Benzodiazepine use and risk of dementia: prospective population based study

Targeting Sleep Physiology to Modulate Glymphatic Brain Clearance

Sleep has been postulated to play an important role in the removal of potentially neurotoxic molecules, such as amyloid-β, from the brain via the glymphatic system. Disturbed sleep, on the other hand, may contribute to the accumulation of neurotoxins in brain tissue, eventually leading to neuronal death. A bidirectional relationship has been proposed between impaired sleep and neurodegenerative processes, which start years before the onset of clinical symptoms associated with conditions like Alzheimer's and Parkinson's diseases. Given the heavy burden these conditions place on society, it is imperative to develop interventions that promote efficient brain clearance, thereby potentially aiding in the prevention or slowing of neurodegeneration. In this review, we explore whether the metabolic clearance function of sleep can be enhanced through sensory (e.g., auditory, vestibular) or transcranial (e.g., magnetic, ultrasound, infrared light) stimulation, as well as pharmacological (e.g., antiepileptics) and behavioral (e.g., sleeping position, physical exercise, cognitive intervention) modulation of sleep physiology. A particular focus is placed on strategies to enhance slow-wave activity during nonrapid eye movement sleep as a driver of glymphatic brain clearance. Overall, this review provides a comprehensive overview on the potential preventative and therapeutic applications of sleep interventions in combating neurodegeneration, cognitive decline, and dementia.

Impact of potentially inappropriate psychotropic medicines on falls among older adults in 23 residential aged care facilities in Australia: a retrospective longitudinal cohort study

OBJECTIVE

Falling is common among older adults in residential aged care facilities (RACFs) and potential inappropriate psychotropic medicines (PIPMs) use may increase the risk of falling. This study aimed to determine the impact of PIPMs on falls using longitudinal observational data.

METHODS

A retrospective longitudinal cohort study was conducted using routinely collected electronic health data from 23 RACFs in Sydney, New South Wales, Australia. The study included 3064 permanent residents aged ≥65 (2020-2021). PIPMs were identified using updated Beers criteria 2023. We considered three fall outcome groups: all falls, injurious falls and falls requiring hospitalisation. The falls incidence rates (IRs) were calculated for overall residents in RACFs as well as for central nervous system (CNS)-PIPM users and non-users. We applied a zero-inflated negative binomial regression model to assess the association between falls and CNS-PIPMs.

RESULTS

A total of 40% (n=1224) of long-term care residents used at least one CNS-PIPM and 10% of residents (n=302) used two or more. The falls IRs of CNS-PIPM users were 16.2 falls per 1000 resident days (95% CI 15.9 to 16.5) for all falls, 5.68 falls per 1000 resident days (95% CI 5.48 to 5.88) for injurious falls and 1.77 falls per 1000 resident days (95% CI 1.66 to 1.88) for falls requiring hospitalisation, whereas the falls IRs of non-CNS-PIPM users were 10.8 falls per 1000 resident days (95% CI 10.6 to 11.0) for all falls, 3.65 falls per 1000 resident days (95% CI 3.52 to 3.78) for injurious falls and 1.26 falls per 1000 resident days (95% CI 1.19 to 1.33) for falls requiring hospitalisation. CNS-PIPM users had a significantly greater rate of falls overall compared with non-users (IRR 1.29; 95% CI 1.16 to 1.44) for all outcomes.

CONCLUSIONS

Falls are frequent among CNS-PIPM users resulting in injury and hospitalisation, with 70% of CNS-PIPM users falling at least once and one in three requiring admissions to hospital. Reviewing residents' use of psychotropic medicines should be considered as part of strategies to reduce falls incidence among older adults in RACFs.

Choline Alphoscerate: A Therapeutic Option for the Management of Subthreshold Depression in the Older Population

Background and Objectives: Subthreshold depression (StD) presents with depressive symptoms similar to major depressive disorder (MDD) but of lower intensity. Despite its milder form, StD is significantly prevalent in the older population, affecting up to 12.9%. StD is associated with adverse outcomes, such as an increased risk of MDD and mild cognitive impairment (MCI). Treating StD in older adults is challenging due to the limited efficacy and side effects of traditional antidepressants. As a result, clinicians often adopt a "watchful waiting" strategy, which increases the risk of StD progressing into MDD or MCI. Choline alphoscerate (α-GPC), a cholinergic drug, is indicated in the treatment of pseudodepression in the elderly, a condition that corresponds to the actual definition of StD. This review highlights the role of α-GPC in the treatment of StD in older subjects. Methods: A comprehensive review of preclinical and clinical studies was conducted, focusing on the efficacy of α-GPC in improving cognitive and behavioral functions in mental conditions and in modulating neurotransmitter systems involved in depression, such as dopamine and serotonin. Results: Evidence points to the therapeutic benefits of using α-GPC in StD as it acts on cholinergic dysfunction and cognitive impairment. Additionally, it may improve mood regulation and motivation, key factors in StD and in depressive disorders. These findings suggest that α-GPC may reduce the risk of progression from StD to MDD or MCI. Conclusions: α-GPC represents an effective and safe therapeutic option for the treatment of StD in the older population, improving clinical outcomes and enhancing the quality of life in this high-risk group.

AI-Driven Innovation in Skin Kinetics for Transdermal Drug Delivery: Overcoming Barriers and Enhancing Precision

Transdermal drug delivery systems (TDDS) offer an alternative to conventional oral and injectable drug administration by bypassing the gastrointestinal tract and liver metabolism, improving bioavailability, and minimizing systemic side effects. However, widespread adoption of TDDS is limited by challenges such as the skin's permeability barrier, particularly the stratum corneum, and the need for optimized formulations. Factors like skin type, hydration levels, and age further complicate the development of universally effective solutions. Advances in artificial intelligence (AI) address these challenges through predictive modeling and personalized medicine approaches. Machine learning models trained on extensive molecular datasets predict skin permeability and accelerate the selection of suitable drug candidates. AI-driven algorithms optimize formulations, including penetration enhancers and advanced delivery technologies like microneedles and liposomes, while ensuring safety and efficacy. Personalized TDDS design tailors drug delivery to individual patient profiles, enhancing therapeutic precision. Innovative systems, such as sensor-integrated patches, dynamically adjust drug release based on real-time feedback, ensuring optimal outcomes. AI also streamlines the pharmaceutical process, from disease diagnosis to the prediction of drug distribution in skin layers, enabling efficient formulation development. This review highlights AI's transformative role in TDDS, including applications of models such as Deep Neural Networks (DNN), Artificial Neural Networks (ANN), BioSIM, COMSOL, K-Nearest Neighbors (KNN), and Set Covering Machine (SVM). These technologies revolutionize TDDS for both skin and non-skin diseases, demonstrating AI's potential to overcome existing barriers and improve patient care through innovative drug delivery solutions.

Long-Term Insomnia Treatment with Benzodiazepines and Alzheimer's Disease: A Systematic Review

Alzheimer's disease is the most common form of dementia. Benzodiazepines are the most widely used pharmacological class in the treatment of insomnia and other sleep disorders. Some literature suggests that the chronic use of benzodiazepines is associated with the development of cognitive decline. This review aims to evaluate the use of benzodiazepines and its association with the development of Alzheimer's disease. A systematic review of the literature was carried out using the MEDLINE and Embase databases. Protocols followed the PRISMA-P 2020 methodology, and, after the analysis of the included studies, a narrative synthesis of the results was carried out. Only two cohort studies were identified that met defined eligibility criteria. In the retrospective study, a significant risk of developing Alzheimer's disease after treatment with benzodiazepines was found. In the prospective study, the prevalence of Alzheimer's disease was not associated with treatment with benzodiazepines. Results suggest that only the largest study presented a significant risk of developing Alzheimer's disease. Given the scarce scientific evidence found, it is concluded that further research on this topic is necessary.

Chronic Use of Benzodiazepine in Older Adults and Its Relationship with Dementia: A Systematic Review and Meta-Analysis

LEARNING OBJECTIVE

After participating in this CME activity, the psychiatrist should be better able to:• Explain current understanding of the relationship between chronic benzodiazepine use and dementia.

BACKGROUND

Chronic use of benzodiazepines (BZ) for managing conditions such as anxiety disorders, depression, sleep disorders, and other chronic diseases is widespread; yet, there is considerable controversy regarding its potential links to dementia risk. This systematic review and meta-analysis aims to clarify this relationship by synthesizing and analyzing the available evidence to provide a clearer understanding of whether prolonged BZ use contributes to developing dementia.

METHODS

This study adheres to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered with PROSPERO to ensure methodological rigor and transparency. The research strategy incorporated terms such as "benzodiazepines" OR "benzodiazepine" AND "cognitive dysfunction" OR "dementia" AND "adult" OR "elderly" OR "aged." We included prospective and retrospective observational studies, as well as case-control studies. Data were meticulously extracted regarding chronic BZ use and dementia risk. Each study's risk of bias was assessed to ensure result validity. Statistical analysis was performed using hazard ratios (HR) as the primary meta-analysis summary measure to provide a precise evaluation of associated risk.

RESULTS

Analysis of five studies showed that chronic BZ use was associated with a nonsignificant risk of dementia-without specification of cause-with an HR of 1.17 (95% CI: 0.96-1.43). Regarding Alzheimer's disease, three studies found no significant association with an HR of 1.00 (95% CI: 0.87-1.15).

CONCLUSIONS

Our findings did not reach statistical significance, suggesting no strong link between chronic BZ use and dementia. Further research is needed to clarify this potential association.

Health outcomes in chronic kidney disease patients with cognitive impairment or dementia: a global collaborative analysis

Background and hypothesis

Mild cognitive impairment and dementia (CI) are common in patients with CKD. We aim to clarify whether and how CKD and CI coexistence increases adverse health outcomes.

Methods

This retrospective observational cohort study was conducted on CKD patients (stages 3-5) from the TriNetX platform. CKD patients with and without pre-existing CI were included from 115 healthcare organizations, and their outcomes were compared. The two cohorts were propensity score matched (PSM) for age, sex, ethnicity, comorbidities, BMI, blood parameters, and medications. The proportional hazard assumption was tested with a 95% confidence interval. Kaplan-Meier analysis was used to calculate survival probability. Outcomes were included from 1 day after the CKD diagnosis until 10 years afterwards.

Results

We identified 533 772 CKD patients, and 8184 had co-existent CI. Two cohorts of 8170 PSM patients each were generated. The mean age was 60.5 ± 7.0 years and the eGFR was 52.1±19 mL/min. Mean follow-up was 23.2 months. CKD patients with CI had higher all-cause mortality (18.5% vs 12.6%), higher risk of cerebrovascular disease (11.3% vs 6.9%), transient cerebral ischemic attacks (2.7% vs 1.6%), hypotension (16.5%-12.5%), malnutrition (6.7% vs 4.0%), pneumonia (10.7% vs 7.9%), urinary infections (13.2% vs 9.3%), encephalopathy (9.9% vs 5.0%), mood disorders (13.6% vs 9.7%), psychosis (9.8% vs 4.6%), and epilepsy (4.3% vs 1.5%). Higher use of antidepressants (26.3% vs 16.3%), anticonvulsants (19.5% vs 15.1%), antipsychotics (18.6% vs 9.1%), anticholinesterase (5.6% vs 0.1%), and benzodiazepines (30.6% vs 26.6%) was noted in those with CI. All these findings were statistically significant.

Conclusion

Despite the limitations of a retrospective study, real-world data demonstrate that concomitant CI is a decisive risk factor for higher mortality and increased adverse outcomes in patients with CKD. These results highlight the need for routine comprehensive cognitive assessments in patients at any stage of CKD.

Drug burden index of people ageing with intellectual disability and cognitive complaints attending a specialist memory service

BACKGROUND

Medications with sedative or anticholinergic properties should be prescribed with caution in those with cognitive complaints. This is particularly relevant in people ageing with an intellectual disability (ID). Higher drug burden index (DBI) scores are associated with increased frailty and falls and reduced quality of life in older people and increased risk of adverse effects (daytime somnolence, constipation) in those with ID. While previous studies have shown that the ID population has higher rates of drug burden and a higher propensity to be prescribed an antipsychotic than the general population, the degree of burden has not been assessed specifically in those with ID and cognitive complaints.

METHODS

We assessed drug burden in a cohort of sequential referrals to a national memory service for people with ID. All patients were referred for assessment of cognitive complaints (self-reported or caregiver-reported problems with memory or cognition). DBI was calculated individually for each participant, and the impact of aetiology of ID, level of ID, age, psychiatric/neurological comorbidities and diagnostic outcome on DBI scores was assessed.

RESULTS

The study population was 58.6% female with a median age of 55 years and aetiology of ID was Down syndrome (DS) in 71.3%. Consensus diagnosis was Alzheimer's dementia in 40.2%, mild cognitive impairment in 29.9% and cognitively unimpaired from baseline in 25.3%. Medication use was high with 95.4% taking medications, with a median number of medications of 4 (interquartile range 4) and a rate of polypharmacy (≥5 medications) of 51.7%. Overall, 65.5% were exposed to sedative or anticholinergic medications with 39.1% exposed to a clinically significant DBI score >1. Those with psychiatric comorbidities, non-DS aetiology or epilepsy were significantly more likely to have a DBI score >1.

CONCLUSIONS

People with ID and incipient cognitive complaints have a high level of drug burden, which concerningly exceeds that of the general population.

Use of potentially inappropriate psychotropic medicines among older adults in 23 residential aged care facilities in Australia: a retrospective cohort study

BACKGROUND

Psychotropic medications are frequently utilised in residential aged care facilities (RACFs). Longitudinal medication administration data can offer crucial insights into the potential inappropriate use of psychotropic medicines (PIPMs), guiding future quality improvement initiatives. This study aimed to determine the prevalence and predictors of PIPMs use and assess variation in PIPMs use by facility for residents of RACFs.

METHODS

We conducted a retrospective longitudinal cohort study using routinely collected electronic health data (2020-2021) relating to 3064 residents from 23 RACFs in New South Wales, Australia. The study included permanent residents aged ≥ 65 years and median length of stay was 483 days. The prevalence of PIPMs use was estimated using updated Beers criteria 2023. The extent of exposure to PIPMs was measured using two metrics i.e., number of days residents were exposed to PIPMs and the proportion of days covered by PIPMs. We used logistic regression model to determine factors associated with PIPM use. Funnel plots to visualised variation in PIPMs use across facilities.

RESULTS

In total 40% (n = 1224) residents used at least one PIPM and 10% (n = 302) used ≥ 2. The most frequently used PIPMs categories were benzodiazepines and Z-drugs (27.4%), followed by first and second generation antipsychotics (17.2%). Certain diagnoses (dementia, pain, depression, anxiety, and endocrine disorders) were associated with the increased use of PIPMs. For example, residents with dementia were 1.94 times more likely to use ≥ 2 PIPMs (OR 1.94; 95% CI 1.50-2.51). The prevalence of at least one PIPM by residents in each facility ranged from 23.3 to 57.0% across facilities. The overall median number of days residents were exposed to PIPMs were 91 days (IQR 6-320) while the median proportion of days covered by at least one PIPM was 39.3% (IQR 2.6-86.6%).

CONCLUSIONS

Residents in aged care facilities showed a high rate of PIPMs use with substantial variation across facilities. Quality improvement initiatives which target inappropriate psychotropic medication use are necessary, particularly considering the link between psychotropic drug use and adverse events such as falls.

Assessment of beliefs and attitudes towards benzodiazepines using machine learning based on social media posts: an observational study

BACKGROUND

Benzodiazepines are frequently prescribed drugs; however, their prolonged use can lead to tolerance, dependence, and other adverse effects. Despite these risks, long-term use remains common, presenting a public health concern. This study aims to explore the beliefs and opinions held by the public regarding benzodiazepines, as understanding these perspectives may provide insights into their usage patterns.

METHODS

We collected public tweets published in English between January 1, 2019, and October 31, 2020, that mentioned benzodiazepines. The content of each tweet and the characteristics of the users were analyzed using a mixed-method approach, including manual analysis and semi-supervised machine learning.

RESULTS

Over half of the Twitter users highlighted the efficacy of benzodiazepines, with minimal discussion of their side effects. The most active participants in these conversations were patients and their families, with health professionals and institutions being notably absent. Additionally, the drugs most frequently mentioned corresponded with those most commonly prescribed by healthcare professionals.

CONCLUSIONS

Social media platforms offer valuable insights into users' experiences and opinions regarding medications. Notably, the sentiment towards benzodiazepines is predominantly positive, with users viewing them as effective while rarely mentioning side effects. This analysis underscores the need to educate physicians, patients, and their families about the potential risks associated with benzodiazepine use and to promote clinical guidelines that support the proper management of these medications.

CLINICAL TRIAL NUMBER

Not applicable.

Comparative efficacy of various pharmacologic treatments for alcohol withdrawal syndrome: a systematic review and network meta-analysis

This study was to compare multiple classes of medications and medication combinations to find alternatives or additives for patients not applicable to benzodiazepines (BZDs). We performed a network meta-analysis to assess the comparative effect of 11 pharmacologic treatments in patients with alcohol withdrawal syndrome. Forty-one studies were included, comprising a total sample size of 4187 participants. The pooled results from the randomized controlled trials showed that there was no significant difference in the Clinical Institute Withdrawal Assessment-Alcohol, revised (CIWA-Ar) reduction with other medications or medication combinations compared to BZDs. Compared to BZDs, the mean difference in ICU length of stay of anticonvulsants + BZDs was -1.71 days (95% CI = -2.82, -0.59). Efficacy rankings from cohort studies showed that anticonvulsant + BZDs were superior to other treatments in reducing CIWA-Ar scores and reducing the length of stay in the ICU. Synthesis results from randomized controlled trials indicate that there are currently no data suggesting that other medications or medication combinations can fully replace BZDs. However, synthetic results from observational studies have shown that BZDs are effective in the context of adjuvant anticonvulsant therapy, particularly with early use of gabapentin in combination with BZDs in the treatment of alcohol withdrawal syndrome, which represents a promising treatment option.

Benzodiazepines for pediatric epilepsies and their risks in a cohort within the French health care data

OBJECTIVE

The management of antiseizure treatment in patients with epilepsy relies on the benefit-risk ratio. Data on antiseizure medication (ASM) use in children are limited. We described antiseizure medication use in children with epilepsy (CwE) in France, with a focus on the chronic use of benzodiazepines and related implications.

METHODS

We conducted a 5-year cohort study from January 2012, using data from the French national health care data system (Système National des Données de Santé). We included CwE identified through International Classification of Diseases, 10th Revision codes and medications from January 2012 to December 2015 and followed them until December 2016. We described ASMs and assessed whether the risk of initiating a polytherapy after a bitherapy depends on whether benzodiazepine was included in the bitherapy.

RESULTS

We identified 62 885 CwE. Valproate was the most reimbursed ASM (40%), followed by lamotrigine (17.6%), levetiracetam (9.3%), clobazam (6.1%), and carbamazepine (5.8%). Prescriptions were initiated at the hospital in 74.5% of CwE. We observed a decrease in the number of CwE with at least one benzodiazepine reimbursement from 15.3% in 2013 to 10.1% in 2016 (p < .0001). The prevalence of CwE with levetiracetam reimbursements increased, whereas that of CwE with valproate decreased. A switch from a bitherapy to a polytherapy was more likely when the bitherapy included a benzodiazepine (subdistribution hazard ratio [sHR] = 1.20 [1.03-1.39]).

SIGNIFICANCE

The prevalence of CwE with at least one benzodiazepine reimbursement decreased during the study period. Benzodiazepines were associated with an increased use of subsequent ASM polytherapy.

History of Psychoactive Medication a Risk Factor for Neurocognitive Decline After Cardiac Surgery

INTRODUCTION

Neurocognitive decline (NCD) is a common complication after cardiac surgery with implications for outcomes and quality of life. Identifying risk factors can help surgeons implement preventative measures, optimize modifiable risk factors, and counsel patients about risk and prognosis.

METHODS

Prospective cohort study at a single academic center. 104 patients planned to undergo cardiac surgery were enrolled. The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) was used to measure neurocognitive function preoperatively, on postoperative day four, and postoperative day 30. NCD is defined as a change in RBANS scaled score of < -8 from baseline to postoperative day 4. Patient charts were reviewed for medication history: beta-blockers, angiotensin-converting enzyme and angiotensin receptor blockers, calcium channel blockers, statins, oral hypoglycemic agents, and psychoactive medications. Charts were also reviewed to calculate postoperative opioid usage.

RESULTS

NCD was detected in 42.9% of patients. Incidence of NCD was significantly higher in patients taking a psychoactive medication (56.8%) than patients not (31.9%), P < 0.03. There was no relationship between historical use of beta-blocker, calcium-channel blocker, statin, or oral hypoglycemic medications and incidence of NCD. Simple linear regression showed no relationship between change in RBANS total scaled score and opioid usage. There was no difference in incidence of NCD at 1 mo.

CONCLUSIONS

Patients with a history of taking psychoactive medications prior to cardiac surgery have an increased risk of acute postoperative NCD.

Benzodiazepine use and risk of incident MCI and dementia in a community sample

OBJECTIVES

Older adults commonly take benzodiazepines (BZDs) that may have long-term adverse cognitive effects. We investigated whether BZD use was related to developing mild cognitive impairment (MCI) or dementia in cognitively normal older adults in the community.

SETTING/PARTICIPANTS

A population-based cohort (n = 1959) of adults aged 65 and over, recruited from communities of low socioeconomic status.

MEASUREMENTS

BZD use, Clinical Dementia Rating (CDR), anxiety symptoms, depression symptoms, sleep difficulties, and APOE genotype.

DESIGN

We examined time from study entry to MCI (CDR = 0.5) and time from study entry to dementia (CDR ≥ 1) in participants who were cognitively normal at baseline (CDR = 0). We used survival analysis (Cox model), adjusted for age, sex, education, sleep, anxiety, and depression. For all the models, we included an interaction term between BZD use and APOE*4.

RESULTS

Taking BZDs was significantly associated with higher risk of developing MCI, but not of developing dementia. The effect was not affected by APOE genotype.

CONCLUSIONS

In a population-based sample of cognitively normal older adults, BZD use is associated with developing MCI, but not dementia. BZD use may be a potentially modifiable risk factor for MCI.

Benzodiazepine Use and the Risk of Dementia in the Elderly Population: An Umbrella Review of Meta-Analyses

The prevalence of dementia among the elderly is high, and it is the leading cause of death globally. However, the relationship between benzodiazepine use and dementia risk has produced inconsistent results, necessitating an updated review of the evidence. To address this, we conducted an umbrella review of meta-analyses to summarize the available evidence on the association between benzodiazepine use and dementia risk and evaluate its credibility. We systematically evaluated the meta-analyses of observational studies that examined the connection between benzodiazepine use and dementia risk. For each meta-analysis, we collected the overall effect size, heterogeneity, risk of bias, and year of the most recent article and graded the evidence based on pre-specified criteria. We also used AMSTAR, a measurement tool to evaluate systematic reviews, to assess the methodological quality of each study. Our review included five meta-analyses encompassing 30 studies, and the effect size of the association between benzodiazepine use and dementia risk ranged from 1.38 to 1.78. Nonetheless, the evidence supporting this relationship was weak, and the methodological quality of the studies included was low. In conclusion, our findings revealed limited evidence of a link between benzodiazepine use and dementia risk, and more research is required to determine a causal connection. Physicians should only prescribe benzodiazepine for appropriate indications.

Trajectories of Benzodiazepine Use among Older Adults from a Concordance-with-Guidelines Perspective: A Nationwide Cohort Study

BACKGROUND AND OBJECTIVE

Benzodiazepines (including zolpidem and zopiclone) are often associated with higher-than-recommended intake and durations of use, especially in older adults. The objective of this study was to characterize trajectories of benzodiazepine use according to recommended patterns in older adults, and to assess predictors of the risk of developing each of these trajectories.

METHODS

Using the French Health Insurance database, we constituted a cohort of adults aged ≥ 65 years who initiated benzodiazepines in 2007 and were followed for up to 8 years. Concordance with benzodiazepine use guidelines was assessed on a quarterly basis according to a "concordance-with-guideline score" with values 1-5. Group-based trajectory modeling was then applied as implemented in the Proc Traj procedure in SAS to define guideline-concordant trajectories based on seven baseline patient-centered characteristics: sex, complementary health insurance coverage, treated alcohol and tobacco use disorder, polypharmacy, hospital stay, and registered chronic diseases.

RESULTS

Among 5080 new users (64.1% women, median age 74 years), six trajectories of benzodiazepine use were identified. Three, representing 70% of users, were concordant with guidelines, whereas three implied non-concordant benzodiazepine use for part or all of the benzodiazepine use follow-up. Polymedicated patients were more prone to develop chronic non-guideline-concordant initially guideline-concordant use, whereas those with a history of long-term disease and hospitalization were more likely to develop chronic non-guideline-concordant use. The number of prescribers during the first quarter, number of daily defined doses, use of loperamide, and use of psychostimulants were associated with a higher risk of developing an initial and persistent non-guideline-concordant use. Treatment initiation by a psychiatrist, initial use of World Health Organization (WHO) step-2 opioids and non-benzodiazepine anxiolytics or sedatives were associated with a higher risk of late non-guideline-concordant use.

CONCLUSIONS

Concordance with guidelines varied over time during benzodiazepine use in older adults. A third of these adults will hypothetically follow one of the identified non-guideline-concordant trajectories, consisting of initial and/or late non-guideline concordance. This was associated with modifiable and nonmodifiable factors that clinicians should be aware of for tailoring the monitoring of patients.

Drugs and the elderly: A complex interaction

Although it can be difficult to define who should be considered an elderly person, the population aged 65 and over is experiencing the fastest demographic expansion and will represent almost one billion inhabitants of the 2030 World. Drug use increases dramatically with age and the elderly population is, by far, the highest consumer of medicines, up to 10 times more than younger adults. This consumption is in many aspects inappropriate, unjustified or sub-optimal and associated with a huge number of adverse reactions, admissions in emergency units and attributable deaths. A good part of which could be prevented if basic rules of good prescription and ad-hoc guidelines were systematically used. Even if older adults are more likely to present an adverse drug reaction, available data tend to support that the main risk factor of iatrogenesis in the elderly is the number of drugs used. Moreover, it is often irrelevant to transpose to this population the conclusions concerning the benefit-risk balance of drugs assessed in younger adults; similarly, approaches and programs classically used in pharmacovigilance and pharmacoepidemiology should be tailored to this specific population.

Hypnotic prescription trends and patterns for the treatment of insomnia in Japan: analysis of a nationwide Japanese claims database

BACKGROUND

There is limited consensus regarding the optimal treatment of insomnia. The recent introduction of orexin receptor antagonists (ORA) has increased the available treatment options. However, the prescribing patterns of hypnotics in Japan have not been comprehensively assessed. We performed analyses of a claims database to investigate the real-world use of hypnotics for treating insomnia in Japan.

METHODS

Data were retrieved for outpatients (aged ≥ 20 to < 75 years old) prescribed ≥ 1 hypnotic for a diagnosis of insomnia between April 1^st, 2009 and March 31^st, 2020, with ≥ 12 months of continuous enrolment in the JMDC Claims Database. Patients were classified as new or long-term users of hypnotics. Long-term use was defined as prescription of the same mechanism of action (MOA) for ≥ 180 days. We analyzed the trends (2010-2019) and patterns (2018-2019) in hypnotics prescriptions.

RESULTS

We analyzed data for 130,177 new and 91,215 long-term users (2010-2019). Most new users were prescribed one MOA per year (97.1%-97.9%). In 2010, GABA_A-receptor agonists (benzodiazepines [BZD] or z-drugs) were prescribed to 94.0% of new users. Prescriptions for BZD declined from 54.8% of patients in 2010 to 30.5% in 2019, whereas z-drug prescriptions remained stable (~ 40%). Prescriptions for melatonin receptor agonist increased slightly (3.2% to 6.3%). Prescriptions for ORA increased over this time from 0% to 20.2%. Prescriptions for BZD alone among long-term users decreased steadily from 68.3% in 2010 to 49.7% in 2019. Prescriptions for ORA were lower among long-term users (0% in 2010, 4.3% in 2019) relative to new users. Using data from 2018-2019, multiple (≥ 2) MOAs were prescribed to a higher proportion of long-term (18.2%) than new (2.8%) users. The distribution of MOAs according to psychiatric comorbidities, segmented by age or sex, revealed higher proportions of BZD prescriptions in elderly (new and long-term users) and male (new users) patients in all comorbidity segments.

CONCLUSION

Prescriptions for hypnotics among new and long-term users in Japan showed distinct patterns and trends. Further understanding of the treatment options for insomnia with accumulating evidence for the risk-benefit balance might be beneficial for physicians prescribing hypnotics in real-world settings.

Benzodiazepines in the Treatment of Behavioural and Psychological Symptoms Associated with Dementia and Their Impact on Cognitive Impairment: Review of Clinical Evidence

Alzheimer’s disease (AD) is the most common form of progressively disabling degenerative dementia. In dementia in general, there are, unfortunately, even from the earliest stages of the disease, associated behavioural and psychological symptoms of dementia (BPSD), and even more pronouncedly in AD, in addition to cognitive impairment. There are no specific drugs for the treatment of BPSDs. Therefore, there remains an unmet medical need. To date, despite side effects, benzodiazepines, anti-psychotics, mood stabilisers, and anti-depressants continue to be used in the clinic. The aim of this research work is to provide an understanding of the role of benzodiazepines when used for the treatment of BPSD and cognitive impairment in AD.

Behavioral Despair Is Blocked by the Flavonoid Chrysin (5,7-Dihydroxyflavone) in a Rat Model of Surgical Menopause

Women have a high susceptibility to the negative effects of stress. Hormonal changes experienced throughout their reproductive life partially contribute to a higher incidence of anxiety and depression symptoms, particularly, during natural or surgical menopause. In preclinical research, the flavonoid chrysin (5,7-dihydroxyflavone) exerts anxiolytic- and anti-despair-like effects; however, it is unknown whether chrysin exerts a protective effect against the behavioral changes produced by acute stress on locomotor activity and behavioral despair in rats at 12-weeks post-ovariectomy. Ovariectomized female Wistar rats were assigned to eight groups: vehicle group (10% DMSO), three groups with chrysin and three groups with the same dose of allopregnanolone (0.5, 1, and 2 mg/kg), and one group with diazepam (2 mg/kg). The treatments were administered for seven consecutive days and the effects were evaluated in the locomotor activity and swimming tests. Chrysin (2 mg/kg) increased the latency to first immobility and decreased the total immobility time in the swimming test as the reference drugs allopregnanolone and diazepam (2 mg/kg); while locomotor activity prevented the behavioral changes produced by swimming. In conclusion, chrysin exerts a protective effect against the behavioral changes induced by acute stress, similarly to the neurosteroid allopregnanolone and the benzodiazepine diazepam in rats subjected to a surgical menopause model.

Effect of mindfulness on anxiety and depression in insomnia patients: A systematic review and meta-analysis

Background

As a common clinical symptom, insomnia has a high incidence of combined mental illness and it is also a risk factor for the development of depression, anxiety and suicide. As a new concept in the field of health in recent years, mindfulness therapy can improve insomnia, anxiety and depression, which is a new way to solve such diseases.

Objective

This study aims to systematically evaluate the effects of mindfulness compared with conventional treatment on scores of the Hamilton Depression Scale (HAMD), Hamilton Anxiety Scale (HAMA), Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS) in people with insomnia and anxiety-depressive symptoms.

Methods

Articles published before October 2022 were searched from seven databases and included in randomized controlled trials (RCTs) to evaluate mindfulness therapy. The assessment tool of Cochrane bias risk was used to evaluate the methodological quality of the literature. The main outcome indicators were HAMD and HAMA scores, and the secondary outcome indicators were SDS and SAS scores.

Results

Ten randomized controlled trials including 1,058 subjects were systematically evaluated and meta-analyzed in this study. In the main outcome indicators, there was a significant difference between mindfulness therapy and conventional treatment in reducing HAMD score (MD: -3.67, 95% CI: -5.22-2.11, p < 0.01) and HAMA score (MD: -3.23, 95% CI: -3.90-2.57, p < 0.01). In the secondary outcome indicators, mindfulness therapy also showed a significant difference in reducing SDS scores (MD: -6.49, 95% CI: -6.86-6.11, p < 0.01) and SAS scores (MD: -7.97, 95% CI: -9.68-6.27, p < 0.01) compared with conventional treatment.

Conclusion

For the people with insomnia, anxiety and depression, the use of conventional treatment with the addition of 4-12 weeks of mindfulness treatment can significantly improve anxiety and depression symptoms of patients. This is a new diagnosis and treatment idea recommended for insomniacs with or without anxiety and depression symptoms. Due to the methodological defects in the included study and the limited sample size of this paper, more well-designed randomized controlled trials are needed for verification.

Benzodiazepine-related dementia risks and protopathic biases revealed by multiple-kernel learning with electronic medical records

Objectives

To simultaneously estimate how the risk of incident dementia nonlinearly varies with the administration period and cumulative dose of benzodiazepines, the duration of disorders with an indication for benzodiazepines, and other potential confounders, with the goal of settling the controversy over the role of benzodiazepines in the development of dementia.

Methods

The classical hazard model was extended using the techniques of multiple-kernel learning. Regularised maximum-likelihood estimation, including determination of hyperparameter values with 10-fold cross-validation, bootstrap goodness-of-fit test, and bootstrap estimation of confidence intervals, was applied to cohorts retrospectively extracted from electronic medical records of our university hospitals between 1 November 2004 and 31 July 2020. The analysis was mainly focused on 8160 patients aged 40 or older with new onset of insomnia, affective disorders, or anxiety disorders, who were followed up for 4.10 ± 3.47 years.

Results

Besides previously reported risk associations, we detected significant nonlinear risk variations over 2-4 years attributable to the duration of insomnia and anxiety disorders, and to the administration period of short-acting benzodiazepines. After nonlinear adjustment for potential confounders, we observed no significant risk associations with long-term use of benzodiazepines.

Conclusions

The pattern of the detected nonlinear risk variations suggested reverse causation and confounding. Their putative bias effects over 2-4 years suggested similar biases in previously reported results. These results, together with the lack of significant risk associations with long-term use of benzodiazepines, suggested the need to reconsider previous results and methods for future analysis.

Twenty-First Century Global ADR Management: A Need for Clarification, Redesign, and Coordinated Action

Adverse drug reactions (ADRs) are estimated to be between the fourth and sixth most common cause of death worldwide, taking their place among other prevalent causes of mortality such as heart disease, cancer, and stroke. ADRs impact a broad range of populations across a wide variety of global geography and demographics, with significant mortality and morbidity burden in vulnerable groups such as older people, pediatric populations, and individuals in low-income settings. Too large a share of medicines risk management remains limited to signal detection in big ADR databases (USFDA, EMA, WHO, etc.) This resource allocation is antiquated and applied statistical signal detection methodologies have reached their limits of usefulness. In addition, existing databases are designed for short-term reactions, closely related to medication use and, thus, can only partially assess important broader consequences across geography, time, and clinical relevance. There is an urgent need change the dynamic. We need to identify (earlier and more regularly) many of the important but often overlooked or missed ADRs. Rather than assigning blame, we need to identify the root causes of the problem so they can be clearly addressed and fixed. The public health implications are profound-particularly as we recognize the importance of predicting and mitigating the next pandemic. Consequently, medicines risk management must be integrated within a broader global public health vision. To accomplish this, we need to develop the new tools and methodologies critical to assessing these public health imperatives.

Tau protein plays a role in the mechanism of cognitive disorders induced by anesthetic drugs

Cognitive disorders are mental health disorders that can affect cognitive ability. Surgery and anesthesia have been proposed to increase the incidence of cognitive dysfunction, including declines in memory, learning, attention and executive function. Tau protein is a microtubule-associated protein located in the axons of neurons and is important for microtubule assembly and stability; its biological function is mainly regulated by phosphorylation. Phosphorylated tau protein has been associated with cognitive dysfunction mediated by disrupting the stability of the microtubule structure. There is an increasing consensus that anesthetic drugs can cause cognitive impairment. Herein, we reviewed the latest literature and compared the relationship between tau protein and cognitive impairment caused by different anesthetics. Our results substantiated that tau protein phosphorylation is essential in cognitive dysfunction caused by anesthetic drugs, and the possible mechanism can be summarized as "anesthetic drugs-kinase/phosphatase-p-Tau-cognitive impairment".

Impact of the 2018 Japan Floods on benzodiazepine use: a longitudinal analysis based on the National Database of Health Insurance Claims

PURPOSE

Natural disaster has an impact on mental health. The 2018 Japan Floods, which took place in July 2018 were one of the largest water disasters in Japan's recorded history. We aimed to evaluate the change in the number of benzodiazepine prescriptions by physicians before and after the disaster.

METHODS

A retrospective cohort study based on the National Database of Health Insurance Claims was conducted in the flood-stricken areas between July 2017 and June 2019. The subjects were divided between victims and non-victims according to certification by local governments. Members of both groups were then categorized into three groups based on their pre-flood use of benzodiazepines: non-user, occasional user, and continuous user. Difference-in-differences (DID) analysis with a logistic regression model was conducted to estimate the effect of the disaster among victims by comparing the occurrence of benzodiazepine prescriptions before and after the disaster.

RESULTS

Of 5,000,129 people enrolled, 31,235 were victims. Among all participants, the mean prescription rate for benzodiazepines in victims before the disaster (11.3%) increased to 11.8% after the disaster, while that in non-victims (8.3%) decreased to 7.9%. The DID analysis revealed that benzodiazepine prescription among victims significantly increased immediately after the disaster (adjusted ratio of odds ratios (ROR) 1.07: 95% confidence interval 1.05-1.11), and the effect of the disaster persisted even 1 year after the disaster (adjusted ROR 1.2: 95% confidence interval 1.16-1.24).

CONCLUSION

The flood increased the number of benzodiazepines prescriptions among victims, and the effect persisted for at least 1 year.

A bibliometric analysis of the recent advances in diazepam from 2012 to 2021

Background: Diazepam is a classic benzodiazepine drug that has been widely used for disorders such as anxiety, sleep disorders, and epilepsy, over the past 59 years. The study of diazepam has always been an important research topic. However, there are few bibliometric analyses or systematic studies in this field. This study undertook bibliometric and visual analysis to ascertain the current status of diazepam research, and to identify research hotspots and trends in the past 10 years, to better understand future developments in basic and clinical research. Methods: Articles and reviews of diazepam were retrieved from the Web of Science core collection. Using CiteSpace, VOSviewer, and Scimago Graphica software, countries, institutions, authors, journals, references, and keywords in the field were visually analyzed. Results: A total of 3,870 publications were included. Diazepam-related literature had high volumes of publications and citations. The majority of publications were from the USA and China. The highest number of publications and co-citations, among the authors, was by James M Cook. Epilepsia and the Latin American Journal of Pharmacy were the journals with the most publications on diazepam and Epilepsia was the most frequently cited journal. Through a comprehensive analysis of keywords and references, we found that current research on diazepam has focused on its mechanism of action, application in disease, pharmacokinetics, risk, assessment, and management of use, status epilepticus, gamma-aminobutyric acid receptors (GABAR), intranasal formulation, gephyrin, and that ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) is the current research hotspot. Conclusion: Research on diazepam is flourishing. We identified research hotspots and trends in diazepam research using bibliometric and visual analytic methods. The clinical applications, mechanisms of action, pharmacokinetics, and assessment and management of the use of diazepam are the focus of current research and the development trend of future research.

Promoting benzodiazepine cessation through an electronically-delivered patient self-management intervention (EMPOWER-ED): Randomized controlled trial protocol

Background

Long-term benzodiazepine dependence carries significant health risks which might be reduced with low-cost patient self-management interventions. A booklet version of one such intervention (Eliminating Medications Through Patient Ownership of End Results; EMPOWER) proved effective in a Canadian clinical trial with older adults. Digitizing such an intervention for electronic delivery and tailoring it to different populations could expand its reach. Accordingly, this article describes the protocol for a randomized controlled trial to test the effectiveness of an electronically-delivered, direct-to-patient benzodiazepine cessation intervention tailored to U.S. military veterans.

Methods

Design: Two-arm individually randomized controlled trial.

Setting

US Veterans Health Administration primary care clinics.

Participants

Primary care patients taking benzodiazepines for three or more months and having access to a smartphone, tablet or desktop computer.

Intervention and comparator

Participants will be randomized to receive either the electronically-delivered EMPOWER (EMPOWER-ED) protocol or asked to continue to follow provider recommendations regarding their benzodiazepine use (treatment-as-usual).

Measurements

The primary outcomes are complete benzodiazepine cessation and 25% dose reduction, assessed using administrative and self-report data, between baseline and six-month follow-up. Secondary outcomes are self-reported anxiety symptoms, sleep quality, and overall health and quality of life, measured at baseline and 6-month follow-up, and benzodiazepine cessation at 12-month follow-up.

Comments

This randomized controlled trial will evaluate whether the accessibility and effectiveness of a promising intervention for benzodiazepine cessation can be improved through digitization and population tailoring.

Quality Use of Medicines Indicators and Associated Factors in Residential Aged Care Facilities: Baseline Findings from the Pharmacists in RACF Study in Australia

Prescribing potentially inappropriate medications (PIMs), including antipsychotics and benzodiazepines, has been used as an indicator of the quality use of medicines in residential aged care facilities (RACFs). PIMs are associated with an increased risk of falls and hospitalisations in the elderly. The purpose of this study is to assess the extent of prescribing of PIMs in RACFs at baseline in the Pharmacists in residential aged care facilities (PiRACF) study and examine the association of resident and system factors with the number of PIMs. A cross-sectional analysis of 1368 participants from 15 Australian RACFs was performed to detect PIMs using the American Geriatrics Society 2019 Beers® criteria. Most residents (68.1%) were taking at least one regular PIM; 16.9% were taking regular antipsychotics and 11.1% were taking regular benzodiazepines. Long-term proton pump inhibitors were the most frequent class of PIMs. History of falls and higher Charlson Comorbidity Index were associated with an increased number of prescribed PIMs, while dementia diagnosis and older age (85 years or more) were associated with decreased number of PIMs (p-value <0.05). Residents in facilities with lower nurse-to-resident ratios were more likely to have an increased number of PIMs (p value = 0.001). This study indicates that potentially inappropriate prescribing is common in RACFs and interventions to target residents at highest risk are needed.

Benzodiazepine use and the risk of dementia

Introduction

Benzodiazepines (BZDs) are commonly prescribed for anxiety and agitations, which are early symptoms of Alzheimer's disease and related dementias (ADRD). It is unclear whether BZDs causally affect ADRD risk or are prescribed in response to early symptoms of dementia.

Methods

We replicate prior case-control studies using longitudinal Medicare claims. To mitigate bias from prodromal use, we compare rates of ADRD diagnosis for beneficiaries exposed and unexposed to BZDs for cervical/lumbar pain, stenosis, and sciatica, none of which are associated with dementia.

Results

Approximately 8% of Medicare beneficiaries used a BZD in 2007, increasing to nearly 13% by 2013. Estimates from case-control designs are sensitive to duration of look-back period, health histories, medication use, and exclusion of decedents. Incident BZD use is not associated with an increased risk of dementia in an "uncontaminated" sample of beneficiaries prescribed a BZD for pain (odds ratios (ORs) of 1.007 [95% confidence interval [CI] = 0.885, 1.146] and 0.986 [95% CI = 0.877, 1.108], respectively, in the 2013 and 2013 to 2015 pooled samples). Higher levels of BZD exposure (>365 days over a 2-year period) are associated with increased odds of a dementia diagnosis, but the results are not statistically significant at the 5% or 10% levels (1.190 [95% CI = 0.925, 1.531] and 1.167 [95% CI = 0.919, 1.483]).

Discussion

We find little evidence of a causal relation between BZD use and dementia risk. Nonetheless, providers should limit the extended use in elderly populations.

Role of Melatonin in the Management of Substance Addiction: A Systematic Review

Recent evidence links melatonin hormone and its receptor to the etiology and behavioral manifestation of addiction. The role of exogenous melatonin in addiction treatment is still inconsistent and unclear. The present study aimed to review the literature on randomized clinical trials that evaluated the role of melatonin supplementation, compared to placebo, in the treatment of various substance addictions. The literature searches of relevant articles published in the English language in MEDLINE and Google Scholar databases were performed from inception up to May 2021. We included only randomized clinical trials investigating the effect of melatonin treatment, compared to placebo, on substance addiction-related parameters. Non-randomized clinical trials, observation studies, and animal studies were excluded. The risk of bias-2 was used to assess the quality of the studies. Of 537 articles, 12 randomized control trials (RCT) met our inclusion criteria. Studies have been conducted on substances of addiction including benzodiazepine (BZD), alcohol, nicotine, and opioids. Our results indicated that melatonin treatment had mixed results in improving sleep quality and was not found beneficial in BDZ cessation/discontinuation rate among patients with BDZ dependence. Sleep quality and mental health had improved by melatonin supplements in opioid addiction. In nicotine addiction, melatonin treatment showed effectiveness only on mood changes but not in performance tests. In patients with alcohol use disorder (AUD), melatonin treatment did not show any improvement in sleep quality. We found that the use of exogenous melatonin in substance addiction has mixed results which do not provide sufficient evidence, relative to randomized clinical trials, to establish its role.

Short-term, but not long-term, beneficial effects of concomitant benzodiazepine use on clinical course in patients with schizophrenia

This study aims to examine possible differences in the effect on the course characteristics of the disease in cases of no use, short-term use and long-term use of benzodiazepines in patients with schizophrenia. In this retrospective observational study, the sample comprised patients with schizophrenia who were admitted to our psychiatric clinics from January 2015 to January 2019. Patients were also retrospectively tracked from the date of the first admission during the specified time until the end of the observation period (24 months) for clinical course characteristics. Data for 1710 patients with schizophrenia were included in the analyses. Patients with short-term benzodiazepines use had fewer psychiatric hospitalizations and shorter lengths of stay at psychiatric services than patients with no use or long-term use. Rates of antipsychotic drug discontinuation and suicidal behavior were also significantly lower among short-term benzodiazepines users than among those with no use or long-term use. In conclusion, our study indicates that short-term benzodiazepines use is associated with a better clinical course in patients with schizophrenia. Future studies should evaluate the effects of different benzodiazepines use patterns on disease prognosis with longer-term follow-up and prospective methodology and should concomitantly examine psychopathological variables.

Use of Benzodiazepines and Risk of Incident Dementia: A Retrospective Cohort Study

BACKGROUND

Previous findings regarding the association between benzodiazepine exposure and dementia have conflicted, though many have not accounted for anticholinergic exposure. The goal of this study was to evaluate the association of benzodiazepine exposure with the risk of developing dementia, accounting for the anticholinergic burden.

METHODS

Using a retrospective cohort design, we identified veterans 65 or older without dementia during a 10-year baseline period and then followed participants for 5 years to evaluate the risk of dementia diagnosis. The primary exposure was cumulative benzodiazepine exposure. Cox proportional hazards survival model was used to examine the association between benzodiazepine exposure and dementia, adjusting for anticholinergic burden and other demographic and clinical characteristics associated with increased dementia risk.

RESULTS

Of the 528 006 veterans in the study cohort, 28.5% had at least one fill for a benzodiazepine. Overall, 7.9% developed a diagnosis of dementia during the observation period. Compared to veterans with no exposure to benzodiazepines, the adjusted hazard ratios for dementia risk were 1.06 (95% confidence interval [CI] 1.02-1.10) for low benzodiazepine exposure, 1.05 (95% CI 1.01-1.09) for medium benzodiazepine exposure, and 1.05 (95% CI 1.02-1.09) for high benzodiazepine exposure.

CONCLUSIONS

Cumulative benzodiazepine exposure was minimally associated with increased dementia risk when compared with nonuse but did not increase in a dose-dependent fashion with higher exposure. Veterans with low benzodiazepine exposure had essentially the equivalent risk of developing dementia as veterans with high exposure. While benzodiazepines are associated with many side effects for older adults, higher cumulative use does not appear to increase dementia risk.

Evaluation of a multicomponent intervention consisting of education and feedback to reduce benzodiazepine prescriptions by general practitioners: The BENZORED hybrid type 1 cluster randomized controlled trial

BACKGROUND

Current benzodiazepine (BZD) prescription guidelines recommend short-term use to minimize the risk of dependence, cognitive impairment, and falls and fractures. However, many clinicians overprescribe BZDs and chronic use by patients is common. There is limited evidence on the effectiveness of interventions delivered by general practitioners (GPs) on reducing prescriptions and long-term use of BZDs. We aimed to evaluate the effectiveness of a multicomponent intervention for GPs that seeks to reduce BZD prescriptions and the prevalence of long-term users.

METHODS AND FINDINGS

We conducted a multicenter two-arm, cluster randomized controlled trial in 3 health districts in Spain (primary health centers [PHCs] in Balearic Islands, Catalonia, and Valencian Community) from September 2016 to May 2018. The 81 PHCs were randomly allocated to the intervention group (n = 41; 372 GPs) or the control group (n = 40; 377 GPs). GPs were not blinded to the allocation; however, pharmacists, researchers, and trial statisticians were blinded to the allocation arm. The intervention consisted of a workshop about the appropriate prescribing of BZDs and tapering-off long-term BZD use using a tailored stepped dose reduction with monthly BZD prescription feedback and access to a support web page. The primary outcome, based on 700 GPs (351 in the control group and 349 in the intervention group), compared changes in BZD prescriptions in defined daily doses (DDDs) per 1,000 inhabitants per day after 12 months. The 2 secondary outcomes were the proportion of long-term users (≥6 months) and the proportion of long-term users over age 65 years. Intention-to-treat (ITT) analysis was used to assess all clinical outcomes. Forty-nine GPs (21 intervention group and 28 control group) were lost to follow-up. However, all GPs were included in the ITT analysis. After 12 months, there were a statistically significant decline in total BZD prescription in the intervention group compared to the control group (mean difference: -3.24 DDDs per 1,000 inhabitants per day, 95% confidence interval (CI): -4.96, -1.53, p < 0.001). The intervention group also had a smaller number of long-term users. The adjusted absolute difference overall was -0.36 (95% CI: -0.55, -0.16, p > 0.001), and the adjusted absolute difference in long-term users over age 65 years was -0.87 (95% CI: -1.44, -0.30, p = 0.003). A key limitation of this clustered design clinical trial is the imbalance of some baseline characteristics. The control groups have a higher rate of baseline BZD prescription, and more GPs in the intervention group were women, GPs with a doctorate degree, and trainers of GP residents.

CONCLUSIONS

A multicomponent intervention that targeted GPs and included educational meeting, feedback about BZD prescriptions, and a support web page led to a statistically significant reduction of BZD prescriptions and fewer long-term users. Although the effect size was small, the high prevalence of BZD use in the general population suggests that large-scale implementation of this intervention could have positive effects on the health of many patients.

TRIAL REGISTRATION

ISRCTN ISRCTN28272199.

Co-occurring OCD and Panic Disorder: A Review of Their Etiology and Treatment

Estimated rates of co-occurrence between obsessive and compulsive disorder (OCD) and panic disorder (PD) are notable, but vary considerably, with rates from epidemiological and clinical studies ranging from 1.8% to 22% (Rector et al., 2017). We reviewed the current empirical literature on the etiology, treatment, diagnostic assessment, and differential diagnosis of co-occurring OCD/PD. Best practices for cognitive-behavioral treatment, including identifying and addressing treatment barriers are also addressed. Although it is acknowledged in current literature that co-occurring OCD and PD levels may be clinically significant, there remains a need to thoroughly examine the possible consequences and future research directions of this overlap. Future research must continue to elucidate the biological and environmental causes of OCD/PD co-occurrence.

The association between benzodiazepine use and greater risk of neurocognitive impairment is moderated by medical burden in people with HIV

Benzodiazepine use is linked to neurocognitive impairment (NCI) in the general population and people with HIV (PWH); however, this relationship may depend on age-related factors such as medical comorbidities, which occur at an elevated rate and manifest earlier in PWH. We retrospectively examined whether chronological age or medical burden, a clinical marker for aging, moderated the relationship between benzodiazepine use and NCI in PWH. Participants were 435 PWH on antiretroviral therapy who underwent neurocognitive and medical evaluations, including self-reported current benzodiazepine use. A medical burden index score (proportion of accumulated multisystem deficits) was calculated from 28 medical deficits. Demographically corrected cognitive deficit scores from 15 neuropsychological tests were used to calculate global and domain-specific NCI based on established cut-offs. Logistic regressions separately modeled global and domain-specific NCI as a function of benzodiazepine x age and benzodiazepine x medical burden interactions, adjusting for current affective symptoms and HIV disease characteristics. A statistically significant benzodiazepine x medical burden interaction (p = .006) revealed that current benzodiazepine use increased odds of global NCI only among those who had a high medical burden (index score > 0.3 as indicated by the Johnson–Neyman analysis), which was driven by the domains of processing speed, motor, and verbal fluency. No age x benzodiazepine interactive effects on NCI were present. Findings suggest that the relationship between BZD use and NCI among PWH is specific to those with greater medical burden, which may be a greater risk factor for BZD-related NCI than chronological age.

Psychotropic Medication Use Is Associated With Greater 1-Year Incidence of Dementia After COVID-19 Hospitalization

Background

COVID-19 has been associated with an increased risk of incident dementia (post-COVID dementia). Establishing additional risk markers may help identify at-risk individuals and guide clinical decision-making.

Methods

We investigated pre-COVID psychotropic medication use (exposure) and 1-year incidence of dementia (outcome) in 1,755 patients (≥65 years) hospitalized with COVID-19. Logistic regression models were used to examine the association, adjusting for demographic and clinical variables. For further confirmation, we applied the Least Absolute Shrinkage and Selection Operator (LASSO) regression and a machine learning (Random Forest) algorithm.

Results

One-year incidence rate of post-COVID dementia was 12.7% (N = 223). Pre-COVID psychotropic medications (OR = 2.7, 95% CI: 1.8-4.0, P < 0.001) and delirium (OR = 3.0, 95% CI: 1.9-4.6, P < 0.001) were significantly associated with greater 1-year incidence of post-COVID dementia. The association between psychotropic medications and incident dementia remained robust when the analysis was restricted to the 423 patients with at least one documented neurological or psychiatric diagnosis at the time of COVID-19 admission (OR = 3.09, 95% CI: 1.5-6.6, P = 0.002). Across different drug classes, antipsychotics (OR = 2.8, 95% CI: 1.7-4.4, P < 0.001) and mood stabilizers/anticonvulsants (OR = 2.4, 95% CI: 1.39-4.02, P = 0.001) displayed the greatest association with post-COVID dementia. The association of psychotropic medication with dementia was further confirmed with Random Forest and LASSO analysis.

Conclusion

Confirming prior studies we observed a high dementia incidence in older patients after COVID-19 hospitalization. Pre-COVID psychotropic medications were associated with higher risk of incident dementia. Psychotropic medications may be risk markers that signify neuropsychiatric symptoms during prodromal dementia, and not mutually exclusive, contribute to post-COVID dementia.

Deprescribing clonazepam in primary care older patients: a feasibility study

Background Inappropriate use of clonazepam by older adults is associated with cognitive impairment, delirium, and falls. Strategies to optimize its use are important to increase patient safety. Objective To evaluate the feasibility of a clonazepam deprescription protocol in the elderly. Methods This is a quasi-experimental study. Elderly people with chronic use of clonazepam and attended in primary care units in two Brazilian municipalities were selected. A deprescription protocol was used, which included five fortnightly meetings between the older adults and the research team, to reduce the dose by 25%. Patients received instructions on sleep hygiene behaviors and the advantages of clonazepam deprescription; family physicians followed a flowchart for gradual dose reduction. In the 1st and 5th meetings, there were medical appointments for anamnesis and discharge. The monitoring of patients and the application of tests were carried out by the research team. Results Of the 35 elderly people included in the study, 27 reached the end; 81.5% achieved deprescription: 22.2% stopped completely and 59.3% decreased the dose. At the last meeting, 20% of elderly patients reported an increase in blood pressure. Conclusion The high rate of deprescription and the little relevance of clonazepam withdrawal reactions, showed that the use of the protocol was effective. However, the increase in blood pressure and the worsening of sleep quality in the last meeting show the need for adjustment in the last stage of the deprescription process.

The risk of dementia in patients using psychotropic drugs: Antidepressants, mood stabilizers or antipsychotics

OBJECTIVE

The risk of dementia associated with the use of psychotropic drugs is not fully understood. A nested case-control study was carried out to assess the risk of dementia broadly defined or Alzheimer's disease associated with antidepressants, mood stabilizers or antipsychotics.

METHODS

A cohort was formed from healthcare claim databases including all patients aged 50 and over with a first dispensing of the psychotropic drugs concerned between 2006 and 2017. Patients who developed dementia over the study period were considered as cases. The association between drug exposure prior to a five-year lag time and diagnosis of dementia was assessed by conditional logistic regression models.

RESULTS

No association was found between dementia, either broadly defined or Alzheimer disease, and antidepressant or mood stabilizers. Findings were conflicting with regard to antipsychotics. First- and second-generation antipsychotics (FGA and SGA) were not associated with Alzheimer disease. SGA treatments of more than 3 months were associated with a higher risk of dementia broadly defined than no use of antipsychotics (Odds ratio [OR] 2.00; 95%CI 1.06-3.79; p = 0.03). In a sensitivity analysis using a lag time of 3 years, ever use of SGA and SGA treatments of more than 3 months were associated with a higher risk of dementia broadly defined than no use of antipsychotics (OR 1.71; 1.10-2.67; p = 0.02 and OR 1.84; 1.03-3.32; p = 0.04, respectively).

CONCLUSION

The association between antipsychotics and dementia should be further investigated to establish patients, specific drugs, and patterns of treatment at risk. Prescribers should remain cautious when prescribing them.

Geriatric Depression and Inappropriate Medication: Benefits of Interprofessional Team Cooperation in Nursing Homes

An investigation of inappropriate medication use in treatment of depressivity in institutionalized older adults, based on a nurse-led evaluation of functional status and depressive symptoms in nursing home residents. Methods: A cross-sectional multicenter study was performed using records from 1087 residents cared for in fifteen nursing homes (NHs) in the Czech Republic. Inclusion criteria were being a permanent resident of one of the facilities, being 60 years of age or older, having a Geriatric Depression Scale score of 6 or more, and having a Mini Mental State examination score 10 or more. The final sample for analysis included 317 depressed NH residents. Results: 52 percent of NH residents with depressivity had no antidepressant treatment. Benzodiazepines were the only medication in 16 percent of depressed residents, and were added to antidepressant treatment in 18 percent of residents. Benzodiazepine users had significantly higher GDS scores compared to non-users (p = 0.007). Conclusion: More than half of depressed NH residents remained without antidepressant treatment. Residents inappropriately treated with benzodiazepines were more depressed than residents treated with antidepressants only, or even not treated at all. Cooperation of the interprofessional team in the screening of depressive symptoms has the potential to improve the quality of care.

Challenges and visions for managing pain-related insomnia in primary care using the hybrid CBT approach: a small-scale qualitative interview study with GPs, nurses, and practice managers

Background

Chronic pain and insomnia have a complex, bidirectional relationship – addressing sleep complaints alongside pain may be key to alleviating patient-reported distress and disability. Healthcare professionals have consistently reported wanting to offer psychologically informed chronic pain management at the primary care level. Research in secondary care has demonstrated good treatment efficacy of hybrid CBT for chronic pain and insomnia. However, primary care is typically the main point of treatment entry, hence may be better situated to offer treatments using a multidisciplinary approach. In this study, primary care service providers’ perception of feasibility for tackling pain-related insomnia in primary care was explored.

Methods

The data corpus originates from a feasibility trial exploring hybrid CBT for chronic pain and insomnia delivered in primary care. This formed three in-depth group interviews with primary care staff (n = 9) from different primary care centres from the same NHS locale. All interviews were conducted on-site using a semi-structured approach. Verbal data was recorded, transcribed verbatim and analysed using the thematic analysis process.

Results

Eight themes were identified – 1) Discrepant conceptualisations of the chronic pain-insomnia relationship and clinical application, 2) Mismatch between patients’ needs and available treatment offerings, 3) Awareness of psychological complexities, 4) Identified treatment gap for pain-related insomnia, 5) Lack of funding and existing infrastructure for new service development, 6) General shortage of psychological services for complex health conditions, 7) Multidisciplinary team provision with pain specialist input, and 8) Accessibility through primary care. These mapped onto four domains - Current understanding and practice, Perceived facilitators, Perceived barriers, Ideal scenarios for a new treatment service – which reflected the focus of our investigation. Taken together these provide key context for understanding challenges faced by health care professionals in considering and developing a new clinical service.

Conclusions

Primary care service providers from one locale advocate better, multidisciplinary treatment provision for chronic pain and insomnia. Findings suggest that situating this in primary care could be a feasible option, but this requires systemic support and specialist input as well as definitive trials for success.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01552-3.

Impact of Pharmacotherapy on Insomnia in Patients with Alzheimer's Disease

Insomnia is a pervasive sleep disorder affecting numerous patients across diverse demographical populations and comorbid disease states. Contributing factors are often a complex interaction of biological, psychological, and social components, requiring a multifaceted approach in terms of both diagnosis and management. In the setting of Alzheimer’s disease, insomnia is an even more complicated issue, with a higher overall prevalence than in the general population, greater complexity of contributing etiologies, and differences in diagnosis (at times based on caregiver observation of sleep disruption rather than subjective complaints by the individual with the disorder), and requiring more discretion in terms of treatment, particularly in regard to adverse effect profile concerns. There also is growing evidence of the bidirectional nature of sleep disruption and Alzheimer’s disease, with insomnia potentially contributing to disease progression, making the condition even more paramount to address. The objective of this review was to provide the clinician with an overview of treatment strategies that may have value in the treatment of disturbed sleep in Alzheimer’s disease. Nonpharmacological approaches to treatment should be exhausted foremost; however, pharmacotherapy may be needed in certain clinical scenarios, which can be a challenge for clinicians given the paucity of evidence and guidelines for treatment in the subpopulation of Alzheimer’s disease. Agents such as sedating antidepressants, melatonin, and site-specific γ-aminobutyric acid agonists are often employed based on historical usage but are not necessarily supported by high-quality trials. Newer agents such as dual orexin receptor antagonists have demonstrated some promise but still need further evaluation.

General practitioners' compliance with benzodiazepine discontinuation guidelines in patients treated with long-term lorazepam: A case-vignette cross-sectional survey

AIM

To study determinants associated with GPs' compliance with benzodiazepine discontinuation guidelines through a case-vignette of a patient with multimorbidity treated with long-term lorazepam for insomnia.

METHODS

This cross-sectional survey was performed in a sample of French GPs. The questionnaire included items on their characteristics and questions related to the management of a case-vignette with long-term lorazepam use consulting for a prescription renewal. GPs who proposed a dedicated consultation to discuss discontinuation or progressive discontinuation were considered as "following guidelines", while they were considered as "out-of-guidelines" if they proposed immediate discontinuation or decided not to discontinue lorazepam. A backward selection process was used to select factors to be included in the final logistic regression model. The probabilities of out-of-guidelines practice and their 95% confidence interval (95% CI) were then plotted using a heatmap graph.

RESULTS

Of 1,177 GPs, the majority (92.2%) were aware of the necessity to discontinue lorazepam and reported practice consistent with good practice guidelines. Women GPs aged under 50 years had the lowest estimated probability of out-of-guidelines practice. Conversely, men aged over 58 years with high consideration of patient preferences and low concern about the benefit-risk ratio of lorazepam had the highest probability of out-of-guidelines practice (27.3% [18.7%; 34.7%]).

CONCLUSION

GPs largely reported practice compliant with benzodiazepine discontinuation guidelines, although some GPs, mainly older men who overemphasise patient preferences, were more likely to adopt out-of-guidelines practice.

Tie Decay and Dissolution: Contentious Prescribing Practices in the Prescription Drug Epidemic

Although a substantial body of work has investigated drivers of tie formation, there is growing interest in understanding why relationships decay or dissolve altogether. The networks literature has tended to conceptualize tie decay as driven by processes similar to those underlying tie formation. Yet information that is revealed through ongoing interactions can exert different effects on tie formation and tie decay. This paper investigates how tie decay and tie formation processes differ by focusing on contentious practices. To the extent that information about dissimilarities in contentious practices is learned through ongoing interactions, it can exert diverging effects on tie formation and tie decay. Using a longitudinal data set of 141,543 physician dyads, we find that differences in contentious prescribing led ties to weaken or dissolve altogether but did not affect tie formation. The more contentious the practice and the more information available about the practice, the stronger the effect on tie decay and dissolution. Collectively, these findings contribute to a more nuanced understanding of relationship evolution as an unfolding process through which deeper-level differences are revealed and shape the outcome of the tie.

Association Between the Use of Hypnotics and the Risk of Alzheimer's Disease

BACKGROUND

Hypnotics, including benzodiazepines, are extensively and inappropriately prescribed for older people to treat anxiety and sleep disorders, despite the adverse health outcomes associated with their use.

OBJECTIVE

This study aimed to examine the association of the use of long- and short-acting hypnotics with the risk of Alzheimer's disease.

METHODS

Data from 234,634 participants, derived from the Korean National Health Insurance Service National Sample Cohort from 2002 to 2013, were examined. Individuals over the age of 50 years were included in the study. The dependent variable was the risk of Alzheimer's disease. Hypnotics were categorized by the period of the prescription of benzodiazepines, i.e., either till the participants were diagnosed with Alzheimer's disease or the end of the study period (December 31, 2013). Cox regression model was built to analyze the association between variables.

RESULTS

Individuals who used long-acting hypnotics were found to have a higher risk of Alzheimer's disease than non-users. Moreover, among individuals with sleep disorders, those who used hypnotics had a higher risk of Alzheimer's disease than those who did not.

CONCLUSION

This study identified an association between the use of hypnotics and the risk of Alzheimer's disease among South Korean middle-aged and older people.

Cost-utility analysis of a consensus and evidence-based medication review to optimize and potentially reduce psychotropic drug prescription in institutionalized dementia patients

BACKGROUND

Growing evidence shows the effects of psychotropic drugs on the evolution of dementia. Until now, only a few studies have evaluated the cost-effectiveness of psychotropic drugs in institutionalized dementia patients. This study aims to assess the cost-utility of intervention performed in the metropolitan area of Barcelona (Spain) (MN) based on consensus between specialized caregivers involved in the management of dementia patients for optimizing and potentially reducing the prescription of inappropriate psychotropic drugs in this population. This analysis was conducted using the Monitoring and Assessment Framework for the European Innovation Partnership on Active and Healthy Ageing (MAFEIP) tool.

METHODS

The MAFEIP tool builds up from a variety of surrogate endpoints commonly used across different studies in order to estimate health and economic outcomes in terms of incremental changes in quality adjusted life years (QALYs), as well as health and social care utilization. Cost estimates are based on scientific literature and expert opinion; they are direct costs and include medical visits, hospital care, medical tests and exams and drugs administered, among other concepts. The healthcare costs of patients using the intervention were calculated by means of a medication review that compared patients' drug-related costs before, during and after the use of the intervention conducted in MN between 2012 and 2014. The cost-utility analysis was performed from the perspective of a health care system with a time horizon of 12 months.

RESULTS

The tool calculated the incremental cost-effectiveness ratio (ICER) of the intervention, revealing it to be dominant, or rather, better (more effective) and cheaper than the current (standard) care. The ICER of the intervention was in the lower right quadrant, making it an intervention that is always accepted even with the lowest given Willingness to Pay (WTP) threshold value (€15,000).

CONCLUSIONS

The results of this study show that the intervention was dominant, or rather, better (more effective) and cheaper than the current (standard) care. This dominant intervention is therefore recommended to interested investors for systematic application.

Exposure to Anticholinergic and Sedative Drugs and Healthcare Costs in Older Patients with Neurocognitive Disorders

BACKGROUND

Literature supports an increasing number of older patients living with neurocognitive disorders alongside with their annual worldwide costs. Therapeutic management of behavioral and psychological symptoms includes the use of anticholinergic and sedative drugs for which significant exposure is negatively associated with clinical outcomes.

OBJECTIVE

The aim of this study was to assess the healthcare costs differences related to an increase in the exposure to anticholinergic and sedative drugs in older patients with neurocognitive disorder.

METHODS

A longitudinal study was conducted during 3 years on 1,604 participants of the MEMORA cohort linked with both regional public health insurance and hospital discharge databases between 2012 and 2017. Direct medical and non-medical costs were included. Exposure to anticholinergic and sedative drugs was measured by the drug burden index (DBI).

RESULTS

Costs difference associated with a DBI≥0.5 were + 338€ (p < 0.001). After adjustment on comorbidities, NCD stage, cognitive impairment, functional limitation, polypharmacy, and sociodemographic characteristics, a DBI≥0.5 was found to be an independent predictor of an increase of total healthcare costs by 22%(p < 0.001).

CONCLUSION

Anticholinergic and sedative drugs have a substantial economic burden among older patients with neurocognitive disorder. More studies are required to assess the clinical and economic impact of an efficient strategy based on the reduction of the exposure to anticholinergic and sedative drugs and the promotion of non-pharmacological interventions.

Sleep medication use and incident dementia in a nationally representative sample of older adults in the US

BACKGROUND

Sleep difficulties are common among older adults, and clinical management of sleep difficulties commonly includes sleep medication (pharmacological and non-pharmacological). Our research examines sleep medication use and incident dementia over 8 years using nationally representative data from older adults ages 65 years and older in the United States.

METHODS

We used data collected from the National Health and Aging Trends Study (NHATS), a nationally-representative longitudinal study of Medicare beneficiaries. Routine sleep medication use (pharmacological and non-pharmacological) was defined as use "most nights" or "every night." Participants were screened for dementia with validated instruments that assessed memory, orientation, and executive function. We conduct prospective analyses to examine the relationship between routine sleep medication use and incident dementia using Cox proportional hazards modeling and estimated survival curves. Analyses controlled for age, sex, marital status, education, and chronic conditions.

RESULTS

Among respondents at baseline (n = 6373), most participants (21%) were age 70-74 years of age. Participants were 59% female and the sample comprised non-Hispanic White (71%). At baseline, 15% of our study sample reported using sleep medication routinely, which is representative of 4.6 million older adults in the US. Covariate adjusted proportional hazard models revealed that routinely using sleep medication was associated with incident dementia (HR = 1.30, 95%CI: 1.10 to 1.53, p < 0.01).

CONCLUSIONS

Our study observed, in a nationally representative study of older adults in the US across 8 years of data that 15% of older adults report routinely using sleep medication, yet routine use of sleeping medication was associated with incident dementia across the follow-up interval. Future research may examine behavioral approaches to improving sleep among older adults.