognitive function” from database inception to 12 February 2018 to identify prospective longitudinal studies. The records were evaluated for relevance according to the inclusion and exclusion criteria.

Results

Fourteen studies involving 2145 long-term benzodiazepine users were included. Meta-analysis was not undertaken because the combined result would not be meaningful as the included studies differed in several key aspects such as frequency and duration of benzodiazepine use, follow-up periods, cognitive domains, cognitive tests, scoring systems, and statistical analysis. The definition of long-term benzodiazepine use was problematic in all the studies. The exposure was determined by measures which were assumed to represent the whole period in-between the follow-ups. Only 3 of the 14 studies provided support for an association between long-term benzodiazepine use and cognitive decline with a small to medium effect size. However, these three studies used different methods to assess the strength of this association. Global cognitive functioning, verbal memory, intelligence, psychomotor speed, and speed of processing were the cognitive domains affected which also varied across these three studies.

Conclusions

Little evidence of an association between long-term benzodiazepine use and a higher risk of cognitive decline among the general adult population was found. However, discrepancies among the results and inconsistencies regarding the cognitive domains affected and methodological limitations prevent definite conclusions. Therefore, future research with prospective studies specially designed would be of great value.

The Effects of Benzodiazepine Use and Abuse on Cognition in the Elders: A Systematic Review and Meta-Analysis of Comparative Studies

OBJECTIVE

Benzodiazepines (BZD) are one of the most frequently prescribed drugs worldwide. However, the cognitive effects of benzodiazepines in the elderly are highly debated. This systematic review and meta-analysis aims to explore the following two questions in the elderly population: (i) Do BZD lead to any impairments in cognitive functions in elderly users? and (ii) Which specific cognitive domains are most affected by BZD use and abuse?

METHODS

First, we performed a literature search following the PRISMA guidelines. Electronic databases, including PubMed, PsycINFO, EMBASE, Cochrane Library, and Web of Science were searched until May 14^th, 2020. After selecting the relevant articles, we integrated the results of the selected studies with a standardized cognitive classification method. Next, we performed meta-analyses with the random-effects model on the cognitive results. Finally, we specifically examined the cognitive impairments of BZD in the abuse subgroup.

RESULTS

Of the included studies, eight of the thirteen had meta-analyzable data. Compared to the controls, elderly BZD users had significantly lower digital symbol test scores (n=253; SMD: -0.61, 95% CI: -0.91 to 0.31, I² = 0%, p < 0.0001). There was no significant difference in Mini-Mental State Examination, Auditory Verbal Learning Test, and Stroop Color and Word Test scores between BZD users and controls. According to the subgroup analyses, BZD abusers performed significantly worse than controls in Mini-Mental State Examination (n=7726; SMD: -0.23, 95% CI: -0.44 to -0.03, I² = 86%, p = 0.02), while there was no significant difference between the regular BZD users and the controls (n=1536; SMD: -0.05, 95% CI: -0.59 to 0.48, I² = 92%, p =0.85).

CONCLUSION

In the elderly population, the processing speed (digital symbol test scores) was significantly impaired in BZD users; global cognition (Mini-Mental State Examination scores) was significantly impaired in BZD abusers but not in BZD regular users. This study provides insight into the factors that interact with BZD cognitive effects, such as aging, testing tools, and abuse. Clinicians should be cautious when prescribing BZD for the elderly.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, identifier CRD42019124711.

Is the Long-Term Use of Benzodiazepines Associated With Worse Cognition Performance in Highly Educated Older Adults?

Background: Benzodiazepines (BZD) are common medications for sedative, hypnotic, and anxiolytic that are especially prevalent in older adults. Previous studies have shown that BZD use could impair users' cognition, significantly affecting their quality of life. Past research has shown that higher education might play a protective role in the process of cognitive decline. Very few studies had examined the cognitive effects of BZD on highly educated older adults. The study aimed to explore how cognitive functions would be affected by benzodiazepines among highly educated older adults. Method: 140 older adults with an average education period of 14.8 years were included in this study. The subjects were divided into three separate groups, the long-term BZD users (≥180 days), short-term BZD users (<180 days), and non-users. Demographics and cognitive assessments for the three groups were analyzed using the analysis of variance (ANOVA), the chi-squared test, and the analysis of covariance (ANCOVA). To examine the association between BZD use and cognition a multiple linear aggression approach was used. Result: All three groups were significantly different from each other when looking at executive functioning in the Trail Making Test B (TMT-B). Compared to the control group, short-term BZD users showed significant defects in TMT-B time (p = 0.002) and TMT-B errors (p < 0.001); long-term BZD users showed significant defect on TMT-B time (p = 0.041). Compared to short-term BZD users, long-term BZD users showed significant merit on TMT-B errors (p = 0.001). No significant differences were found in other cognitive tasks that reflected general cognition, verbal memory, language fluency, and visual memory. After adjusting for demographic, increased BZD use over time was positively associated with scores for the revised Brief Visuospatial Memory Test (r = 0.377, p = 0.012). Conclusion: BZD use may be significantly associated with worse executive functioning in highly educated older adults. However, there is no association between the duration of BZD use and increased cognitive deficits in highly educated older adults. This study identified future experimental directions including potential longitudinal studies, within-subject studies comparing mood disorder patients' cognitive performance before and after onset of BZD use, and between-subject studies that directly compare BZD's effect on subjects with the same baseline of cognitive functioning.

Is Benzodiazepine Use Associated With the Risk of Dementia and Cognitive Impairment–Not Dementia in Older Persons? The Canadian Study of Health and Aging

Background: The use of benzodiazepines in relation to cognitive decline remains an area of controversy in aging populations. Objective: This study aims to evaluate the risk of cognitive impairment–not dementia (CIND), Alzheimer disease (AD), and all-cause dementia with benzodiazepine use. The effect modification by sex was also investigated. Methods: Data come from the Canadian Study of Health and Aging, a 10-year multicentric study involving 10 263 participants randomly selected, 65 years and older, living in the community and in institutions. Current exposure to benzodiazepines was assessed in a face-to-face interview or self-reported in a questionnaire. Cox proportional hazard regression models, using age as time scale, were conducted to estimate hazard ratios, with adjustment for sex, education, smoking, alcohol intake, depression, physical activity, nonsteroidal anti-inflammatory drug use, and vascular comorbidities. Results: Data sets included 5281 participants for dementia as the outcome, 5015 for AD, and 4187 for CIND. Compared with nonusers, current use of benzodiazepines was associated with an increased risk of CIND (hazard ratio = 1.36; 95% CI = 1.08-1.72) in the simplest model. Results remained similar in the fully adjusted model (hazard ratio = 1.32; 95% CI = 1.04-1.68). There was no association between benzodiazepine use and the risk of dementia or AD. All these effects were similar between men and women. Conclusion and Relevance: Benzodiazepine use in older people from the general population is related to subsequent occurrence of cognitive dysfunction but not implicated in the pathogenesis of dementia or AD. Caution should be exercised when prescribing benzodiazepines to preserve global cognitive function.

Mortality in older adults with frequent alcohol consumption and use of drugs with addiction potential - The Nord Trøndelag Health Study 2006-2008 (HUNT3), Norway, a population-based study

Background

The aim of this study was to investigate whether frequent drinking, use of drugs with addiction potential and the possible combination of frequent drinking and use of prescribed drugs with addiction potential were associated with all-cause mortality in older adults.

Methods

We used data from the Nord-Trøndelag Health Study (HUNT3 2006–08), a population-based study in Norway. A total of 11,545 (6,084 women) individuals 65 years and older at baseline participated. We assessed frequent drinking (≥ 4 days a week), occasional drinking (i.e. a few times a year), never drinking and non-drinking in the last year. Drugs with addiction potential were defined as at least one prescription of benzodiazepines, z-hypnotics or opioids during one year for a minimum of two consecutive years between 2005 and 2009. This information was drawn from the Norwegian Prescription Database. The main outcome was all-cause mortality with information drawn from the Norwegian Cause of Death Registry. Follow-up continued until death or latest at 31 December 2013. Logistic regression analyses were used to investigate all-cause mortality since date of study entry and exact age at time of death was unknown.

Results

The adjusted logistic regression analyses showed that frequent drinking was not associated with all-cause mortality compared to occasional drinking. Men who reported to be never drinkers and non-drinkers in the last year had higher odds of mortality compared to those who drank occasionally. Use of prescribed drugs with addiction potential was associated with increased mortality in men, but not in women. No association was found between the possible combination of frequent drinking and use of prescribed drugs with addiction potential and mortality.

Conclusion

Neither frequent drinking nor the possible combination of frequent drinking and use of prescribed drugs with addiction potential were associated with all-cause mortality in older women and men. Use of prescribed drugs with addiction potential was associated with higher odds of mortality in men. This finding should lead to more caution in prescribing drugs with addiction potential to this group.

Mortality associated with anxiolytic and hypnotic drugs-A systematic review and meta-analysis

BACKGROUND

Use of hypnotics or anxiolytic drugs is common and various studies have reported increased mortality with hypnotics or anxiolytic use.

OBJECTIVE

To consolidate the evidence on mortality risk associated with hypnotics or anxiolytic use

METHODS

Major databases were searched through April 2014 for studies reporting mortality risk associated with hypnotics or anxiolytics use. A pooled hazard ratio with 95% confidence interval was estimated using random-effects model.

RESULTS

After screening 2188 articles, 25 studies (24 cohort, 1 case-control) enrolling 2,350,093 patients with 59% females (age 18-102 years) were included in the meta-analysis. Hypnotics or anxiolytic users had 43% higher risk of mortality than non-users (hazard ratio, 1.43; 95% confidence interval, [1.12, 1.84]). Eight studies reported risk estimates for each gender category and pooled results from these studies showed increased risk of mortality among men (hazard ratio = 1.60, 95% confidence interval = [1.29,1.99]) and women (hazard ratio = 1.68, 95% confidence interval = [1.38, 2.04]). Pooled results from 10 studies showed higher mortality among benzodiazepine users compared to non-users (hazard ratio = 1.60, 95% confidence interval = [1.03, 2.49]), while pooled results from five studies showed an increased risk of mortality with Z-drugs use although the effect could not reach statistical significance (hazard ratio = 1.73, 95% confidence interval = [0.95, 3.16]). Significant heterogeneity was observed in the analyses and the quality of included studies was good.

CONCLUSION

This meta-analysis suggests that hypnotics or anxiolytics drugs use is associated with increased mortality and hence should be used with caution. Future studies focused on underlying mechanism of increased mortality with hypnotics or anxiolytics use are required.

The impact of chronic benzodiazepine use on cognitive evolution in nursing home residents

OBJECTIVE

Chronic use of benzodiazepines and Z-drugs (BZD/Zs) has been linked to cognitive decline. In this one-year prospective cohort study, we explored the impact of chronic BZD/Z use on cognitive decline compared to nonusers.

METHODS

In cognitively capable BZD/Z users and nonusers in 10 Belgian nursing homes, we investigated cognition with the MiniMentalStateExamination(MMSE) at baseline and one year. A decrease of ≥ 4 points on the MMSE (clinically relevant decrease) was used in multiple logistic regression. We collected baseline demographics, functional, psychometric and social characteristics potentially influencing cognition.

RESULTS

In both the 131 BZD/Z users and 95 nonusers, the cognition decreased significantly over time, but without significant difference between the groups. Clinically relevant decrease was present in 34% BZD/Z users and 27% nonusers (NS). Controlled for age, gender, education and BZD/Z use, the significant risk factors for clinically relevant cognitive decline were depression, hearing and functional impairment. Frequent reading was associated with less MMSE decrease. Our findings could not demonstrate with statistical significance that BZD/Z use was associated with fast cognitive decline. The risk factors for fast decline were depression, hearing and functional impairment, and the absence of a reading attitude. In addition, BZD/Z use and depression were associated, indicating a complex relationship.

[Remote consequences of the long-term uncontrolled use of anxiolytic and hypnotic drugs by elderly patients: cognitive disorders]

OBJECTIVE

Frequents cases (10-30% of the elderly population) of regular long-term use of anxiolytic and hypnotic drugs, in particular, benzodiazepines, without control of the physician is an urgent problem of medicine worldwide. Severe and irreversible cognitive impairment is a frequent and severe consequence of this use. Authors studied cognitive impairment in these cases.

MATERIAL AND METHODS

Patients were enrolled in the study from a psychiatric hospital. The study included 56 women, aged over 50 years, admitted to the hospital with the diagnosis of a mental disorder. Before admission, the patients regularly used benzodiazepines without a prescription for more than 2 months. Later on, anxiolytics were withdrawn during 1-5 days. The patients were studied during 4 weeks in the hospital. To assess the severity and dynamics of their condition, authors used MADRS, HAM-A, MMSE.

RESULTS AND CONCLUSION

Severe cognitive impairment, achieving the level of dementia, was found in 57.2% of the patients, mild or moderate of cognitive impairment was in 32.1% and only 10.7% had normal level of cognitive functioning. After 4 weeks of benzodiazepine withdrawal, the percentage of patients with dementia reduced to 21.4%, the severity of cognitive impairment was estimated as mild or moderate. A number of patients without cognitive impairment increased to 37.5%. The old age of patients was a significant negative predictor of the dynamics. An impact of the high anxiolytic dose was shown on trend level. The duration of a mental disorder and duration of uncontrollable consumption of anxiolytics and hypnotics did not exert an effect on the development and reversibility of cognitive impairment. A combination of anxiolytics with alcohol increased the risk of dementia and did not reverse the cognitive pathology.

Screening for alcohol and substance use for older people in geriatric hospital and community health settings

BACKGROUND

We aimed to determine the rates of alcohol and substance use in geriatric hospital and community health settings, and to evaluate the performance of screening instruments.

METHOD

A two-phase cross-sectional study was undertaken in geriatric and aged care psychiatry wards and associated community services of a teaching hospital. Participants were screened with the Brief Alcohol Use Disorders Identification Test (AUDIT-C) and the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) for other substances; Geriatric Depression Scale-15 for mood; the Connor-Davidson Resilience Scale; and the Subjective Quality of Life scale. Medical conditions were established. Screen positives for risky substance use continued with the full AUDIT, full ASSIST, CAGE, Addenbrooke's Cognitive Examination-Revised, and the Functional Activities Questionnaire. Medical records were reviewed after three months to ascertain recognition and management of substance use.

RESULTS

Of 210 participants aged 60+ (mean age 81.9, 63.3% female) without dementia or delirium and Mini Mental State Examination score ≥24, 41 (19.5%) were screen positive - 36 (17.1%) for alcohol, seven for non-medical benzodiazepine use (3.3%) (four alcohol and benzodiazepine) and two for non-medical opioid use (0.95%). Screen positives differed from screen negatives on few demographic or health measures. On the ASSIST, 26 (12.4%) were rated as medium/high risk. The AUDIT-C with cut-point of ≥5 was the optimal measure for detecting risky alcohol use.

CONCLUSIONS

Many patients in geriatric health services have risky alcohol or substance use, but few clinical features distinguish them from other patients. Routine screening of alcohol and substance use is recommended.

Long-term benzodiazepine use in patients with major depressive disorder in China

PURPOSE

There have been no data about long-term benzodiazepine (BZD) use and its correlates in patients with major depressive disorder (MDD) in China. This study aimed to examine the prevalence of long-term BZD use (more than three months) and its demographic and clinical correlates in Chinese patients with MDD.

DESIGN AND METHODS

A total of 1,192 patients with MDD were examined in 10 mental health centers in China. Patients' socio-demographic and clinical characteristics and prescriptions for psychotropic drugs were recorded using a standardized form.

FINDINGS

A large portion of patients (36.2%) received long-term BZD treatment. Univariate analyses revealed that long-term BZD users were older, poorer, and had more impaired occupational functioning than patients not taking BZDs. Long-term BZD users had fewer psychotic symptoms and took less antipsychotic drugs. In multivariate analyses, long-term BZD use was independently associated with older age and more severe impaired occupational functioning; long-term BZD users were less likely to receive antipsychotic medications and traditional antidepressants (tricyclic antidepressants, tetracyclic antidepressant, and monoamine oxidase inhibitors).

PRACTICE IMPLICATIONS

Long-term BZD use was common in patients with MDD in China. A host of demographic and clinical factors were independently associated with long-term BZD use.

Understanding older peoples' decisions about the use of sleeping medication: issues of control and autonomy

Poor sleep is known to impact on health and wellbeing in later life and has implications for the ability of older people to remain active during the day. Medical treatments for chronic poor sleep have primarily included the regular, long-term prescribing of hypnotics, which are known to impact on older people's health, cognitive function and quality of life. Therefore, recent policy and practice has focused on reducing such prescribing, on encouraging older people to stop taking long-term hypnotics and on finding alternative, non-pharmacological ways to manage poor sleep. However, little research has been undertaken to understand the perspectives of older people who choose not to seek professional help for their poor sleep, despite the potential impact of poor sleep on their health and ability to remain active. Through in-depth interviews with 62 older men and women living in their own homes in England, this article explores the factors that deter older people from seeking professional help for their poor sleep. We argue that these are located in their perceptions of the normativity of poor sleep in later life, their beliefs about prescription sleeping medications and their desire to maintain control and autonomy over their everyday and night lives.

Sleep in older people

Insomnia and other sleep disturbances are common in older people, with up to 40% reporting some difficulty sleeping. Insomnia is a syndrome with multiple causes including medications, other illnesses and environmental factors. An accurate diagnosis is needed for effective management. Sleep disturbances are associated with functional and cognitive impairment and excess mortality. Management should initially be non-pharmacological including sleep hygiene education and behavioural therapy. Medications, including benzodiazepines (BZDs), are second-line with little evidence to support long-term usage. BZD usage in older people is associated with a range of disorders including falls, accidents and cognitive impairment. The management of insomnia in specific situations such as residential care, those with dementia and depressed older people can be challenging. Additional research is needed, particularly on the risks/benefit of long-term pharmacotherapy and to determine whether therapy reduces the consequences of sleep disturbances.

Ten-year trends in benzodiazepine use in the Dutch population

BACKGROUND

In the past decades knowledge on adequate treatment of affective disorders and awareness of the negative consequences of long-term benzodiazepine use increased. Therefore, a decrease in benzodiazepine use is expected, particularly in prolonged use. The aim of this study was to assess time trends in benzodiazepine use.

METHODS AND MATERIAL

Data from the Longitudinal Aging Study Amsterdam (LASA) were used to investigate trends in benzodiazepine use between 1992 and 2002 in two population-based samples aged 55-64 years. Differences between the two samples with respect to benzodiazepine use and to sociodemographic, physical health and mental health characteristics were described and tested with chi-square tests and logistic regression analyses.

RESULTS

Benzodiazepine use remained stable over 10 years, with 7.8% in LASA-1 (n = 874) and 7.9% in LASA-2 (n = 919) (p = 0.90) with a persisting preponderance in women and in people with low education, low income, chronic physical diseases, functional limitations, cognitive impairment, depression, anxiety complaints, sleep problems and when using antidepressants. Long-term use remained high with 70% in 1992 and 80% in 2002 of total benzodiazepine use.

CONCLUSION

In the Dutch population aged 55-64, overall benzodiazepine use remained stable from 1992 to 2002, with a high proportion of long-term users, despite the effort to reduce benzodiazepine use and the renewal of the guidelines. More effort should be made to decrease prolonged benzodiazepine use in this middle-aged group, because of the increasing risks with ageing.

Sedative use and incident cognitive decline among persons aged 75 years and older: a population-based longitudinal study

BACKGROUND

Acute exposure to sedative drugs may induce memory impairment, but there is mixed evidence that long-term sedative use may result in incident cognitive decline. The objective of this study was to investigate the use of sedative drugs and incident cognitive decline in a population-based sample of persons aged 75 years and older.

METHODS

The study sample comprised 781 participants in the Geriatric Multidisciplinary Strategy for the Good Care of the Elderly (GeMS) study in Kuopio, Finland. Data on health status, drug use, and sociodemographic factors were elicited during annual nurse interviews from 2004 to 2007. A linear mixed model was used to compare change in Mini-Mental State Examination (MMSE) scores (2005-2007) among users of sedative drugs in 2004 and 2005 (n = 139) to non-users of sedative drugs from 2004 to 2007 (n = 310). The model was adjusted for covariates including age, gender, education, depressive symptoms and antipsychotic use.

RESULTS

Unadjusted mean MMSE scores were 27.50 in 2005, 26.58 in 2006, and 25.95 in 2007 among users of sedative drugs. Unadjusted mean MMSE scores were 28.05 in 2005, 27.61 in 2006, and 27.09 in 2007 among non-users of sedative drugs. Adjusted mean MMSE scores were 0.31 points lower in 2005, 0.62 points lower in 2006, and 0.93 lower in 2007 among users compared to non-users of sedative drugs (P = 0.051).

CONCLUSIONS

Sedatives were not associated with statistically significant cognitive decline. However, clinicians should maintain a judicious approach to prescribing sedative drugs given the risk of adverse drug events.

Benzodiazepine use in Belgian nursing homes: a closer look into indications and dosages

AIM

(1) To describe the prevalence of benzodiazepine use in Belgian nursing homes, with specific attention to indications and dosages. (2) To compare actual and recommended dosages of benzodiazepines for anxiety and insomnia. (3) To explore the risk profile for chronic benzodiazepine use in institutionalised older adults.

METHODS

Medication charts of 1,730 residents from 76 nursing homes in Belgium were collected and analysed, using the ATC classification. Drug name, indication and daily dosage were recorded. From authoritative international sources, we extracted for each drug and each indication a daily dosage recommended not to be exceeded in older adults for comparison with observed actual dosages.

RESULTS

Among the chronic benzodiazepine or z-drug (BZD/Z) users (50% of the residents), the leading indication was 'insomnia' (59% of the users) followed by 'anxiety' (17%) and 'unrest' (10%). In the chronic prescriptions of BZD/Zs indicated for insomnia, the actual daily dose exceeded the geriatric upper limit in 95% of lormetazepam prescriptions, 82% of zolpidem, 78% of zopiclone and 35% of lorazepam prescriptions. For anxiety, daily doses also exceeded the limit but not to the same extent. Multivariate analysis showed BZD/Z use was positively associated with pain (OR 1.58, 95% CI 1.27-1.97), constipation (OR 1.43, 95% CI 1.16-1.76) and depression (OR 1.68, 95% CI 1.35-2.08). Residents with dementia were less likely to receive a BZD/Z (OR 0.60, 95% CI 0.48-0.74).

CONCLUSION

Efforts to reduce the use of BZD/Zs in nursing homes should concentrate on insomnia, with interventions aimed at reducing too high prevalence of chronic use and too high daily dosages in this indication.

Change in psychotropic drug use among community-dwelling people aged 75 years and older in Finland: repeated cross-sectional population studies

BACKGROUND

Older people are at high risk of experiencing psychotropic-related adverse drug events. The objective of this study was to compare and contrast the use of psychotropic drugs among community-dwelling people aged ≥ 75 years in 1998 and 2004.

METHODS

Comparable random samples of people aged ≥ 75 years were extracted from the population register in Kuopio, Finland, in 1998 (n = 700) and 2003 (n = 1000). In 1998 and 2004, 523 and 700 community-dwelling people respectively participated in nurse interviews, during which demographic, diagnostic and drug use data were elicited. Logistic regression was used to compute unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the prevalence of psychotropic drug use in 2004 compared to 1998.

RESULTS

The unadjusted prevalence of total psychotropic (37.3% and 38.4%, OR 1.05; 95% CI 0.83-1.33), anxiolytic, hypnotic and sedative (29.6% and 31.3%, OR 1.08, 95% CI 0.85-1.38), and antidepressant (10.7% and 11.9%, OR 1.12, 95% CI 0.78-1.61) use were similar in 1998 and 2004. There was a decrease in the unadjusted prevalence of antipsychotic use (9.2% and 5.7%, OR 0.60; 95% CI 0.39-0.93). After adjusting for socioeconomic and health status differences, there was an increase in the prevalence of total psychotropic (adjusted OR 1.31, 95% CI 1.01-1.70) and antidepressant (OR 1.59, 95% CI 1.06-2.40) use.

CONCLUSION

The unadjusted prevalence of psychotropic drug use remained stable between 1998 and 2004. However, in adjusted analyses there was a small increase in the prevalence of any psychotropic drug use and antidepressant use specifically.

Heavy drinking and use of sedative or anxiolytic drugs among aging men: an 11-year follow-up of the FinDrink study

BACKGROUND

Most studies on heavy drinking and sedative/anxiolytic drug use have been cross-sectional, and evidence for a possible temporal association is lacking.

OBJECTIVE

To prospectively investigate whether heavy drinking predicts initiation, continuation, or discontinuation of sedative/anxiolytic drugs at 4 and 11 years and, conversely, whether sedative/anxiolytic drug use predicts heavy drinking.

METHOD

This was a longitudinal population-based study conducted in Kuopio, Finland. An age-stratified random sample of 1516 men aged 42, 48, 54, and 60 years received a structured clinical examination at baseline (August 1986-December 1989). Follow-up clinical examinations were conducted at 4 (n = 1038) and 11 (n = 854) years. Multinomial logistic regression was used to compute odds ratios and 95% confidence intervals for the association between sedative/anxiolytic drug use and initiation, continuation, and discontinuation of heavy drinking (≥ 14 drinks/wk). The reverse association between heavy drinking and sedative/anxiolytic drug use was also investigated. Regression models were adjusted for age, working status, smoking, and depressive symptoms.

RESULTS

At baseline 12.9% (134/1038) of participants were heavy drinkers and 4.0% (41/1030) used sedative/anxiolytic drugs. In multivariate analyses, baseline heavy drinking predicted initiation of sedative/anxiolytic drug use at 4 years (OR 2.96; 95% CI 1.23 to 7.15). Conversely, baseline sedative/anxiolytic drug use predicted continuation of heavy drinking at 11 years in unadjusted analysis (OR 3.30; 95% CI 1.19 to 8.44). However, the association was not statistically significant in adjusted analyses (OR 2.69; 95% CI 0.86 to 8.44).

CONCLUSIONS

The main finding of this study was the association between heavy drinking and subsequent initiation of sedative/anxiolytic drugs that was not fully explained by baseline depressive symptoms. This may inform strategies to optimize the use of sedative/anxiolytic drugs, and assist in the early identification of patients at risk of heavy drinking. Clinicians should consider a patient's alcohol consumption prior to prescribing or dispensing sedative/anxiolytic drugs. Clinicians should also monitor patients prescribed sedative/anxiolytic drugs for subsequent heavy drinking.

Mortality associated with benzodiazepines and benzodiazepine-related drugs among community-dwelling older people in Finland: a population-based retrospective cohort study

OBJECTIVE

To investigate the association between the use of benzodiazepines (BDZs) and BDZ-related drugs and mortality among community-dwelling people aged 65 years and older in Finland.

METHOD

This was a population-based retrospective cohort study. Records of all reimbursed drugs purchased by all 2224 residents of Leppävirta, Finland, aged 65 years and older in 2000 were extracted from the Finnish National Prescription Register. Diagnostic data were extracted from the Special Reimbursement Register. All-cause mortality was assessed after 9 years using national registers. Cox proportional hazards models were used to compute unadjusted and adjusted hazard ratios (HRs) and 95% confidence intervals for mortality among prevalent users of BDZs and BDZ-related drugs in 2000 (n = 325), compared with nonusers of BDZs and BDZ-related drugs between 2000 and 2008 (n = 1520).

RESULTS

BDZs and BDZ-related drugs were used by 325 out of the 2224 residents (14.6%) in 2000. The 9-year mortality was 50.2% among BDZ and BDZ-related drug users in 2000 and 36.3% among BDZ and BDZ-related drug nonusers between 2000 and 2008 (HR 1.53; 95% CI 1.28 to 1.82). After adjusting for baseline age, sex, antipsychotic drug use, and diagnostic confounders, the HR was 1.01 (95% CI 0.84 to 1.21).

CONCLUSIONS

Use of BDZs and BDZ-related drugs was associated with an increased mortality hazard in unadjusted analyses. However, after adjusting for age, sex, antipsychotic drug use, and diagnostic confounders, the use of BDZs and BDZ-related drugs was not associated with excess mortality.

Sedative load among long-term care facility residents with and without dementia: a cross-sectional study

BACKGROUND AND OBJECTIVE

People with cognitive impairment are particularly susceptible to adverse drug events linked to sedative and psychotropic drugs. A model to calculate sedative load has been developed to quantify the cumulative effect of taking multiple drugs with sedative properties. The objective of this study was to describe the sedative load and use of sedative and psychotropic drugs among long-term care facility residents with and without dementia.

METHODS

Cross-sectional data were collected from all 53 long-term care wards in Helsinki, Finland, in September 2003. Of the 1444 eligible residents, consent to participate was obtained for 1087 (75%) residents. Medication and diagnostic data were available for 1052 residents. All drugs were classified using the Anatomical Therapeutic Chemical (ATC) classification system. Sedative load was calculated for each resident using a previously published four-group model.

RESULTS

Of the 1052 residents, 781 (74.2%) were determined to have dementia. Residents with and without dementia had a similar sedative load (mean 3.0 vs 2.7, p = 0.267), but residents with dementia were taking fewer drugs than residents without dementia (mean 6.7 vs 7.4, p = 0.011). Residents with dementia were more frequent users of antipsychotics (42.8% vs 32.8%, p = 0.004), but less frequent users of antidepressants (35.6% vs 46.1%, p = 0.002) and sedative-hypnotics (22.8% vs 27.7%, p = 0.003) than residents without dementia. The most frequently used primary sedatives among people with dementia were temazepam (n = 122, 15.6%), oxazepam (n = 98, 12.5%) and lorazepam (n = 95, 12.2%). The most frequently used drugs with sedation as a prominent adverse effect or preparations with a sedating component among people with dementia were citalopram (n = 183, 23.4%), risperidone (n = 155, 19.8%) and olanzapine (n = 73, 9.3%).

CONCLUSIONS

Residents with dementia were less frequent users of sedative-hypnotic drugs than residents without dementia. However, residents with and without dementia had a similar sedative load. Clinicians should be aware of the extent to which all individual drugs, not only those prescribed for intentional sedation, contribute to a resident's sedative load. The very high rates of sedative and psychotropic use observed in long-term care facility residents highlight the need for new strategies to optimize drug use.