Excessive motor impairment two hours after triazolam in the elderly

Quantification of adverse effects of regular use of triazolam on clinical outcomes for older people with insomnia: a retrospective cohort study

OBJECTIVE

Older people are more likely to have insomnia. One of the most prescribed hypnotics in Japan is triazolam. Although some studies showed the possibility of adverse effects of triazolam in older people, there have been few studies investigating these effects in a clinical setting. The aim of this study was to determine whether patients who used triazolam regularly had increased risks of pneumonia, trauma, and pressure ulcers.

METHODS

The research design was a retrospective cohort study using claim data. The subjects of the study were patients who were insured by Fukuoka Late Stage Elderly Healthcare Insurance. We defined patients who had received triazolam for 180 days or longer during fiscal year 2011 as the triazolam group, and those who had not received any hypnotics during the period as the non-triazolam group. Each patient in the triazolam group was then matched with a unique control from the non-triazolam group according to propensity score. Multivariate conditional logistic regression analyses were used to obtain adjusted odds ratios for pneumonia, trauma, and pressure ulcer in the triazolam group compared with the non-triazolam group.

RESULTS

The number of patients in the triazolam and non-triazolam groups in the unmatched cohort was 13,015 and 411,610, respectively. Adjusted odds ratios show that the risks for pneumonia, trauma, and pressure ulcer in the matched cohort increased by approximately 40%, 30%, and slightly less than 30%, respectively (all statistically significant).

CONCLUSIONS

Regular use of triazolam is a risk factor for pneumonia, trauma, and pressure ulcer in older people.

Abuse and dependence liability of benzodiazepine-type drugs: GABA(A) receptor modulation and beyond

Over the past several decades, benzodiazepines and the newer non-benzodiazepines have become the anxiolytic/hypnotics of choice over the more readily abused barbiturates. While all drugs from this class act at the GABA(A) receptor, benzodiazepine-type drugs offer the clear advantage of being safer and better tolerated. However, there is still potential for these drugs to be abused, and significant evidence exists to suggest that this is a growing problem. This review examines the behavioral determinants of the abuse and dependence liability of benzodiazepine-type drugs. Moreover, the pharmacological and putative biochemical basis of the abuse-related behavior is discussed.

Pharmacokinetics of alprazolam in elderly patients with multiple diseases

The pharmacokinetics of alprazolam (1 mg p.o.) were investigated (using a new developed HPLC-assay) in 10 multimorbid elderly patients (five female, five male; mean age 72.8 +/- 8.2 years, creatinine clearance 63.6 +/- 25.9 ml/min, weight 68.9 +/- 13.9 kg). Compared with young and elderly volunteers from other studies peak plasma concentrations of alprazolam were decreased while peak time and elimination half-life were increased. 'Second peak' plasma levels (correlated with age and creatinine clearance) occurred in eight of 10 elderly patients. The variability associated with the pharmacokinetic parameters in the multimorbid elderly patients was far greater than that observed in young and old healthy volunteers. Mean alprazolam concentrations in multimorbid patients aged 72 years or more were elevated as compared to 'younger' patients (age range: 63-71 years). Dose reduction should be considered in the older multimorbid patients.

Increased baseline sway contributes to increased losses of balance in older people following triazolam

OBJECTIVE

Although it has been stated frequently that older people are more sensitive to benzodiazepines, the relative roles of impaired baseline performance, impaired elimination, and altered responsiveness have not been defined. We evaluated postural sway and plasma triazolam concentrations after administration of placebo and triazolam 0.375 mg in both young and older healthy subjects.

DESIGN

Double-blind placebo-controlled trial.

PARTICIPANTS

Nine young and nine older healthy men.

INTERVENTION

All subjects received triazolam 0.375 mg or placebo on different study days, which were separated by at least 48 hours.

MEASUREMENTS

Postural sway, visual analog scale of drowsiness, and plasma triazolam levels.

RESULTS

The older subjects swayed more during triazolam than did the younger subjects, and this resulted in an increased number of losses of balance. This difference appeared to be caused by greater baseline sway in the older subjects rather than higher concentrations or increased responsiveness. A subset of older people had a much greater number of losses of balance during triazolam than did the rest of the subjects, and these individuals could be identified from their baseline sway.

CONCLUSIONS

In this study, the increase in drug effect seen in the older subjects was of similar magnitude to that of the young, but it resulted in greater postural sway after drug administration than was seen in the young. The higher postural sway and the corresponding increased instability seen in the older subjects may put these older persons at increased risk of drug-related falls. This study also suggests that it should be possible to develop techniques that will identify individuals at particular risk of drug-induced postural instability.

Relationship between the administration of selected medications and falls in hospitalized elderly patients

OBJECTIVE

To examine the relationship between administration of selected medications and falls experienced by hospitalized elderly patients. Benzodiazepines and other medications previously associated with falls in elderly patients residing in the community and nursing homes were the primary focus.

DESIGN

Retrospective case control.

SETTING

Private, not-for-profit, 575-bed acute care hospital.

PARTICIPANTS

A total of 100 patients who had fallen and 100 control patients, aged at least 70 years, admitted during the same 17-month time period.

MAIN OUTCOME MEASURES

We examined the relationship between falls and patient demographics, underlying disease states, number of concurrent disease states, and length of hospitalization. Possible associations between the administration of narcotics, benzodiazepines, antidepressants, antipsychotics, other sedating agents, antihypertensives, diuretics, nitrates, and digoxin 48 hours prior to the fall or reference day were explored. The relationships between benzodiazepine half-life, dosage, administration frequency, cumulative dose, and falls were also examined.

RESULTS

Demographically the groups were similar except that patients who had fallen were hospitalized significantly longer (mean 18.8 vs 12.2 d; p < 0.00001) than control patients. Benzodiazepines were received by more (40% vs 20%, odds ratio = 2.67) patients who had fallen than control patients. The use of long (> 24 h) half-life benzodiazepines was similar in patients who had fallen (48%) and control patients (45%). Long half-life benzodiazepines were commonly administered (65%) to patients who had fallen in doses greater than that recommended for the elderly. Benzodiazepine use, expressed as milligrams of diazepam equivalents received during the 48-hour study, was higher in patients who had fallen than in control patients (15.00 +/- 17.80 vs 9.73 +/- 6.58 mg), but this was not statistically significant (p = 0.1030). Congestive heart failure (37% vs 24%), digoxin therapy (35% vs 22%), or administration of 3 or more psychoactive agents (17% vs 4%) were all more common in patients who had fallen than in control patients.

CONCLUSIONS

Falls experienced by the elderly patients in our acute care institution were associated with the presence of congestive heart failure along with digoxin therapy, benzodiazepine use, or the use of at least 3 psychoactive agents.

Behavioral vigilance in rats: task validation and effects of age, amphetamine, and benzodiazepine receptor ligands

An operant task for the measurement of sustained attention or vigilance in rats was characterized. The task requires the animals to respond to the presentation of visual signals (presented for 25, 50, or 500 ms) by operating one lever ("hits") and to the absence of a signal by operating the opposite lever ("correct rejection"). Incorrect responses ("misses" and "false alarms", respectively) were not rewarded. Performance in this task is a function of signal length, i.e., the shorter the signals the higher the number of misses. An increase in "background noise" by flashing the chamber houselight (at 0.5 Hz) impaired the animals' ability to discriminate between signal and non-signal events. Also flashing the houselight augmented the vigilance decrement observed for shortest signals. An increase in the event-rate also resulted in a vigilance decrement. Finally, the inability of the animals to time signals was examined by testing the effects of an increase in event asynchrony. In a second experiment, the performance of differently aged rats (6- and 20 month-old male BNNia/F344 rats) was studied. Compared to young animals, 20-month-old rats showed a decrease in their ability to discriminate between shortest signals (25 ms) and non-signal events but did not differ in their ability to correctly reject non-signal trials. Administration of the benzodiazepine receptor (BZR) agonist chlordiazepoxide (CDP; 3, 5, 8 mg/kg) resulted in an impairment of the animals' ability to discriminate between signal and non-signal events and, similar to the effects of age, this effect was exclusively due to an increase in the number of misses. CDP generally produced potent effects while affecting the aged animals to a greater degree. BZR-ligands with weak or "selective" inverse agonist properties (ZK 93426; beta-CCtB) did not affect vigilance performance. The BZR partial inverse agonist RU 33965 (0.1, 0.5 mg/kg) dose-dependently impaired vigilance performance. The administration of amphetamine (0.4, 0.8 mg/kg) also impaired performance, but these impairments were possibly based on effects unrelated to attentional mechanisms. The finding that performance in this task revealed the interactions between the effects of age and BZR agonists on attentional abilities further supports the validity of measures of performance generated by this task.

Subjective evaluation of sleep and the use of hypnotics in nursing homes

The purpose of the study was to evaluate the sleep habits and the use of hypnotics in the elderly living in nursing homes. The study population consisted of 60 subjects aged 61-99 years who were interviewed by a geriatrician. The use of hypnotics was frequent (53%), but not associated with gender, memory impairment, moving disability, depression, quality of sleep or sleep behaviour. Users of hypnotics had shorter total sleep time (TST) and got up earlier from bed in the morning than the non-users. Most of the subjects perceived their sleep as interrupted but satisfactory. The elderly with impaired memory slept longer, stayed in bed longer, and took their hypnotics significantly earlier than those with normal memory. As we found no explaining factors for the use of hypnotics, we suggest regular evaluation of their administration in nursing homes. The subjective need for hypnotics, not the nursing home practices, should decide the necessity of these drugs and the medication times in nursing home residents.

The use of microcomputer-based psychomotor tests for the evaluation of benzodiazepine effects on human performance: a review with emphasis on temazepam

1. The literature relating to the effects of benzodiazepines in general, and temazepam in particular, on human psychomotor performance as assessed using microcomputer-based testing batteries is surveyed. 2. The adverse effects of central nervous system depressants on performance is an important mediocolegal issue and frequently comes into question in on-the-road and on-the-job accidents. The use of microcomputer-based testing batteries allows for performance evaluation both in the laboratory and at-the-scene, as well as providing the opportunity to model a large number of different behaviours required in routine yet complex psychomotor tasks. 3. The conclusions in general are: (1) The benzodiazepines as a class of drugs impair both cognitive and motor performance. These effects are often subtle when low doses are involved or when testing occurs the morning following evening administration of the medication. (2) No single psychomotor task adequately simulates complex daily tasks such as automobile driving. A battery of tests that evaluates a number of the components of such tasks is necessary to determine adequately the full range of effects of these medications.