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Mercier C, Rollason V, Eshmawey M, Mendes A, Frisoni GB. The treatment of behavioural and psychological symptoms in dementia: pragmatic recommendations. Psychogeriatrics 2024; 24:968-982. [PMID: 38638077 DOI: 10.1111/psyg.13116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/20/2024] [Accepted: 03/19/2024] [Indexed: 04/20/2024]
Abstract
Behavioural and psychological symptoms of dementia (BPSD) are a clinical challenge for the lack of a sound taxonomy, frequent presentation with comorbid BPSD, lack of specific pharmacologic interventions, poor base of methodologically sound evidence with randomized clinical trials, contamination from the treatment of behavioural disturbances of young and adult psychiatric conditions, and small efficacy window of psychotropic drugs. We present here a treatment workflow based on a concept-driven literature review based on the notions that (i) the aetiology of BPSD can be mainly neurobiological (so-called 'primary' symptoms) or mainly environmental and functional ('secondary' symptoms) and that this drives treatment; (ii) the clinical efficacy of psychotropic drugs is driven by their specific profile of receptor affinity; (iii) drug treatment should follow the rules of 'start low-go slow, prescribe and revise'. This article argues in support of the distinction between primary and secondary BPSD, as well as their characteristics, which until now have been just sketchily described in the literature. It also offers comprehensive and pragmatic clinician-oriented recommendations for the treatment of BPSD.
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Affiliation(s)
- Camille Mercier
- Laboratory of Neuroimaging of Aging (LANVIE), University of Geneva, Geneva, Switzerland
- Memory Center, Department of Rehabilitation and Geriatrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Victoria Rollason
- Department of Acute Medicine, Clinical Pharmacology and Toxicology Service, University Hospitals of Geneva, Geneva, Switzerland
| | - Mohamed Eshmawey
- Department of Psychiatry, Geriatric Psychiatry Service, University Hospitals of Geneva, Geneva, Switzerland
| | - Aline Mendes
- Geriatrics and Rehabilitation Department, Department of Rehabilitation and Geriatrics, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
| | - Giovanni B Frisoni
- Laboratory of Neuroimaging of Aging (LANVIE), University of Geneva, Geneva, Switzerland
- Memory Center, Department of Rehabilitation and Geriatrics, University Hospitals of Geneva, Geneva, Switzerland
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Preiss M, Rabl U, Popper V, Watzal V, Treiber M, Ivkic D, Praschak-Rieder N, Naderi-Heiden A, Fugger G, Frey R, Rujescu D, Bartova L. Case report: Hyperactive delirium after a single dose of zolpidem administered additionally to psychopharmacotherapy including clozapine. Front Psychiatry 2023; 14:1204009. [PMID: 37575586 PMCID: PMC10413097 DOI: 10.3389/fpsyt.2023.1204009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/05/2023] [Indexed: 08/15/2023] Open
Abstract
The non-benzodiazepine hypnotic zolpidem is frequently administered as a short term psychopharmacotherapy for insomnia. Although it is well-established in a broad clinical routine and often well-tolerated, severe delirium and complex sleep behavior were reported in rare cases. Hereby, it remains unclear whether zolpidem's potential for delirium might be enhanced when combined with further psychopharmacotherapeutics. The present case report portrays a young male Caucasian inpatient with schizoaffective disorder, who was admitted due to severe hyperactive delirium after a single dose of zolpidem 10 mg that was administered in addition to already established psychopharmacotherapy including clozapine 200 mg/day, aripiprazole 15 mg/day and cariprazine 4.5 mg/day. In detail, disorientation, agitation, confabulations, bizarre behavior, and anterograde amnesia occurred shortly after ingestion of zolpidem and gained in intensity within a couple of hours. Once zolpidem was discontinued, the abovementioned symptoms subsided completely and did not reoccur. Since a clear temporal association could be drawn between the intake of zolpidem and the onset of hyperactive delirium, the present clinical experience should serve as a cautionary note for combining potent sedative-hypnotics and substances with anticholinergic properties, even in young adults in a good general condition. Moreover, our case argues for the necessity of further research into the pathomechanism of the interaction potential of non-benzodiazepines as zolpidem, especially with substances exerting anticholinergic properties, which are known for their potential to precipitate delirium. Therefore, the metabolic pathways of the concurrently administered substances should be further taken into account.
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Affiliation(s)
- Maximilian Preiss
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Ulrich Rabl
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Valentin Popper
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Victoria Watzal
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Michael Treiber
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Dominik Ivkic
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Nicole Praschak-Rieder
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Angela Naderi-Heiden
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Gernot Fugger
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Richard Frey
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Dan Rujescu
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Lucie Bartova
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
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Ricciardulli S, Lattanzi L, Barbuti M, Ceravolo R, Perugi G. Occurrence of involuntary movements after prolonged misuse of zolpidem: a case report. Int Clin Psychopharmacol 2023; 38:117-120. [PMID: 36719339 DOI: 10.1097/yic.0000000000000443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Zolpidem is a non-benzodiazepine agent used for short-term treatment of insomnia. Several cases of dependence and withdrawal from zolpidem are reported in the literature. Furthermore, involuntary movements after prolonged zolpidem misuse have been described. In this case report, a 69-year-old Italian woman with no history of diagnosed psychiatric or neurologic diseases developed uncontrolled movements and a depressive-anxious syndrome after twelve-year zolpidem misuse. The underlying mechanisms of involuntary movements occurring after long-term zolpidem intake are unknown; yet, we suggest that zolpidem might induce an increase in dopamine release through inhibition of gamma-aminobutyric acid neurons tonically suppressing dopamine cells. Future studies on the occurrence of persistent disorders after long-term benzodiazepine or Z-drug abuse are needed and clinicians should pay attention to the risk of tardive syndromes related to zolpidem misuse, especially in the case of long-term intake of over-therapeutic dosages.
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Affiliation(s)
- Sara Ricciardulli
- Psychiatry 2 Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa
| | - Lorenzo Lattanzi
- Psychiatry 2 Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa
| | - Margherita Barbuti
- Psychiatry 2 Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa
| | - Roberto Ceravolo
- Neurology Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Giulio Perugi
- Psychiatry 2 Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa
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DeMaagd GA, DeMaagd DR, Philip A. Delirium and Its Pharmacological Causes in Older People, Part Three. Sr Care Pharm 2021; 36:619-631. [PMID: 34861903 DOI: 10.4140/tcp.n.2021.619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Delirium is a syndrome that can arise from many causes or underlying conditions, and though it has been reported in younger patients, it is more prevalent in older people, though it can occur in other age groups as well. Identifying delirium is challenging in older people because of the coexistence of underlying dementia or depression, which may further complicate the presentation. Drug-induced delirium is one of the major causes of delirium, and evaluation of this potential cause or contribution is an important component of the evaluation process, since it can lead to poor patient outcomes. Part one of this three part series reviewed the epidemiology, pathophysiology, evaluation, diagnostic process, and causes of delirium in older people. Parts two and three continued to review the pharmacological classes of medications that cause or contribute to delirium in older people.
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Affiliation(s)
| | | | - Ashok Philip
- Union University College of Pharmacy, Jackson, Tennessee
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Mian R. Visual Hallucinations from Zolpidem Use for the Treatment of Hospital Insomnia in a Septuagenarian. Cureus 2019; 11:e3848. [PMID: 30891388 PMCID: PMC6411327 DOI: 10.7759/cureus.3848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Insomnia and parasomnias are common patient complaints during hospital stay. New environment, the severity of underlying disease, level of care, medications, and infections are all known factors that contribute toward insomnia. Zolpidem is a common sleep aid used for this purpose. We report a case of Zolpidem-induced visual hallucination in a septuagenarian in the inpatient setting.
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Affiliation(s)
- Raza Mian
- Internal Medicine, University of California San Francisco, Fresno, USA
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Jang Y, Song I, Oh IS, Shin JY. Twelve-year trend in the use of zolpidem and physicians’ non-compliance with recommended duration: a Korean national health insurance database study. Eur J Clin Pharmacol 2018; 75:109-117. [PMID: 30280207 DOI: 10.1007/s00228-018-2563-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 09/21/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Yunjeung Jang
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
| | - Inmyung Song
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
| | - In-Sun Oh
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea.
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Kalan U, Soysal P, Isik AT. Delirium associated with only one dose of zopiclone in an older adult. Psychogeriatrics 2018; 18:321-323. [PMID: 30133934 DOI: 10.1111/psyg.12320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 10/18/2017] [Accepted: 02/03/2018] [Indexed: 11/28/2022]
Abstract
Both insomnia and its treatment can lead to the development of delirium in older adults. In the present case, delirium occurred after a single dose of zopiclone was given for insomnia treatment in an 84-year-old patient. Considering the case, patients and caregivers should be informed about the rare complication when zopiclone is prescribed.
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Affiliation(s)
- Ugur Kalan
- Kayseri Education and Research Hospital, Department of Internal Medicine, Kayseri, Turkey
| | - Pinar Soysal
- Kayseri Education and Research Hospital, Geriatric Center, Kayseri, Turkey
| | - Ahmet Turan Isik
- Unit for Aging Brain and Dementia, Department of Geriatric Medicine, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
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JoonWoo Han, Young-Jin Ko, Byung-Joo Park, Seonji Kim. Signal Detection of Adverse Drug Reaction of Zolpidem Using the Korea Adverse Event Reporting System Database. ACTA ACUST UNITED AC 2018. [DOI: 10.34161/johta.2018.6.1.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Shuster J. • Renal Tubular Acidosis and Dyspnea in Patients Taking ACE Inhibitors • Aplastic Anemia Associated with Ketoconazole • Leflunomide-Induced Fever, Thrombocytosis, and Leukocytosis • Radiographic Contrast Material Causes Dystonia • Zolpidem and Delirium • Hepatotoxicity with Short-Term Trazodone Therapy. Hosp Pharm 2017. [DOI: 10.1177/001857870203700305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this feature is to heighten awareness of specific adverse drug reactions (ADRs), to discuss methods of prevention, and to promote reporting of ADRs to the FDA's medWatch program (1-800-FDA-1088). If you have reported an interesting preventable ADR to medWatch, please consider sharing the account with our readers.
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Affiliation(s)
- Joel Shuster
- Temple University School of Pharmacy, Philadelphia
- Medical College of Pennsylvania Hospital, Philadelphia
- Institute for Safe Medication Practices, Huntingdon Valley, PA 19006
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Chung S, Youn S. The Optimizing Strategies for Prescription of Sleeping Pills for Insomnia Patients. SLEEP MEDICINE RESEARCH 2017. [DOI: 10.17241/smr.2017.00024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Lin Y, Tang WK, Liang HJ, Tang A, Ungvari GS. Psychiatric Morbidity in Dependent Z-Drugs and Benzodiazepine Users. Int J Ment Health Addict 2016. [DOI: 10.1007/s11469-016-9679-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Rooney S, Qadir M, Adamis D, McCarthy G. Diagnostic and treatment practices of delirium in a general hospital. Aging Clin Exp Res 2014; 26:625-33. [PMID: 24789220 DOI: 10.1007/s40520-014-0227-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 04/08/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Despite the increase in research on delirium, it remains underdiagnosed and difficult to manage, and the outcome is poor especially in older people. AIMS To identify the clinically diagnosed rates of delirium, the possible aetiologies, to describe treatment, number and type of psychotropic medication used and to investigate the reasons for referral to a liaison psychiatric team. METHODS Retrospective study of medical records of inpatients admitted to Sligo Regional Hospital during an 18-month period. RESULTS One hundred and fifty-six files had a documentation of delirium (time prevalence 2%). Mean age of the sample was 82 years (SD = 7.2), 66 (42%) were male. Sixty-nine (44.2%) of the total sample had a previous history of dementia, and 57 (36.5%) had a previous history of delirium. In 67 (43.2%) samples, the cause was infection, while in 4, no specific cause was identified. Ninety (58%) were referred to the liaison service, but only in 26 (28.9 %), the reason for referral was "acute confusion" or "delirium". In a majority of referrals, the reason was an affective disorder more often depression. There were no significant differences between delirium subtypes and referrals (χ(2) = 3.868, df 3, p = 0.28). Examination of the amount of antipsychotics prescribed before, during and after delirium shows that there was a significant increase in use during the delirium (χ(2) = 17.512, df 8, p = 0.025) and decrease in z-hypnotics medication (zopiclone/zolpidem), (χ(2) = 20.114, df 4, p < 0.001), while benzodiazepines and antidepressants remained the same. CONCLUSIONS Delirium is often misdiagnosed and unrecognized in hospital settings; however, when identified the pharmacological management is appropriate.
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Affiliation(s)
- Siobhan Rooney
- Medical Education, Sligo Medical Academy, NUI Galway, Galway, Ireland,
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Abstract
There is an interdependent relationship between insomnia and fatigue in the medical literature, but both remain distinct entities. Insomnia entails problematic sleep initiation, maintenance, or restoration with an accompanying decrease in perceived daytime function. Lethargy is a symptom that has a wide differential diagnosis that heavily overlaps with cancer-related fatigue; however, insomnia may contribute to worsened fatigue and lethargy in cancer patients. Insomnia is a major risk factor for mood disturbances such as depression, which may also contribute to lethargy in this at-risk population. The pathophysiology of fatigue and insomnia is discussed in this review, including their differential diagnoses as well as the emerging understanding of the roles of neurotransmitters, branched-chain amino acids, and inflammatory cytokines. Treatment approaches for insomnia and fatigue are also discussed and reviewed, including the role of hypnotics, psychotropics, hormonal agents, and alternative therapies.
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Hosono T, Homma M, Satoh M, Kohda Y. Variables influencing patient satisfaction for hypnotics: difference between zolpidem and brotizolam. J Clin Pharm Ther 2014; 39:507-10. [PMID: 24828966 DOI: 10.1111/jcpt.12174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 04/15/2014] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE The pharmacokinetics of zolpidem and brotizolam is affected by gender and age, that is, increased clearance in males taking zolpidem and younger subjects taking brotizolam. The purpose of this study was to determine the variables including gender and age influencing patient satisfaction for hypnotics, zolpidem and brotizolam. METHODS The study included 329 patients who were treated with zolpidem (n = 172) and brotizolam (n = 157) for insomnia. Patients were interviewed to evaluate individual satisfaction and drug efficacy. The factors associated with dissatisfaction of zolpidem and brotizolam were identified using multiple logistic analysis. RESULTS AND DISCUSSION Of the participating patients, 40 (23%) and 41 (26%) complained of dissatisfaction with zolpidem and brotizolam, respectively. An insufficient amount of sleep (<6 h) and the number of awakenings were common factors cited for dissatisfaction for both drugs. Males were found to report a higher rate of dissatisfaction for zolpidem, whereas patients younger than 65 years and those receiving corticosteroid therapy reported a higher rate of dissatisfaction with brotizolam. WHAT IS NEW AND CONCLUSION These results suggested that patient satisfaction was different between zolpidem and brotizolam in terms of gender for zolpidem and age and corticosteroid co-administration for brotizolam, which could be used to help choose a better drug among the two in patients with insomnia.
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Affiliation(s)
- T Hosono
- Department of Pharmaceutical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Ibaraki, Japan
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Mortaz Hejri S, Faizi M, Babaeian M. Zolpidem-induced suicide attempt: a case report. Daru 2013; 21:77. [PMID: 24359886 PMCID: PMC3878174 DOI: 10.1186/2008-2231-21-77] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 09/16/2013] [Indexed: 11/10/2022] Open
Abstract
Zolpidem is a popular drug indicated for the short-term treatment of insomnia. Side effects are not uncommon with zolpidem. Herein we describe an Iranian 27-year-old man with no known mood disorder or neuropsychological disease who attempted suicide upon taking zolpidem. There are two interesting facts about this case: Firstly, the patient had not history of suicide attempt or thinking. Secondly, this case had experienced suicide ideation after taking 20 mg of zolpidem, suggesting a possible correlation between zolpidem psychological effects and dangerous psychological behaviors.
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Affiliation(s)
| | - Mehrdad Faizi
- Department of Pharmacology & Toxicology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Babaeian
- National Drugs and Poisons Information Center, Deputy of Food and Drug, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Pharmacognosy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Vali-e-Asr Avenue, Niayesh Junction, P.O. Box: 14155–6153, Tehran, Iran
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Paradis CM, Siegel LA, Kleinman SB. Two cases of zolpidem-associated homicide. Prim Care Companion CNS Disord 2012; 14:12br01363. [PMID: 23251862 DOI: 10.4088/pcc.12br01363] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Accepted: 04/02/2012] [Indexed: 10/28/2022] Open
Abstract
Zolpidem is the most commonly prescribed medication for the short-term treatment of insomnia. Adverse reactions include nightmares, confusion, and memory deficits. Reported rare adverse neuropsychiatric reactions include sensory distortions such as hallucinations. Previous research has identified 4 factors that may place a patient at increased risk of zolpidem-associated psychotic or delirious reactions: (1) concomitant use of a selective serotonin reuptake inhibitor (SSRI), (2) female gender, (3) advanced age, and (4) zolpidem doses of 10 mg or higher. In this article, 2 cases are presented in which individuals killed their spouses and claimed total or partial amnesia. Neither individual had a history of aggressive behavior. Both had concomitantly taken 10 mg or more of zolpidem in addition to an SSRI (paroxetine).
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Affiliation(s)
- Cheryl M Paradis
- Department of Psychology, Marymount Manhattan College, New York, and Department of Psychiatry, The State University of New York, Downstate Medical Center, Brooklyn, USA
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Complex Behaviors Related to Zolpidem: An Analysis of Published Clinical Cases from Taiwan. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.jecm.2012.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Inagaki T, Miyaoka T, Tsuji S, Inami Y, Nishida A, Horiguchi J. Adverse reactions to zolpidem: case reports and a review of the literature. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2011; 12. [PMID: 21494350 DOI: 10.4088/pcc.09r00849bro] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Accepted: 04/22/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Zolpidem, a nonbenzodiazepine hypnotic, is very effective and widely prescribed in clinical practice for the treatment of insomnia and is thought to have few adverse effects. However, zolpidem-induced adverse effects have begun to be reported in the literature, but few systemic descriptions of the adverse effects (especially for psychotic reactions) of zolpidem have been undertaken. In light of the accumulating reports of adverse reactions to zolpidem, we present 2 case reports of zolpidem-induced adverse effects and review the literature on this subject. DATA SOURCES Articles were selected by the authors on the basis of our experience and by a PubMed search using the terms zolpidem or side effects or adverse effects or adverse reactions. STUDY SELECTION AND DATA EXTRACTION Publications relevant to the objective of this article were obtained (1992-2010), and some adverse neuropsychiatric reactions were summarized. DATA SYNTHESIS Zolpidem has been associated with the development of adverse neuropsychiatric reactions, such as hallucinations/sensory distortion, amnesia, sleepwalking/somnambulism, and nocturnal eating. The following 4 variables should be considered when prescribing zolpidem: (1) gender: women have been found to have a significantly higher serum zolpidem concentration than men; (2) zolpidem dose: the adverse reactions that develop are dose dependent; (3) protein binding affinity: a high proportion of zolpidem is protein bound; therefore, low serum albumin results in a higher level of free zolpidem leading to adverse psychiatric reactions; and (4) cytochrome P450 (CYP) isoenzyme inhibition: concomitant administration of zolpidem and other drugs may cause interactions that lead to increased concentrations of zolpidem. CONCLUSIONS Zolpidem is clinically very effective in treating insomnia. However, while rare, zolpidem-induced unusual complex behavior may develop. Primary care physicians should be alert to the possible unusual complex adverse effects of zolpidem.
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Affiliation(s)
- Takuji Inagaki
- Department of Psychology and Special Support Education, Shimane University, Shimane, Japan.
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Johnell K, Fastbom J. The use of benzodiazpines and related drugs amongst older people in Sweden: associated factors and concomitant use of other psychotropics. Int J Geriatr Psychiatry 2009; 24:731-8. [PMID: 19127524 DOI: 10.1002/gps.2189] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To determine the factors associated with use of benzodiazepines and benzodiazepine related drugs (BZDs/BZDRDs) in a nationwide population of older people. METHODS We analyzed data on age, sex, type of residential area (urban/rural), and dispensed drugs for people aged > or = 75 years registered in the Swedish Prescribed Drug Register from October to December 2005 (n = 731,105; corresponds to 91% of the domain population). Multivariate logistic regression analysis was used for analyzing whether age, sex, type of residential area, number of other drugs, and concomitant psychotropic drug use was associated with use of BZDs/BZDRDs. RESULTS > or =1 BZDs/BZDRDs and > or =2 BZDs/BZDRDs were used by 25% and 5% of the study population, respectively. The most commonly used BZDs/BZDRDs were zopiclone, zolpidem, oxazepam, flunitrazepam, and diazepam. The probability of use BZDs/BZDRDs increased with age, female gender, living in an urban area, use of many other drugs, and concomitant use of other psychotropics, particularly antidepressants. In the comparisons of different BZDs/BZDRDs (n = 179,632), the medium-acting BZDs were associated with higher age, female gender, and use of other psychotropics, whereas BZDRDs showed the opposite pattern. Also, the two BZDRDs zopiclone and zolpidem showed different patterns regarding age, sex, and use of other drugs. CONCLUSIONS One in four of the elderly used one or more BZD/BZDRD, which should be prescribed cautiously and with the recognition of the potentially negative effects. There were differences in patterns of use for different BZDs/BZDRDs, even within the same drug class. Hence, large study populations are needed for future research of individual BZDs/BZDRDs.
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Affiliation(s)
- Kristina Johnell
- Aging Research Center, Karolinska Institutet, Stockholm, Sweden.
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20
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Licata SC, Jensen JE, Penetar DM, Prescot AP, Lukas SE, Renshaw PF. A therapeutic dose of zolpidem reduces thalamic GABA in healthy volunteers: a proton MRS study at 4 T. Psychopharmacology (Berl) 2009; 203:819-29. [PMID: 19125238 PMCID: PMC2818041 DOI: 10.1007/s00213-008-1431-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2008] [Accepted: 11/30/2008] [Indexed: 11/29/2022]
Abstract
BACKGROUND Zolpidem is a nonbenzodiazepine sedative/hypnotic that acts at GABA(A) receptors to influence inhibitory neurotransmission throughout the central nervous system. A great deal is known about the behavioral effects of this drug in humans and laboratory animals, but little is known about zolpidem's specific effects on neurochemistry in vivo. OBJECTIVES We evaluated how acute administration of zolpidem affected levels of GABA, glutamate, glutamine, and other brain metabolites. MATERIALS AND METHODS Proton magnetic resonance spectroscopy ((1)H MRS) at 4 T was employed to measure the effects of zolpidem on brain chemistry in 19 healthy volunteers. Participants underwent scanning following acute oral administration of a therapeutic dose of zolpidem (10 mg) in a within-subject, single-blind, placebo-controlled, single-visit study. In addition to neurochemical measurements from single voxels within the anterior cingulate (ACC) and thalamus, a series of questionnaires were administered periodically throughout the experimental session to assess subjective mood states. RESULTS Zolpidem reduced GABA levels in the thalamus, but not the ACC. There were no treatment effects with respect to other metabolite levels. Self-reported ratings of "dizzy," "nauseous," "confused," and "bad effects" were increased relative to placebo, as were ratings on the sedation/intoxication (PCAG) and psychotomimetic/dysphoria (LSD) scales of the Addiction Research Center Inventory. Moreover, there was a significant correlation between the decrease in GABA and "dizzy." CONCLUSIONS Zolpidem engendered primarily dysphoric-like effects and the correlation between reduced thalamic GABA and "dizzy" may be a function of zolpidem's interaction with alpha1GABA(A) receptors in the cerebellum, projecting through the vestibular system to the thalamus.
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Affiliation(s)
- Stephanie C. Licata
- Behavioral Psychopharmacology Research Laboratory, McLean Hospital/Harvard Medical School
| | - J. Eric Jensen
- Brain Imaging Center, McLean Hospital/Harvard Medical School
| | - David M. Penetar
- Behavioral Psychopharmacology Research Laboratory, McLean Hospital/Harvard Medical School
| | | | - scott E. Lukas
- Behavioral Psychopharmacology Research Laboratory, McLean Hospital/Harvard Medical School,Brain Imaging Center, McLean Hospital/Harvard Medical School
| | - Perry F. Renshaw
- Brain Institute and Department of Psychiatry, University of Utah School of Medicine
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21
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Tsai MJ, Tsai YH, Huang YB. Compulsive activity and anterograde amnesia after zolpidem use. Clin Toxicol (Phila) 2007; 45:179-81. [PMID: 17364638 DOI: 10.1080/15563650600956741] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Zolpidem is a selective GABAAalpha1 receptor modulator used for its hypnotic-sedative properties. Zolpidem has side effects that are similar but not identical to the benzodiazepines. We report the first cases of compulsive activity combined with anterograde amnesia after the use of zolpidem. CASE REPORT Three women experienced anterograde amnesia and compulsive repetitive behaviors after zolpidem use. These activities consisted of cleaning, shopping, and eating. These behaviors stopped after discontinuation of the zolpidem. CONCLUSION These reports demonstrate that compulsive activity combined with anterograde amnesia may be associated with the use of zolpidem. Physicians and pharmacists should be aware of this potential side effect.
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Affiliation(s)
- Ming-Jun Tsai
- Institute of Basic Medical Sciences, National Cheng Kung University, Tinan City, Taiwan.
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22
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Mahoney JE, Webb MJ, Gray SL. Zolpidem prescribing and adverse drug reactions in hospitalized general medicine patients at a veterans affairs hospital. ACTA ACUST UNITED AC 2004; 2:66-74. [PMID: 15555480 DOI: 10.1016/s1543-5946(04)90008-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2004] [Indexed: 11/20/2022]
Abstract
BACKGROUND Zolpidem is prescribed for sleep disruption in hospitalized patients, but data on the incidence of adverse drug reactions (ADRs) are based largely on outpatient studies. Thus, the incidence of ADRs in hospitalized patients may be much higher. OBJECTIVE The goal of this study was to describe prescribing patterns of zolpidem for hospitalized medical patients aged 50 years, the incidence of ADRs possibly and probably associated with its use, and the factors associated with central nervous system (CNS) ADRs. METHODS This case series was conducted in 4 general medicine wards at a Veterans Affairs hospital and was a consecutive sample of patients aged 50 years who were hospitalized between 1993 and 1997 and received zolpidem as a hypnotic during hospitalization, but had not received it in the previous 3 months. Chart review was conducted by 2 evaluators. Data extracted from the medical records included admission demographic characteristics, medications, comorbidities, and levels of function in performing basic and instrumental activities of daily living. The main outcome measure was ADRs possibly or probably related to zolpidem use. The association between zolpidem and the occurrence of CNS ADRs (eg, confusion, dizziness, daytime somnolence) was analyzed separately. RESULTS The review included 119 medical patients aged > or =50 years who had newly received zolpidem for sleep disruption during hospitalization. The median age of the population was 70 years; 86 (72.3%) patients were aged 65 years. The initial zolpidem dose was 5 mg in 42 patients (35.3%) and 10 mg in 77 patients (64.7%). Twenty-three patients had a respective 16 and 10 ADRs possibly and probably related to zolpidem use (19.3% incidence). Of a total of 26 ADRs, 21 (80.8%) were CNS ADRs, occurring with both zolpidem 5 mg (10.8% of users) and 10 mg (18.3% of users). On univariate analyses, the only factor significantly associated with a CNS ADR was functional impairment at baseline (P = 0.003). Zolpidem was discontinued in 38.8% of patients experiencing a CNS ADR CONCLUSIONS: In this case series in medical inpatients, there was a high frequency of ADRs, particularly CNS ADRs, associated with zolpidem use. Zolpidem should be used cautiously in the hospital setting.
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Affiliation(s)
- Jane E Mahoney
- Section of Geriatrics, Department of Medicine, University of Wisconsin School of Medicine, Madison, Wisconsin, USA.
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Hill KP, Oberstar JV, Dunn ER. Zolpidem-induced delirium with mania in an elderly woman. PSYCHOSOMATICS 2004; 45:88-9. [PMID: 14709766 DOI: 10.1176/appi.psy.45.1.88] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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McCarberg B, Barkin RL, Wright JA, Cronan TA, Groessl E, Schmidt SM. Tender points as predictors of distress and the pharmacologic management of fibromyalgia syndrome. Am J Ther 2003; 10:176-92. [PMID: 12756425 DOI: 10.1097/00045391-200305000-00005] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The object of this study was to determine the association between tender point pain ratings, tender point counts and distress in people with fibromyalgia and to review the pharmacotherapy of fibromyalgia. Demographic, psychosocial, and health status information was collected from 316 health maintenance organization members with fibromyalgia. A manual tender point exam was conducted. Tender point counts predicted 3.0%, and tender point severity ratings predicted 8.3%, of the variance in distress. Little difference was found between the variance predicted for physical versus psychologic distress. A principal components analysis of all measures produced four distinct factors: global-physical functioning, tender points, psychologic, and physical. Tender point pain ratings and counts predicted a small but significant amount of variance in distress. In addition, FMS involves at least four rather distinct factors, one of which is related to tender points. Pharmacotherapeutic management is provided on a patient-specific basis including pharmacokinetics, pharmacodynamic, pathophysiologic, and psychosocial needs designed and modulated for each individual patient.
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Affiliation(s)
- Bill McCarberg
- Kaiser Permanente, San Diego State University, San Diego, CA, USA.
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Huang CL, Chang CJ, Hung CF, Lin HY. Zolpidem-induced distortion in visual perception. Ann Pharmacother 2003; 37:683-6. [PMID: 12708947 DOI: 10.1345/aph.1c318] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To describe a patient who developed visual perception distortion after a single dose of zolpidem. CASE SUMMARY A 50-year-old Asian woman had been prescribed conjugated estrogen 1 tablet daily for hormone replacement therapy and tricalcium phosphate twice daily for osteoporosis. One day, she took zolpidem 10 mg for insomnia as well as acetaminophen 500 mg for headache at bedtime and began to have visual perception distortion (e.g., the shapes of objects were twisted, houses were crooked) within 20 minutes, lasting for approximately 30 minutes, and then her vision returned to normal. She only partially recalled the event. She had never taken zolpidem before, and she had not had any such disturbances in the past. DISCUSSION There have been 21 case reports of zolpidem-related psychotic symptoms in the literature; however, the exact mechanism by which zolpidem may cause visual perception changes is undetermined. Many factors have been correlated with zolpidem-induced visual experiences, such as pharmacokinetic factors, gender, age, and hypoalbuminemia. This patient shared certain similarities such as gender, dosage, and time of onset and duration of adverse reactions. CONCLUSIONS An objective causality assessment revealed that the zolpidem-induced visual perception distortion in this patient was probable. Clinicians should be aware of the potential for visual perception distortion, as this is an uncommon adverse effect.
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Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2002; 11:345-60. [PMID: 12138604 DOI: 10.1002/pds.660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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