Does the Prescription of Anxiolytic and Hypnotic Drugs Increase Mortality in Older Adults?

Initiation of Psycholeptic Medication During Hospitalization With Recommendation for Discontinuation After Discharge

OBJECTIVES

Psycholeptic drugs have been used in the older population for years, especially to control delirium and neuropsychiatric symptoms (NPS) of dementia. However, data from the literature confirm that the prolonged use of psycholeptics may be responsible for adverse reactions in older patients. The aim of this study was (1) to identify how many patients receive the first prescription of a psycholeptic drug during the hospital stay; (2) to evaluate the main sociodemographic and clinical characteristics of these patients; and (3) to verify if the prescribed psycholeptic drugs are continued after 3 months from the hospital discharge.

DESIGN

Our retrospective study was based on data from the REPOSI (REgistro POliterapie SIMI) registry, a cohort of older patients hospitalized in internal medicine and geriatric wards throughout Italy from 2010 to 2018.

SETTING AND PARTICIPANTS

Patients aged 65 years or older who were not on home therapy with psycholeptic drugs were considered in the analyses.

METHODS

We did both univariate and multivariate analyses in order to find the variables associated independently to an increased risk for first psycholeptic prescription at hospital discharge.

RESULTS

At hospital discharge, 193 patients (5.8%) out of a total sample of 3322 patients were prescribed at least 1 psycholeptic drug. Cognitive impairment was the main risk factor for the introduction of psycholeptic drugs at discharge. Among them, 89.1% were still on therapy with a psycholeptic drug after 3 months from the hospital discharge.

CONCLUSIONS AND IMPLICATIONS

Cognitive impairment represents the main risk factor for psycholeptic initiation in hospitalized older patients. The vast majority of these treatments are chronically continued after the discharge. Therefore, special attention is needed in prescribing psycholeptics at discharge, because their prolonged use may lead to cognitive decline. Moreover, their continued use should be questioned by physicians providing post-acute care, and deprescribing should be considered.

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.

Trajectories in hypnotic use and approaching death: a register linked case-control study

PURPOSE

Whether the association between hypnotic and increased mortality risk is created by causation or confounding, has been long debated. We further examined the possibility of confounding by indication with a comprehensive approach.

METHODS

The National FINRISK Study cohorts of 1997, 2002, and 2007 (25,436 participants aged 25-74) were followed up until July 2012. There were 1822 deaths, and at least one gender, baseline age and cohort matched 'control' was found for 1728 'cases' yielding a final analytical sample of 3955 individuals. An index age, equivalent to the age at death of their respective cases' was set for each control. Hypnotic drug purchases were followed from the Finnish nationwide register during a 36-month run-up period before the date of death/index date. The prevalence and incidence of hypnotic purchases were compared between cases and matched controls. Moreover, latent developmental trajectories of purchases were modelled and their relations with specific and all-cause death risks were analysed.

RESULTS

An increasing difference between cases and controls was observed as regards the use of hypnotic drugs. During the last 30 months before the date of death/index date, the rate ratio of incident purchases between cases and controls was 2.37 (95% CL, 1.79-3.12) among older and 3.61 (95% CL, 2.37-5.89) among younger individuals. The developmental trajectories of hypnotic drug purchases were differently and by interpretation plausibly associated with specific mortality risks.

CONCLUSIONS

In most cases the association between hypnotics and mortality risk is created by symptomatic treatment when death is approaching.

Psychotropic drug use and mortality in old people with dementia: investigating sex differences

Background

Psychotropic drugs are common among old people with dementia, and have been associated with increased mortality. Previous studies have not investigated sex differences in this risk. This study was conducted to analyse associations between the use of antipsychotics, antidepressants, and benzodiazepines and 2-year mortality in old people with dementia, and to investigate sex differences therein.

Methods

In total, 1037 participants (74% women; mean age, 89 years) with dementia were included from four cohort studies and followed for 2 years. Data were collected through home visits and medical records. Cox proportional hazard regression models were used to analyse associations between ongoing baseline drug use and mortality. Multiple possible confounders were evaluated and adjusted for.

Results

In fully adjusted models including data from the whole population, no association between baseline psychotropic drug use and increased 2-year mortality was seen. Significant sex differences were found in mortality associated with antidepressant use, which was protective in men, but not in women (hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.40–0.92 and HR 1.09, 95% CI 0.87–1.38, respectively). The interaction term for sex was significant in analyses of benzodiazepine use, with a higher mortality risk among men than among women.

Conclusions

Among old people with dementia, ongoing psychotropic drug use at baseline was not associated with increased mortality in analyses adjusted for multiple confounders. Sex differences in mortality risk associated with antidepressant and benzodiazepine use were seen, highlighting the need for further investigation of the impact of sex.

Electronic supplementary material

The online version of this article (doi:10.1186/s40360-017-0142-9) contains supplementary material, which is available to authorized users.

Mortality Risk of Hypnotics: Strengths and Limits of Evidence

Sleeping pills, more formally defined as hypnotics, are sedatives used to induce and maintain sleep. In a review of publications for the past 30 years, descriptive epidemiologic studies were identified that examined the mortality risk of hypnotics and related sedative-anxiolytics. Of the 34 studies estimating risk ratios, odds ratios, or hazard ratios, excess mortality associated with hypnotics was significant (p < 0.05) in 24 studies including all 14 of the largest, contrasted with no studies at all suggesting that hypnotics ever prolong life. The studies had many limitations: possibly tending to overestimate risk, such as possible confounding by indication with other risk factors; confusing hypnotics with drugs having other indications; possible genetic confounders; and too much heterogeneity of studies for meta-analyses. There were balancing limitations possibly tending towards underestimates of risk such as limited power, excessive follow-up intervals with possible follow-up mixing of participants taking hypnotics with controls, missing dosage data for most studies, and over-adjustment of confounders. Epidemiologic association in itself is not adequate proof of causality, but there is proof that hypnotics cause death in overdoses; there is thorough understanding of how hypnotics euthanize animals and execute humans; and there is proof that hypnotics cause potentially lethal morbidities such as depression, infection, poor driving, suppressed respiration, and possibly cancer. Combining these proofs with consistent evidence of association, the great weight of evidence is that hypnotics cause huge risks of decreasing a patient's duration of survival.