Problems with benzodiazepines in elderly patients

Mother's little helper turned a foe: Alprazolam use, misuse, and abuse

Benzodiazepines are effective in managing anxiety and related disorders when used properly (short-term). Their inappropriate use, however, carries significant risks, involving amnesia, rebound insomnia, rebound anxiety, depression, dependence, abuse, addiction, and an intense and exceedingly prolonged withdrawal, among other complications. Benzodiazepines also amplify the effects of opioids and, consequently, have been implicated in approximately 30 % of opioid overdose deaths. Despite their unfavorable profile, sharp increases in medical and non-medical use of benzodiazepines have been steadily reported worldwide. Alprazolam (Xanax®), a potent, short-acting benzodiazepine, is among the most prescribed and abused anxiolytics in the United States. This medication is commonly co-abused with opioids, increasing the likelihood for oversedation, overdose, and death. Notwithstanding these risks, it is surprising that research investigating how benzodiazepines, such as alprazolam, interact with opioids is severely lacking in clinical and preclinical settings. This review therefore aims to present our current knowledge of benzodiazepine use and misuse, with an emphasis on alprazolam when data is available, and particularly in populations at higher risk for developing substance use disorders. Additionally, the potential mechanism(s) surrounding tolerance, dependence and abuse liability are discussed. Despite their popularity, our understanding of how benzodiazepines and opioids interact is less than adequate. Therefore, it is now more important than ever to understand the short- and long-term consequences of benzodiazepine/alprazolam use.

Benzodiazepine Initiation Effect on Mortality Among Medicare Beneficiaries Post Acute Ischemic Stroke

Rationale

Despite guideline warnings, older acute ischemic stroke (AIS) survivors still receive benzodiazepines (BZD) for agitation, insomnia, and anxiety despite being linked to severe adverse effects, such as excessive somnolence and respiratory depression. Due to polypharmacy, drug metabolism, comorbidities, and complications during the sub-acute post-stroke period, older adults are more susceptible to these adverse effects. We examined the impact of receiving BZDs within 30 days post-discharge on survival among older Medicare beneficiaries after an AIS.

Methods

Using the Medicare Provider Analysis and Review (MedPAR) dataset, Traditional fee-for-service Medicare (TM) claims, and Part D Prescription Drug Event data, we analyzed a random 20% sample of TM beneficiaries aged 66 years or older who were hospitalized for AIS between July 1, 2016, and December 31, 2019. Eligible beneficiaries were enrolled in Traditional Medicare Parts A, B, and D for at least 12 months before admission. We excluded beneficiaries who were prescribed a BZD within 90 days before hospitalization, passed away during their hospital stay, left against medical advice, or were discharged to institutional post-acute care. Our primary exposure was BZD initiation within 30 days post-discharge, and the primary outcome was 90-day mortality risk differences (RD) from discharge. We followed a trial emulation process involving cloning, weighting, and censoring, plus we used inverse-probability-of-censoring weighting to address confounding.

Results

In a sample of 47,421 beneficiaries, 826 (1.74%) initiated BZD within 30 days after discharge from stroke admission or before readmission, whichever occurred first, and 6,392 (13.48%) died within 90 days. Our study sample had a median age of 79, with an inter-quartile range (IQR) of 12, 55.3% female, 82.9% White, 10.1% Black, 1.7% Hispanic, 2.2% Asian, 0.4% American Native, 1.5% Other and 1.1% Unknown. After standardization based on age, sex, race/ethnicity, length of stay in inpatient, and baseline dementia, the estimated 90-day mortality risk was 159 events per 1,000 (95% CI: 155, 166) for the BZD initiation strategy and 133 events per 1,000 (95% CI: 132, 135) for the non-initiation strategy, with an RD of 26 events per 1,000 (95% CI: 22, 33). Subgroup analyses showed RDs of 0 events per 1,000 (95% CI: -4, 11) for patients aged 66-70, 3 events per 1,000 (95% CI: -1, 13) for patients aged 71-75, 10 events per 1,000 (95% CI: 3, 23) for patients aged 76-80, 27 events per 1,000 (95% CI: 21, 46) for patients aged 81-85, and 84 events per 1,000 (95% CI: 73, 106) for patients aged 86 years or older. RDs were 34 events per 1,000 (95% CI: 26, 48) and 20 events per 1,000 (95% CI: 11, 33) for males and females, respectively. RDs were 87 events per 1,000 (95% CI: 63, 112) for patients with baseline dementia and 18 events per 1,000 (95% CI: 13, 21) for patients without baseline dementia.

Conclusion

Initiating BZDs within 30 days post-AIS discharge significantly increased the 90-day mortality risk among Medicare beneficiaries aged 76 and older and for those with baseline dementia. These findings underscore the heightened vulnerability of older adults, especially those with cognitive impairment, to the adverse effects of BZDs.

The effect of polypharmacy on healthcare services utilization in older adults with comorbidities: a retrospective cohort study

BACKGROUND

Older adults are more prone to increasing comorbidities and polypharmacy. Polypharmacy is associated with inappropriate prescribing and an increased risk of adverse effects. This study examined the effect of polypharmacy in older adults on healthcare services utilization (HSU). It also explored the impact of different drug classes of polypharmacy including psychotropic, antihypertensive, and antidiabetic polypharmacy on HSU.

METHODS

This is a retrospective cohort study. Community-dwelling older adults aged ≥ 65 years were selected from the primary care patient cohort database of the ambulatory clinics of the Department of Family Medicine at the American University of Beirut Medical Center. Concomitant use of 5 or more prescription medications was considered polypharmacy. Demographics, Charlson Comorbidity index (CCI), and HSU outcomes, including the rate of all-cause emergency department (ED) visits, rate of all-cause hospitalization, rate of ED visits for pneumonia, rate of hospitalization for pneumonia, and mortality were collected. Binomial logistic regression models were used to predict the rates of HSU outcomes.

RESULTS

A total of 496 patients were analyzed. Comorbidities were present in all patients, with 22.8% (113) of patients having mild to moderate comorbidity and 77.2% (383) of patients having severe comorbidity. Patients with polypharmacy were more likely to have severe comorbidity compared to patients with no polypharmacy (72.3% vs. 27.7%, p = 0.001). Patients with polypharmacy were more likely to visit the ED for all causes as compared to patients without polypharmacy (40.6% vs. 31.4%, p = 0.05), and had a significantly higher rate of all-cause hospitalization (adjusted odds ratio aOR 1.66, 95 CI = 1.08-2.56, p = 0.022). Patients with psychotropic polypharmacy were more likely to be hospitalized due to pneumonia (crude odds ratio cOR 2.37, 95 CI = 1.03-5.46, p = 0.043), and to visit ED for Pneumonia (cOR 2.31, 95 CI = 1.00-5.31, p = 0.049). The association lost significance after adjustment.

CONCLUSIONS

The increasing prevalence of polypharmacy amongst the geriatric population with comorbidity is associated with an increase in HSU outcomes. As such, frequent medication revisions in a holistic, multi-disciplinary approach are needed.

Non-antipsychotic medicines and modified electroconvulsive therapy are risk factors for hospital-acquired pneumonia in schizophrenia patients

BACKGROUND

Hospital-acquired pneumonia (HAP) has a significant and detrimental impact on schizophrenia patients. Non-antipsychotic medicines and modified electroconvulsive therapy (MECT) are frequently used in conjunction with antipsychotics to treat schizophrenia. Whether non-antipsychotic medicines or MECT are risk factors for HAP in schizophrenia treated with antipsychotics is still unknown.

METHODS

Patients with schizophrenia who were admitted to the Fourth People's Hospital of Chengdu between January 2015 and April 2022 were included in this retrospective cohort study. Individuals with HAP were 1:1 matched to individuals without HAP (non-HAP) using propensity score matching (PSM). The risk factors for HAP were analyzed by comparing the two groups.

RESULTS

A total of 7,085 schizophrenia patients were included in this study, with a mean age of 39.77 ± 14.45 years. 193 patients developed HAP on an average of 22.26 ± 21.68 days after admission with an incidence of 2.73%. After 1:1 PSM, 192 patients from each group (HAP and non-HAP) were included. The HAP group had significantly more patients with MECT and taking benzodiazepines, antidepressants, mood stabilizers, and anti-parkinsonians both before and after PSM by Bonferroni correction (P < 0.001). Multivariate logistic regression analysis showed that, combined with antipsychotics, non-antipsychotic medicines including benzodiazepines (OR = 3.13, 95%CI = 1.95-5.03, P < 0.001), mood stabilizers (OR =3.33, 95%CI =1.79-6.20, P < 0.001) and MECT (OR =2.58, 95%CI =1.49-4.46, P = 0.001) were associated with a significantly increased incidence of HAP.

CONCLUSION

The incidence of HAP in schizophrenia patients in our cohort was 2.73%. MECT and non-antipsychotic medicines, including benzodiazepines and mood stabilizers were risk factors for HAP in schizophrenia patients treated with antipsychotics.

Psychotropic Drug-Associated Pneumonia in Older Adults

The use of psychotropic drugs (antipsychotics, benzodiazepines and benzodiazepine-related drugs, and antidepressants) is common, with a prevalence estimates range of 19-29% among community dwelling older adults. These drugs are often prescribed for off-label use, including neuropsychiatric symptoms. The older adult population also has high rates of pneumonia and some of these cases may be associated with adverse drug events. In this narrative review, we summarize the findings from current observational studies on the association between psychotropic drug use and pneumonia in older adults. In addition to studies assessing the use of psychotropics, we included antiepileptic drugs, as they are also central nervous system-acting drugs, whose use is becoming more common in the aging population. The use of antipsychotics, benzodiazepine, and benzodiazepine-related drugs are associated with increased risk of pneumonia in older adults (≥ 65 years of age), and these findings are not limited to this age group. Minimal and conflicting evidence has been reported on the association between antidepressant drug use and pneumonia, but differences between study populations make it difficult to compare findings. Studies regarding antiepileptic drug use and risk of pneumonia in older persons are lacking, although an increased risk of pneumonia in antiepileptic drug users compared with non-users in persons with Alzheimer's disease has been reported. Tools such as the American Geriatric Society Beers Criteria and the STOPP/START criteria for potentially inappropriate medications aids prescribers to avoid these drugs in order to reduce the risk of adverse drug events. However, risk of pneumonia is not mentioned in the current criteria and more research on this topic is needed, especially in vulnerable populations, such as persons with dementia.

Taking Policy Action to Reduce Benzodiazepine Use and Promote Self-Care Among Seniors

This article reviews current knowledge on the risks and benefits of benzodiazepine use for seniors and addresses potential policies that could be made to reduce use and support sentors' mental health. Although seniors are only 12% to 15% of the population, they consume between 35% and 52% of all benzodiazepines prescribed in Canada and the United States. Despite significant long-term use among seniors, relatively few studies demonstrate the efficacy of more than short-term use for anxiety and insomnia. There is significant data to suggest that use is associated with increased potential for injury, cognitive and memory deficits, and a dependency syndrome. This article argues that the current controversy rests not so much in the scientific data but in the willingness of clinicians to interpret and act on that information. As internationally developed guidelines for practice suggest that benzodiazepine treatment for anxiety and insomnia may not be without risks, other first-line treatments should be developed.

A comparison of two versions of the clinical institute withdrawal assessment for alcohol: the CIWA-Ar and CIWA-AD

Scores from two versions of the Clinical Institute Withdrawal Assessment for Alcohol, the CIWA-Ar and CIWA-AD, were compared in 135 alcohol detoxification episodes. The paired mean score for withdrawal severity was statistically higher with the CIWA-AD (p < 0.001), but the mean difference of 0.45 (95% CI: 0.38-0.53, t = 11.74) is not likely to be clinically significant. The difference in the total score between the two scales was 1 point or less 82.6% of the time, and nearly all (97.7%) of the CIWA-AD scores were within 3 points of the paired CIWA-Ar score (range - 6 to + 6).

Modeling cumulative dose and exposure duration provided insights regarding the associations between benzodiazepines and injuries

BACKGROUND AND OBJECTIVES

Accurate assessment of medication impact requires modeling cumulative effects of exposure duration and dose; however, postmarketing studies usually represent medication exposure by baseline or current use only. We propose new methods for modeling various aspects of medication use history and employment of them to assess the adverse effects of selected benzodiazepines.

STUDY DESIGN AND SETTING

Time-dependent measures of cumulative dose or duration of use, with weighting of past exposures by recency, were proposed. These measures were then included in alternative versions of the multivariable Cox model to analyze the risk of fall related injuries among the elderly new users of three benzodiazepines (nitrazepam, temazepam, and flurazepam) in Quebec. Akaike's information criterion (AIC) was used to select the most predictive model for a given benzodiazepine.

RESULTS

The best-fitting model included a combination of cumulative duration and current dose for temazepam, and cumulative dose for flurazepam and nitrazepam, with different weighting functions. The window of clinically relevant exposure was shorter for flurazepam than for the two other products.

CONCLUSION

Careful modeling of the medication exposure history may enhance our understanding of the mechanisms underlying their adverse effects.

Prevalence of sedative drug use in geriatric in-patients: a multi-centre study

OBJECTIVE

This cross-sectional study registered the prevalence of sedative drug use and withdrawal strategies in geriatric in-patients from 30 centres in nine European countries.

METHODS

We conducted a survey among young geriatricians using a standardised questionnaire on sedative drug use for more than three weeks. The study population consisted of 1972 in-patients aged 75 years or older. Acute care (620), intermediate care/rehabilitation (359), long-term care (261), terminal care (47) and nursing home (685) settings were represented. The pre-specified outcomes included the prevalence of sedative drug use; the identification of main prescribers and main reasons for prescribing and, the assessment of withdrawal policy, including psychological counselling and involvement of general practitioners.

RESULTS

Prevalence of sedative use was highest in long-term care (72%), followed by nursing homes (70%) and terminal care (59%). Geriatricians started prescribing sedatives after admission on 52% of all occasions. The main reasons for prescribing were continuation of medication taken at home (37%), sleep problems emerging after admission (26%) and post-admission worsening of existing sleep problems (20%). Most prescribers (70%) applied an active withdrawal policy. Short-term withdrawal programmes were mostly applied (57%). Most patients (60%) were psychologically counselled during withdrawal from sedatives. General practitioners were often (60%) involved in withdrawal policy.

CONCLUSION

The prevalence of prescription of sedative drugs in geriatric in-patients is high. Appropriate setting specific guidelines are needed to control use of sedatives in geriatric in-patients and to ensure withdrawal from these drugs whenever possible.

Psychological treatment of late-life anxiety: an empirical review

This study provides a meta-analytic review of nonpharmacological interventions for late-life anxiety, focusing on treatment efficacy. Included in the analysis are studies in which a comparison was made either to a control condition or to another treatment. A total of 15 outcome studies, published or reported between January 1975 and January 2002, were identified involving 495 participants (mean age exceeding 55.0 years and a grand mean of 69.5 years) and providing 20 separate treatment interventions. The analysis indicated that psychological interventions were reliably more effective than no treatment on self-rated and clinician-rated measures of anxiety, yielding an effect size of .55. Maintenance of treatment gains (a minimum of 6 months follow-up) was insufficiently reported across studies to allow for a reliable demonstration of an overall estimate of long-term efficacy. It is concluded that psychological interventions produce significant improvements, but the analyses must be qualified by data limitations in the research synthesis.

Fast-track cardiac anaesthesia in the elderly: effect of two different anaesthetic techniques on mental recovery

Elderly patients may be considered for 'fast-track' cardiac anaesthesia, but can suffer psychological complications and slow recovery of mental function after surgery, which can interfere with recovery. Reduced metabolism and changed distribution of anaesthetic and sedative agents can cause poor recovery. We made a prospective randomized comparison of mental function, haemodynamic stability and extubation and discharge times in elderly patients (65-79 yr) receiving two premedication, anaesthetic and sedative techniques. Patients received either propofol (n=39) (fentanyl 10-15 microg kg(-1) and propofol 2-6 mg kg(-1) intraoperatively and a propofol infusion for 3 h postoperatively) or premedication with lorazepam followed by midazolam for anaesthesia (n=39) (fentanyl 10-15 microg kg(-1) and midazolam 0.05-0.075 mg kg(-1) intraoperatively and a midazolam infusion for 3 h postoperatively). Impairment of mental function was noted in 41% of patients in the propofol group and 83% in the lorazepam and midazolam group (P=0.001) 18 h after extubation. Patients in the propofol group were extubated earlier [1.4 (SD 0.6) vs 1.9 (0.8) h, P=0.02]; and reached standard intensive care unit discharge criteria [7.6 (4.6) vs 14.2 (13) h, P=0.02] and hospital discharge criteria [4.3 (1.0) vs 4.9 (1.1) days, P=0.04) sooner than patients in the lorazepam and midazolam group, but actual discharge times did not differ between the groups. Haemodynamic values were stable in both groups.

Long-term continuous use of benzodiazepines by older adults in Quebec: prevalence, incidence and risk factors

OBJECTIVE

To determine the prevalence and incidence of long-term use of benzodiazepines and to assess patient-, prescriber-, and drug-related risk factors.

DESIGN

Cohort study.

PARTICIPANTS

1,423 community-dwelling older adults in Quebec who participated in the Canadian Study of Health and Aging (CSHA1).

MEASUREMENTS

Patient characteristics were obtained from the CSHA1 database. These were linked to provincial health insurance data to ascertain benzodiazepine use and prescriber characteristics.

MAIN OUTCOME MEASURE

Use of benzodiazepines for at least 135 of the first 180 days following initiation of use.

RESULTS

Twelve-month prevalence of long-term continuous use, standardized by age and gender to the Quebec population, was 19.8%. Twelve-month cumulative incidence of long-term continuous use was 1.9%. Older patients were more likely to proceed to long-term continuous use.

CONCLUSIONS

Risk of long-term continuous use of benzodiazepines seems to increase with age. This association was found to be independent of gender, health status, anxiety, cognitive status, benzodiazepine type, and physician characteristics.

[Long-term benzodiazepine use in women at a daycare center for older people]

While experts recommend caution against long-term benzodiazepine use in the elderly, survey data suggests that the use of benzodiazepine increase with age. The patterns of benzodiazepine use and factors associated with long-term use in population at risk were studied with a standarlized questionnaire applied to 634 women over 60, who attended a daycare center for older people in Rio de Janeiro between May, 1992 and December, 1995. Prevalence of benzodiazepine use in the last 15 days was 21.3% (CI 95% 18.1-24.5), and prevalence of daily use for 12 or more months was 7.4% (CI 95% 5.4-9.4). In a multivaried analysis the amount of drugs being consumed displayed an important and progressive association with long-term benzodiazepine use, with OR = 2.77 (CI 95% 1.17-6.57) for those who take from four to six drugs, and OR = 7.62 (CI 95% 3.18-18.26) for those who take more than seven drugs. Insomnia (OR = 8.87 CI 95% 2.53-31.06) and chronic headache (OR = 3.53 CI 95% 1.82-6.89) have also been associated with this pattern of use.

Sedative-hypnotic use and increased hospital stay and costs in older people

OBJECTIVE

To assess the relationship between sedative-hypnotic (S/H) utilization, severity of illness, length of stay, and hospital costs among older patients admitted to a tertiary care university hospital.

DESIGN

Retrospective review of computerized hospital and pharmacy data bases.

SUBJECTS

A total of 856 older consecutive medical and surgical admissions from November 1993 to March 1994.

MEASUREMENTS

Sedative/hypnotic utilization in accord with the Health Care Financing Administration (HCFA) guidelines for S/H use in nursing homes. Jefferson Disease Staging to estimate severity of illness. Hospital records to obtain demographic characteristics, length of stay, and hospital costs.

RESULTS

Patients whose S/H use exceeded HCFA guide lines, compared with those within the guidelines and those receiving no drugs, had longer lengths of stay (21.5 days vs 12.3 days vs 6.7 days, P < .001), increased hospital costs ($29,245 vs $15,219 vs $7,516, P < .001). and greater severity of illness (245.8 vs 189.5 vs 148.5, P < .001). S/H use exceeding and within HCFA guidelines were associated with increased length of stay (both P < .0001) and hospital costs (both P < .0001).

CONCLUSIONS

Older hospitalized patients receiving S/H have greater severity of illness, longer lengths of stay, and higher hospital costs compared with other patients. S/H use, and, in particular, S/H use exceeding the HCFA guidelines, are associated with increased hospital stay and cost.

Drug-induced taste and smell disorders. Incidence, mechanisms and management related primarily to treatment of sensory receptor dysfunction

Drugs in every major pharmacological category can impair both taste and smell function and do so more commonly than presently appreciated. Impairment usually affects sensory function at a molecular level, causing 2 major behavioural changes--loss of acuity (i.e. hypogeusia and hyposmia) and/or distortion of function (i.e. dysgeusia and dysosmia). These changes can impair appetite, food intake, cause significant lifestyle changes and may require discontinuation of drug administration. Loss of acuity occurs primarily by drug inactivation of receptor function through inhibition of tastant/odorant receptor: (i) binding; (ii) Gs protein function; (iii) inositol trisphosphate function; (iv) channel (Ca++,Na++) activity; (v) other receptor inhibiting effects; or (vi) some combination of these effects. Distortions occur primarily by a drug inducing abnormal persistence of receptor activity (i.e. normal receptor inactivation does not occur) or through failure to activate: (i) various receptor kinases; (ii) Gi protein function; (iii) cytochrome P450 enzymes; or other effects which usually (iv) turn off receptor function; (v) inactivate tastant/odorant receptor binding; or (vi) some combination of these effects. Termination of drug therapy is commonly associated with termination of taste/smell dysfunction, but occasionally effects persist and require specific therapy to alleviate symptoms. Treatment primarily requires restoration of normal sensory receptor growth, development and/or function. Treatment which restores sensory acuity requires correction of steps initiating receptor and other pathology and includes zinc, theophylline, magnesium and fluoride. Treatment which inhibits sensory distortions requires reactivation of biochemical inhibition at the receptor or inactivation of inappropriate stimulus receptor binding and/or correction of other steps initiating pathology including dopaminergic antagonists, gamma-aminobutyric acid (GABA)-ergic agonists, calcium channel blockers and some orally active local anaesthetic, antiarrhythmic drugs.