Use of benzodiazepines in primary-care geriatric patients

Insights into patient characteristics and documentation of the use of sedative-hypnotic/anxiolytics in primary care: a retrospective chart review study

Background

Despite the known safety risks of long-term use of sedative-hypnotic/anxiolytic medications, there has been limited guidance for the safe and effective use of their chronic use in a primary care clinic setting. Understanding the characteristics of patients who receive sedative-hypnotic/anxiolytic medication and the clinical documentation process in primary care is the first step towards understanding the nature of the problem and will help inform future strategies for clinical research and practice.

Objectives

Characterize patients who received a sedative-hypnotic/anxiolytic prescription in primary care, and (2) gain an understanding of the clinical documentation of sedative-hypnotic/anxiolytic indication and monitoring in electronic medical records (EMR).

Methods

A random selection of patients who received a prescription for a benzodiazepine or Z-drug hypnotic between January 2014 and August 2016 from four primary care clinics in Winnipeg were included. Data was collected retrospectively using the EMR (Accuro®). Patient variables recorded included sex, age, comorbidities, medications, smoking status, and alcohol status. Treatment variables included drug type, indication, pattern of use, dose, adverse events, psychosocial intervention, tapering attempts, social support, life stressor, and monitoring parameters for sedative-hypnotic use. Demographic and clinical characteristics were described using descriptive statistics.

Results

Records from a sample of 200 primary care patients prescribed sedative-hypnotic/anxiolytics were analyzed (mean age 55.8 years old, 61.5% ≥ 65 years old, 61.0% female). Long-term chronic use (≥ 1 year) of a sedative-hypnotic/anxiolytic agent was observed in 29.5% of the sample. Zopiclone (30.7%) and lorazepam (28.7%) were the most common agents prescribed. Only 9.5% of patients had documentation of a past tapering attempt of their sedative-hypnotic/anxiolytic. The most common indications for sedative-hypnotic/anxiolytic use recorded were anxiety (33.0%) and sleep (18.0%), but indication was undetermined for 57.0% of patients. Depression (33.5%) and falls (18.5%) were reported by patients after the initiation of these agents.

Conclusions

A higher proportion of females and users 65 years and older received a prescription for a sedative-hypnotic/anxiolytic, consistent with previous studies on sedative-hypnotic use. We found inconsistencies in the documentation surrounding sedative-hypnotic/anxiolytic use. The indication for their use was unclear in a large number of patients. These findings will help us understand the state of the problem in primary care and inform future strategies for clinical research.

Patients' and physicians' characteristics associated with the purchase of benzodiazepines by older primary care patients in Israel

This study evaluated patients' and physicians' characteristics associated with the purchase of benzodiazepines by older primary care patients in Israel. The analytic sample consists of those 6,421 patients age 65 and older. We used multi-level analysis with whether or not benzodiazepines were purchased at least once between June 2005 and 2007 as an outcome. We also evaluated patients' and physicians' characteristics associated with the purchase of benzodiazepines for 6 months or longer. Almost half the sample (41.5%) purchased benzodiazepines at least once during the study period and more than half (54.5%) of those purchasing benzodiazepines had a continued purchase for 6 months or longer. Physicians' characteristics explained only a small portion of the variance associated with purchasing, whereas patients' demographic and clinical characteristics were associated with purchasing. Any intervention to improve the use of benzodiazepines should be directed at both patients and physicians.

Prescription use disorders in older adults

The number of older adults needing substance abuse treatment is projected to rise significantly in the next few decades. This paper will focus on the epidemic of prescription use disorders in older adults. Particular vulnerabilities of older adults to addiction will be considered. Specifically, the prevalence and patterns of use of opioids, stimulants, and benzodiazepines will be explored, including the effects of these substances on morbidity and mortality. Treatment intervention strategies will be briefly discussed, and areas for future research are suggested.

Older patient perspectives on long-term anxiolytic benzodiazepine use and discontinuation: a qualitative study

OBJECTIVE

The objective of the study is to understand patient factors contributing to the chronicity of benzodiazepine use by older adults as a first step in the development of acceptable intervention strategies for taper/discontinuation or prevention of chronic use.

DESIGN

The design of the study consists of qualitative semi-structured patient interviews.

SETTING AND PARTICIPANTS

The participants were 50 anxiolytic benzodiazepine users, 61-95 years of age, recruited through referrals from primary care physicians who practiced in the general Philadelphia, Pennsylvania area.

RESULTS

Many older chronic users have come to rely and psychologically depend on benzodiazepines for their unique soothing properties, attributing to these medications characteristics that extend beyond an ordinary medication, i.e., affording control over daily stress, bringing tranquility, and even prolonging life. Most of the patients denied or minimized side effects and expressed resistance to taper or discontinuation, ranging from subtle reluctance to outright refusal and fear of being left suffering without these medications.

CONCLUSIONS

The reluctance of older chronic benzodiazepine users to taper or discontinue use highlights the importance of prevention and early intervention strategies to avoid the development of chronic use. Suggestions for curbing chronic use are presented.

Safety of benzodiazepines in the geriatric population

Benzodiazepines are the most frequently prescribed antianxiety drugs in the elderly. Despite their usefulness and safety in the younger population, there is concern about the rationale for their use in the elderly. Studies of the therapeutic use of benzodiazepines in the elderly are rare. Elderly females with co-morbid medical and psychiatric conditions and who are taking multiple medications form the group most frequently prescribed benzodiazepines among the elderly, and the group most likely to experience side effects. Age-related pharmacokinetic and pharmacodynamic changes increase the potential for certain side effects in the elderly. Significant adverse effects that may be associated with benzodiazepine use in the elderly include falls, cognitive impairment, sedation, and impairment of driving skills, all of which are particularly related to the long half-life of benzodiazepines. Long-term use of benzodiazepines should be discouraged because of the risk of dependence, which is a serious problem in the elderly. Unrecognised and untreated benzodiazepine dependence can lead to serious medical complications.

Unconventional indicators of drug dependence among elderly long-term users of benzodiazepines

A quarter of the elderly population is prescribed benzodiazepines (BZD). This has led to growing concerns about drug dependence and the validity of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for dependence to a substance. This study aimed to understand how dependence was experienced by long-term BZD users. Interviews were conducted with 45 elderly persons who had been using BZDs for an average of nine years. These users' comments suggest six indicators of dependence: self-identifying as a dependent user, invoking multiple stressors to justify BZD use, using BZD to cope with anticipated stressors, trivializing the dangers of BZDs, keeping a supply in reserve, having previously tried and failed to stop, and reducing the dosage. Our results stress the need to take a more elaborate, person-centered view of dependence.

Defining patterns of benzodiazepine use in older adults

Benzodiazepines are disproportionately prescribed to older adults. Elderly adults with comorbid medical and psychiatric conditions, elderly adults taking multiple medications, and elderly women are the most likely adults to continuously use benzodiazepines. These are also the groups of elderly who are likely to experience adverse effects, including falls, accidents, and motor vehicle crashes. Despite recommendations for short-term treatment and the potential risks of long-term use, some patients continue to receive benefit for extended time periods, occasionally years. Future research needs to be directed at improved identification of which patients will benefit from intermittent versus continuous treatment while minimizing risk for adverse side effects. In order to advance the study of the risks and benefits of benzodiazepine use, we have proposed a set of definitions for classification of use. These definitions can be used to develop clinical guidelines based on empirically derived clinical research models.

Substance use disorders in a geriatric psychiatry outpatient clinic: prevalence and epidemiologic characteristics

This study was conducted to determine the prevalence of substance use disorders in a geriatric psychiatry outpatient clinic. The overall prevalence for any substance use disorder was 20% (N = 28). The prevalence of benzodiazepine dependence was 11.4% (N = 16); the prevalence of alcohol dependence was 8.6% (N = 12); and the prevalence of prescription narcotic dependence was 1.4% (N = 2). These findings suggest that substance use disorders in the geriatric psychiatry outpatient population exist to a significantly greater extent than previously reported. Descriptive statistics were used to characterize patients with benzodiazepine dependence, alcohol dependence, and no substance use disorder. These groups were compared on demographic and clinical variables using one-way analysis of variance (ANOVA) and chi-squared statistical techniques. Clinicians working in comparable outpatient settings may be in a better position to prevent, detect, and treat substance use disorders in their patients as a result of increased awareness of its epidemiologic characteristics in this population.

Predictors of chronic benzodiazepine use in a health maintenance organization sample

While expert recommendations caution against long-term benzodiazepine use in the elderly, survey data suggest increasing benzodiazepine use with age. Computerized pharmacy records of staff-model HMO were used to examine benzodiazepine prescribing. Six-month prevalence of benzodiazepine use (2.8%) and prevalence of continued use (0.7%) were lower than earlier reports. Prevalence was higher in women and increased steadily with age. Among 7012 patients beginning benzodiazepine treatment, duration of use increased with patient age, prescription by a psychiatrist (vs. primary care or medical/surgical specialist), use of higher-potency drugs (lorazepam, and alprazolem, clonazepam) and larger number of pills in the initial prescription. Individual physicians varied significantly in drug choice, initial prescription size, and likelihood of chronic use. Among 200 patients treated in primary care, the physician-recorded indication for prescription was anxiety or depression in 27%, insomnia in 20%, and pain symptoms in 38%. These findings indicate a gap between benzodiazepine efficacy research and current clinical practice.

Anxiety in medically ill older patients: a review and update

OBJECTIVE

The authors review the evaluation and treatment of anxiety symptoms in elderly patients, with particular emphasis on elderly patients with chronic medical illness.

METHODS

A computer search for articles addressing anxiety symptoms in patients sixty-five and older was supplemented by the authors' clinical experience and knowledge of other literature and textbooks relevant to the topic.

RESULTS

Ten to 20 percent of older patients experience clinically significant symptoms of anxiety. Anxiety complaints may represent the physiological consequence of treatable medical illness, the result of psychiatric illness, or an exaggerated or normal response to life events. Both psychopharmacologic and nonpharmacologic treatments can be effective in relieving symptoms.

CONCLUSIONS

Careful differential diagnosis is an essential preliminary step to successful treatment. Non-pharmacologic interventions (behavioral treatments, in particular) may be effective for many patients. Consideration of both the benefits and the risks of medication management is recommended, as elderly patients are especially vulnerable to side effects.

Social pharmacology: unresolved critical issues

This article describes and analyzes decision-making by patients, physicians, and drug information providers about registered medical drugs. Based on a cognitive psychology perspective, cognitive variables (the individual's mediating system) are assumed to be critical factors determining both patient and physician behavior. The individual's psychological functioning is seen as a continuous reciprocal interaction between behavioral, cognitive, and environmental influences; i.e., an interactional paradigm is applied. The importance of research models including cognitive and situation variables to guide the search for appropriate research methods is stressed. An intensive research strategy with a small sample of respondents will often be necessary. Also, respondents should be asked to describe their reactions to specific medical situations. The drug information sender has to select a set of goals for disseminating information to patients. Among the goals most often selected are: message comprehension, receiver satisfaction, changes in knowledge, attitudes, and drug behavior, as well as health effects. More research is needed on how the patient's mediating system, the actual situation, and the perceived situation steer his search for the use of new drug information. A different set of factors influence the patient's decision to start a medicinal or drug treatment than the factors that influence his decision to continue a treatment. The latter factors include forgetfulness, misunderstandings, and the patient's interpretation of physiological signs. More cognitive-oriented research about drug compliance must be undertaken. In such studies the mediating systems of a group of patients could be considered before and after intervention. There are a great number of types of inappropriate (irrational) prescribing. However, a physician may prescribe rationally in one area but irrationally in another. Face-to-face education of physicians has been shown to be effective in reducing inappropriate prescribing in a number of studies. "Overprescribing" of benzodiazepine has been an issue of intensive professional debate during the last decades. The two groups who criticize and defend the existing use of benzodiazepines build their views on different assumptions about the interaction between mind and brain as well as making different value assumptions regarding the use of a psychotropic drug. There is a need for prescription studies where a cognitive and interactional perspective is combined with an information-processing and a normative perspective. The benzodiazepines dependency problem has provoked lively discussion among professionals and the general public. Long-term benzodiazepine use and personality disorders increase the risk of the patient becoming dependent. A great number of research models have been suggested for the analysis of prescription drug dependency and as guides to the treatment of dependency.(ABSTRACT TRUNCATED AT 400 WORDS)

Anxiety or depression during withdrawal of hypnotic treatments

The prescription of hypnotics, mostly benzodiazepines, continues at a high level, long-, medium- and short-acting compounds all being used. The indication for these hypnotics is the symptom of insomnia which is often secondary to a primary anxiety or depressive disorder. One problem with the use of hypnotics, particularly shorter-acting ones, is rebound insomnia in that discontinuation may be followed by sleep which is worse than pretreatment levels. Anxiety, which may well have been assuaged by the hypnotic treatment, may also rebound but depression, usually not really helped by the hypnotic, does not alter much. A second problem, on discontinuation of long-term treatment, particularly longer-acting hypnotics, is a physical withdrawal syndrome characterized by general malaise, and perceptual symptoms as well as marked increases in anxiety and insomnia. In some patients, however, depressive symptoms predominate. These may be an exaggeration of an on-going depressive disorder or it may appear to arise de novo in patients hitherto free of such an illness. The depression can be quite severe and need rigorous treatment in its own right. It is always useful to enquire about hypnotic/anxiolytic withdrawal in patients presenting with a depressive disorder. Depression is also a prognostic indicator of poor outcome (failure to withdraw successfully) in patients taking benzodiazepine hypnotics chronically.

Benzodiazepines and the elderly. A review of potential problems

This article reviews the literature describing the extent of benzodiazepine use and abuse in the elderly and specific problems attendant upon this use, Unrecognized, undocumented use and abuse of psychoactive drugs is frequent in this population and can lead to serious problems with untreated dependence and withdrawal. The elderly appear to be more sensitive to the effects of benzodiazepines, both because of changed pharmacokinetics and pharmacodynamics with aging and because of altered postreceptor cerebral response. All problems identified with benzodiazepines such as dependence, withdrawal, and cognitive and psychomotor impairment are proportionally greater among the elderly, who can least afford these risks. Review of the literature leads to the conclusion that benzodiazepine prescribing for the elderly should be undertaken with the greatest caution and only with the recognition of all potentially disastrous effects.

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)

Drug therapy in the elderly. How to achieve optimum results

Pharmacologic management of elderly patients is difficult because of two age-related factors: (1) physiologic changes, especially in hepatic and renal function, and (2) presence of more diseases, requiring combination drug therapy and resulting in increased drug interactions and drug-induced side effects. Nevertheless, drugs have essentially the same benefits in the elderly as in younger patients and should be used for the same indications. Fewer problems will result if the clinician remembers that most drugs produce exaggerated responses, both beneficial and detrimental, in the elderly.

The natural history of tolerance to the benzodiazepines

Dependence on benzodiazepines following continued use is by now a well-documented clinical phenomenon. Benzodiazepines differ in their dependence potential. The present studies were aimed at examining the possibility that differential rates of tolerance development might account for differences in dependence risk. Four studies are reported. The first three studies concerned normal subjects. The development of tolerance over a fifteen day period was demonstrated for three different benzodiazepines (ketazolam, lorazepam and triazolam) using two paradigms. Tolerance in terms of a reduction in effectiveness of a repeated given dose was most notable for the benzodiazepine with a medium elimination half-life (lorazepam) for physiological, behavioural and subjective measures. In the case of the drug with the longest elimination half-life (ketazolam) reduction in effectiveness could only be assumed to be occurring if account was taken of the steady increase in plasma concentrations of active metabolites. For this drug it seemed that the physiological measures were those most likely to demonstrate the development of tolerance. Although triazolam showed few significant drug effects on this paradigm (testing being 12 hours after ingestion of this short half-life benzodiazepine), tolerance was seen to develop on some subjective measures. Using an alternative method of testing tolerance, assessing responses to a diazepam challenge dose, a high degree of tolerance on two-thirds of the measures was observed in subjects when pretreated with the benzodiazepine with the most marked accumulation of active metabolites (ketazolam). The other two drugs also led to tolerance development on a range of measures; this was more marked for lorazepam than triazolam. Blunting of the growth hormone response to diazepam was the most sensitive and reliable method of detecting tolerance to the benzodiazepines. Symptoms on discontinuation of the two weeks' intake of the benzodiazepines were marked for all the drugs but unrelated to either the tolerance induced or the elimination half-life of the particular drug. A further clinical study revealed that tolerance persisted in a group of long-term benzodiazepine users for between four months and two years following complete abstinence from the drug. These patients appeared to be less affected by diazepam in terms of its commonly observed subjective effects, regardless of their original medication. These ex-long-term users of benzodiazepines were, however, more likely to manifest two specific types of effects--immediate 'symptom' reduction and exacerbation of 'withdrawal symptoms' over the subsequent week.(ABSTRACT TRUNCATED AT 400 WORDS)

Psychotropic drugs in the elderly. Selection of the appropriate agent

Caution is required when prescribing psychotropic drugs to elderly patients, because of altered pharmacokinetics. Benzodiazepines with a relatively short half-life, such as temazepam (Restoril), alprazolam (Xanax), and lorazepam (Ativan), are better hypnotics for the elderly than those with a long half-life. Lorazepam and clorazepate dipotassium (Tranxene) are appropriate anxiolytics for elderly patients. Antipsychotics have anticholinergic and extrapyramidal symptoms in varying degrees. Thiothixene (Navane) and haloperidol (Haldol) in low doses are the drugs of choice despite their extrapyramidal symptoms. Trazodone (Desyrel) is a good antidepressant for the elderly because of its minimal anticholinergic effects, although it is quite sedating. Desipramine (Norpramin) is the least sedating and has the fewest anticholinergic effects of the tricyclic antidepressants and therefore may be better tolerated. Monoamine oxidase inhibitors and lithium should be used with great caution.