The use of benzodiazepine hypnotics in the elderly

Appropriate use of triazolam in elderly patients considering a quantitative benefit-risk assessment based on the pharmacokinetic-pharmacodynamic modeling and simulation approach supported by real-world data

BACKGROUND

Triazolam is a typical drug commonly used in the elderly; however, there have been concerns about its adverse events resulting from age-related changes in physiological function and drug interactions with concomitant drugs. Thus, updated information contributing to the appropriate use based on the latest pharmacokinetic and post-marketing surveillance methods is needed. In this study, we evaluated the appropriate use of triazolam in the elderly by integrating real-world data with a modeling and simulation approach.

METHODS

The occurrence risk of adverse events in the elderly was evaluated using the spontaneous adverse event reporting regulatory databases from Japan and the United States. Information on drug concentrations and reactions was extracted from previous publications to estimate the threshold for plasma triazolam concentrations that cause adverse events. The pharmacokinetic/pharmacodynamic (PK/PD) model was then constructed, and the dose and administration were evaluated in various situations anticipated in medical practice.

RESULTS

Among all prescriptions, 25.4% were prescribed to individuals aged 80 years or above, and 51.8% were for those aged 70 years or above. A majority of cases involved CYP3A-metabolized drug combinations, accounting for 85.6%. Elderly individuals were at a higher risk of developing delirium and fall-fracture. Based on the constructed PK/PD model, the risk of adverse events increased when the plasma concentration of triazolam exceeded the calculated threshold of 0.44 ng/mL at approximately 6 h after administration. Administering 0.125 mg of triazolam, is half the approved dose for the elderly in Japan was deemed appropriate. Moreover, there was a substantial risk of adverse events even at a dosage of 0.0625 mg in combination with a moderate or strong inhibitor of cytochrome P450 3 A.

CONCLUSION

Analyzing large-scale databases and existing research publications on PK/PD can practically contribute to optimizing triazolam drug therapy for the elderly in the daily clinical setting.

The Phenomenon of Substance Abuse among the Elderly: Part I

Because substance abuse, already a major problem among elderly people, is expected to worsen significantly during the 1990s, healthcare providers must be better prepared to identify and deal effectively with this important area of geriatric care. We present an overview of the phenomenon of substance abuse among the elderly with particular attention to the abuse of alcohol and benzodiazepines, the two substances most commonly abused by elderly people. Traditionally, substance abuse among the elderly has gone largely unrecognized because of a low level of suspicion, misdiagnosis, and concealment. It is axiomatic that problems cannot be solved unless they are first identified and appropriately characterized. To respond to the increasing problem of substance abuse among the elderly, healthcare providers must recognize that elderly people are at particular risk for substance abuse, and because of their heterogeneity, they require individualized and diverse prevention and treatment approaches. Once the abuse is identified and properly characterized, specific prevention and treatment strategies can be developed and implemented.

High daily doses of benzodiazepines among Quebec seniors: prevalence and correlates

BACKGROUND

Use of high daily doses of benzodiazepines is generally contraindicated for seniors. While both patient and physician factors may influence the use of high daily doses, previous research on the effect of patient factors has been extremely limited. The objectives of this study were to determine the one year prevalence of use of high daily doses of benzodiazepines, and examine physician and patient correlates of such use among Quebec community-dwelling seniors.

METHODS

Patient information for 1423 community-dwelling Quebec seniors who participated in the Canadian Study of Health and Aging was linked to provincial health insurance administrative data bases containing detailed information on prescriptions received and prescribers.

RESULTS

The standardized one year period prevalence of use of high daily doses of benzodiazepines was 7.9%. Use of high daily doses was more frequent among younger seniors and those who had reported anxiety during the previous year. Patients without cognitive impairment were more likely to receive high dose prescriptions from general practitioners, while those with cognitive impairment were more likely to receive high dose prescriptions from specialists.

CONCLUSION

High dose prescribing appears to be related to both patient and physician factors.

General practitioners' prescribing patterns of benzodiazepine hypnotics: are elderly patients at particular risk for overprescribing? A report from the Møre & Romsdal Prescription Study

OBJECTIVE

To compare general practitioners' (GPs) prescribing patterns of benzodiazepine hypnotics with current recommendations.

DESIGN

Observational, cross-sectional study.

SETTING

The Norwegian county Møre and Romsdal.

SUBJECTS

3452 prescriptions for benzodiazepine hypnotics prescribed by GPs for patients aged 20 years and older during two months.

MAIN OUTCOME MEASURES

Prescriptions (strength of tablets, amount prescribed given in Defined and Prescribed Daily Doses: DDDs and PDDs, directions for use); initial or repeat, patients (age, sex); kind of GP-patient contact during prescribing.

RESULTS

68.4% of the prescriptions for benzodiazepine hypnotics were for women; 52.7% were for patients aged 65 or older (65+); 59.9% were issued during indirect contacts; 81.9% were repeat prescriptions. The amount of drug per prescription increased with patients' age: 65+ received on average 69.9 DDDs (76.9 PDDs) per prescription compared with 34.4 DDDs (37.1 PDDs) for young adults (20-29 years). About four of five prescriptions were for the "strong" (i.e. 1 tablet = 1 DDD) sleeping pills irrespective of patients' age and type of prescription (initial or repeat). Written directions for use were: "to be taken daily" in 55.1%, and "only if required" in 38.0% of the prescriptions. Written information on duration of "cure" was only found in one case.

CONCLUSIONS

GPs' prescribing patterns are not in accordance with recommended dosage and duration of treatment; this pattern is most pronounced for elderly patients.

Alleviation of sleep maintenance insomnia with timed exposure to bright light

OBJECTIVE

Half of the population over 65 suffers from chronic sleep disturbance. As a consequence, almost 40% of hypnotic medications are prescribed to people over age 60. Yet, hypnotics are often of little benefit in this population. As such, an effective non-drug alternative could prove important in the management of age-related sleep maintenance insomnia. The current study sought to evaluate the efficacy of bright light exposure in the treatment of sleep maintenance insomnia.

DESIGN

Following baseline sleep and circadian rhythms assessment, subjects with sleep-maintenance insomnia were treated with timed exposure to either bright white light or dim red light for 12 consecutive days. Sleep and circadian rhythms recordings were subsequently obtained and measures of sleep quality were compared to assess efficacy of the treatments.

SETTING

Baseline and post-treatment sleep and circadian rhythms assessments took place in the Laboratory of Human Chronobiology, Department of Psychiatry, Cornell University Medical College. The treatment phase of the study was conducted in participants' homes.

PARTICIPANTS

Sixteen men and women between the ages of 62 and 81 years were studied. All subjects were free of hypnotic medication, and all had experienced sleep disturbance for at least 1 year prior to entering the study.

RESULTS

Exposure to bright light resulted in substantial changes in sleep quality. Waking time within sleep was reduced by an hour, and sleep efficiency improved from 77.5% to 90%, without altering time spent in bed. Increased sleep time was in the form of Stage 2 sleep, REM sleep, and slow wave sleep. The effects were remarkably consistent across subjects.

CONCLUSIONS

The findings demonstrate the effectiveness of timed exposure to bright light in the treatment of age-related sleep maintenance insomnia. With further refinement of treatment regimens, this non-drug intervention may prove useful in a large proportion of sleep disturbed elderly.

Metoclopramide: an analysis of inappropriate long-term use in the elderly

OBJECTIVE

To present a case of possible metoclopramide-induced tardive dyskinesia and document the frequent use of metoclopramide for inappropriate lengths of treatment in elderly, ambulatory subjects.

DESIGN

Descriptive study that identified long-term users of metoclopramide among a population of 4515 elderly subjects.

SETTING

Participants in an ambulatory health-screening program in Florida (Florida Geriatric Research Program).

PARTICIPANTS

Individuals (2898 women and 1617 men) over the age of 65 years who volunteered for annual health screening.

INTERVENTIONS

All medication histories for participants were reviewed to identify subjects who reported metoclopramide use on at least one visit to the program.

RESULTS

Thirty-four participants (0.75 percent) reported the use of metoclopramide during at least one visit. Eleven subjects (32.4 percent) reported that they had used this drug for longer than one year. Nine of the 34 subjects (26.5 percent) also reported the use of metoclopramide at their next annual visit.

CONCLUSIONS

Results from this study suggest that metoclopramide is frequently prescribed inappropriately to treat gastrointestinal disorders. Long-term use of this drug exposes patients to an unnecessary risk of adverse drug reactions.

Problems and pitfalls in the use of benzodiazepines in the elderly

Benzodiazepines are frequently prescribed for elderly patients living in the community and for those in hospitals and institutions. Their use is more prevalent in women. Prolonged use of benzodiazepines is particularly likely in old age for the treatment not only of insomnia and anxiety, but also of a wide range of nonspecific symptoms. Long term users are likely to have multiple concomitant physical and psychological health problems. The distinction between benzodiazepine anxiolytics and hypnotics is difficult and somewhat arbitrary, since the differences between the compounds are less than their similarities, especially in respect of adverse reactions. Despite their wide therapeutic range, elderly patients are particularly prone to adverse reactions to benzodiazepines. The incidence of unwanted effects, predominantly manifestations of central nervous system depression, has been found to be significantly increased in hospitalised elderly patients, particularly in the frail elderly. Studies on unwanted effects during long term use are scarce, but there is some evidence of tolerance to side effects. However, benzodiazepines have been found to be frequently implicated in drug-associated hospital admissions. There is suggestive evidence that benzodiazepines, especially compounds with long half-lives, may contribute to the falls which are a major health problem in old age. The incidence of benzodiazepine dependence in elderly patients is unknown. The features of benzodiazepine withdrawal in the elderly may differ from those seen in young patients; withdrawal symptoms include confusion and disorientation which often does not precipitate milder reactions such as anxiety, insomnia and perceptual changes. Problems due to both adverse reactions and to benzodiazepine withdrawal may easily be overlooked in multimorbid elderly patients, particularly in those suffering from disorders of the central nervous system. There are numerous studies on benzodiazepine pharmacokinetics indicating that alterations, especially in distribution and elimination of certain compounds, occur in old age. Benzodiazepines with oxidative metabolic pathways and longer half-lives are likely to accumulate with regular administration. However, changes in pharmacodynamics may be more important to explain altered responses to benzodiazepines in the elderly. Although information on pharmacodynamics is still limited, there is convincing evidence of increased pharmacodynamic response in the elderly which may be further accentuated by disease factors. Since the variability of pharmacological response increases with age and is not always predictable, there is good reason at least to start therapy at lower doses and to titrate dosages individually. This may also be appropriate for the newer benzodiazepines, irrespective of advantageous pharmacokinetics.(ABSTRACT TRUNCATED AT 400 WORDS)

Sleep disorders and their management. Special considerations in the elderly

Complaints of insomnia and disordered sleep are pervasive among the elderly, and reduced total sleep time and changes in sleep architecture are considered to be normal in the aging process. Additionally, numerous medical and psychiatric disorders that are highly prevalent in the geriatric population are known to affect sleep adversely. Epidemiologic data indicate that at least 5 million older adults suffer severe disorders of sleep and that most people with severe insomnia receive no treatment for this troubling symptom. However, although the elderly comprise only about 12 percent of the American population, between 35 and 40 percent of all prescriptions for sedative hypnotics are written for people over the age of 60. Moreover, approximately 23 percent of Americans over age 85 reside in long-term care facilities, and institutionalization is an important risk factor for disordered sleep and for sedative hypnotic prescription. Consequently, the evaluation of any sedative hypnotic agent must include substantial assessment of efficacy, safety, and tolerance in geriatric patients.

Changing patterns of psychotropic drug use in the elderly: a five-year update

Psychotropic drug use was evaluated in 2022 ambulatory elderly subjects in 1978-80 and again in 1984-86. Use of hypnotic drugs declined from 8.5 percent (n = 3234) in 1978-80 to 6.3 percent (n = 2681) in 1984-86 (p less than 0.01). Use of the long-acting hypnotic flurazepam decreased (p less than 0.01) and use of two short-acting drugs, triazolam and temazepam, increased. Prescribing of long half-life benzodiazepines, such as diazepam (p less than 0.01) and chlordiazepoxide, clorazepate, halazepam, and prazepam as a group (p less than 0.01) decreased as well as the use of nearly all products containing barbiturates (p less than 0.01).