Sedative-hypnotic drugs and the risk of hip fracture

Benzodiazepines and risk of pneumonia in schizophrenia: a nationwide case-control study

OBJECTIVES

To investigate the relationship between benzodiazepine and risk of developing pneumonia in patients with schizophrenia, whose benzodiazepine dosage and usage frequency was higher than that of the general population.

METHODS

We conducted a nested case-control study to assess the association between benzodiazepine use and pneumonia among patients with schizophrenia. By using the Taiwan National Health Insurance Research Database, we identified a schizophrenia cohort comprising 34,929 patients during 2000-2010. Within the schizophrenia cohort, 2501 cases of pneumonia and 9961 matched control patients (1:4 ratio) were identified. Benzodiazepine exposure was categorized by drug, treatment duration, and daily dose. Conditional logistic regression models were used to examine the association between benzodiazepine exposure and the risk of pneumonia.

RESULTS

The current use (within 30 days) of midazolam led to the highest pneumonia risk (adjusted risk ratio = 6.56, P < 0.001), followed by diazepam (3.43, P < 0.001), lorazepam (2.16, P < 0.001), and triazolam (1.80, P = 0.019). Furthermore, nearly all the benzodiazepines under current use had a dose-dependent effect on pneumonia risk. The risk of pneumonia was correlated with the affinities of γ-aminobutyric acid A α1, α2, and α3 receptors.

CONCLUSIONS

Benzodiazepines had a dose-dependent relationship with pneumonia in patients with schizophrenia. The differences in risk and mechanism of action of the individual drugs require further investigation. Clinicians should be aware of the early signs of pneumonia in patients with schizophrenia receiving benzodiazepines.

Risk for fractures with centrally acting muscle relaxants: an analysis of a national Medicare Advantage claims database

BACKGROUND

In older adults, both muscle relaxants and benzodiazepines are associated with sedation and cognitive impairment. Although benzodiazepines have been linked to falls and fracture injuries, no studies have examined the risk of fracture associated with muscle relaxants.

OBJECTIVE

To determine whether muscle relaxants identified in the Beers criteria are associated with an increased risk of fracture injuries and to compare this risk to that with benzodiazepine use.

METHODS

We conducted a case-control study using both medical and pharmacy claims data from 1.5 million enrollees in the Medicare Advantage plans of a large health maintenance organization. We matched 8164 cases of fractures with 8164 controls based on age, sex, health plan, and comorbidities. We measured the use of muscle relaxants, short-acting benzodiazepines, and long-acting benzodiazepines. Adjusted odds ratios were estimated using conditional logistic regression.

RESULTS

After adjusting demographic and clinical covariates, muscle relaxants, long-acting benzodiazepines, and short-acting benzodiazepines were associated with a high risk of fracture injuries, with odds ratios of 1.40 (95% CI 1.15 to 1.72; p < 0.001), 1.9 (95% CI 1.49 to 2.43; p < 0.001), and 1.33 (95% CI 1.15 to 1.55; p < 0.001), respectively.

CONCLUSIONS

An elevated risk of fracture injuries was noted among older adults using muscle relaxants. Our findings provide evidence of an association between the risk of fractures and the use of centrally acting muscle relaxants in older adults. This association supports current recommendations advising extreme caution in prescribing muscle relaxants to older adults.

Long-term effects of the concomitant use of memantine with cholinesterase inhibition in Alzheimer disease

BACKGROUND

Patients using cholinesterase inhibitors (ChEIs) have a delay in nursing home (NH) admission compared with those who were not using the medication. There are no long-term studies of the effects of memantine in combination with ChEIs use in Alzheimer disease (AD). This study was conducted to examine the effects of ChEIs and memantine on time to death and time to NH admission.

METHODS

Time to NH admission and death was examined in 943 probable AD patients who had at least a 1-year follow-up evaluation. Of these patients, 140 (14.9%) used both ChEIs and memantine, 387 (41%) [corrected] used only ChEIs, and 416 (44.1%) [corrected] used neither. The mean (SD) follow-up time was 62.3 (35.8) months. The analysis was conducted with multivariable Cox proportional hazard models controlling for critical covariates (ie, age, education level, gender, severity of the dementia, hypertension, diabetes mellitus, heart disease, psychiatric symptoms and use of psychotropic medications).

RESULTS

Compared with those who never used cognitive enhancers, patients who used ChEIs had a significant delay in NH admission (HR: 0.37, 95% CI 0.27 to 0.49); this effect was significantly augmented with the addition of memantine (HR: 0.29, 95% CI 0.11 to 0.72) (memantine+ChEI vs ChEI alone). ChEIs alone, or in combination with memantine had no significant association on time to death.

CONCLUSIONS

This observational study revealed that the addition of the NMDA receptor antagonist memantine to the treatment of AD with ChEI significantly altered the treated history of AD by extending time to nursing home admission.

Benzodiazepine and risk of hip fractures in older people: a nested case-control study in Taiwan

OBJECTIVE

To examine the characteristics of benzodiazepines usage and their associations with hip fractures.

METHOD

All subjects were aged 65 and older and enrolled in the National Health Insurance program in Taiwan, 2001-2004. Cases (N = 217) were elderly patients who were identified with hip fractures for the first time in their outpatient claims. They were individually matched to 1,214 comparison patients based on age, gender, and index year. Benzodiazepine usage (doses, duration, half-life) and the other covariates including comorbidities, health care utilization, and psychotropic medications used in the 180 days before index events were constructed.

RESULTS

Using nonusers as reference group, use of benzodiazepines was significantly associated with hip fractures (adjusted odds ratio [AOR] = 1.7, 95% confidence interval [CI] = 1.2-2.5). Such risks appear to be particularly high during the first month (AOR = 5.6, 95% CI = 2.7-11.8) of exposure, doses higher than 3.0 mg/day in diazepam equivalents (AOR = 1.8, 95% CI = 1.1-3.1), and using short-acting benzodiazepines (AOR = 1.8, 95% CI = 1.3-2.7).

CONCLUSIONS

Benzodiazepine exposure in the elderly increases the risk of hip fractures. This is true even with modest dosage, short-acting agents and short-term exposures. Clinicians should prescribe benzodiazepines judiciously with the elderly to minimize drug-related hip fractures.

[Sleep disorders and hypnotic agents: medical, social and economical impact]

Insomnia is a subjective complaint relating to approximately 30% of the adult population in France, described by the patient as a difficulty of initiating and/or maintaining sleep. Its prevalence increases with age and sex: women are more affected than men (24% vs 14%). Insomnia is either occasional (20%), or chronic (10%). Chronic insomnia has an important impact on patients' everyday life e.g. fatigue, perturbed diurnal waking state, impaired quality-of-life... which results in lower work productivity and drowsiness as well as relational difficulties, absenteeism. About 80% of patients consult their general practitioner first. The aim of a hypnotic agent is to obtain sleep as physiological as possible. Benzodiazepines and benzodiazepines-like agents (zopiclone, zolpidem, zaleplon) are the most widely used hypnotics. However, their indications must be limited to occasional insomnia with a limited duration: less than four weeks. There is no advantage with using a combination of hypnotic agents, a practice which should be prohibited. Adverse effects can be serious, e.g. diurnal somnolence associated with risks of road accidents and, in the elderly, the risk of falls. After chronic use, hypnotics can be addictive, as their effects wear off in three to four weeks. After withdrawal, insomnia rebound is frequent. Use of hypnotics in association with alcohol is a well-known drug-addiction behavior. According to the French health insurance fund, 9% of the general population use hypnotics and about half of them regularly. Insurance refunds for hypnotics and sedatives reach more than 110 million euros annually. The efficiency of hypnotics wears off, quickly for benzodiazepines (three - four weeks), or less quickly for zopiclone and zolpidem (a few months). Insomnia is a major public health issue, each year 10% of the incident cases of insomnia treated by hypnotics joint the group of subjects with chronic insomnia. This failure to treat insomnia properly can be explained, at least in part, by several insufficiencies: physicians and pharmacists training, medical profession awareness, research, public information on the rules of good sleep (public health campaigns, booklets, role of physicians and the pharmacists).

Psychotropic medications and the risk of fracture: a meta-analysis

BACKGROUND

Older adults throughout the developed world are at significant risk of osteoporotic fractures. Many studies have examined the relationship between the use of psychotropic medications and the risk of fractures, but these studies have reported conflicting results.

PURPOSE

To resolve discrepancies, we carried out a meta-analysis to assess the risk of fractures among users of several classes of psychotropic drugs.

DATA SOURCES

We retrieved studies published in any language by systematically searching MEDLINE, LILACS, EMBASE and ISI Proceedings databases and by manually examining the bibliographies of the articles retrieved electronically as well as those of recent reviews.

STUDY SELECTION

We included 98 cohort and case-control studies, published in 46 different articles, that reported relative risk (RR) estimates and confidence intervals (CIs) or sufficient data to calculate these values.

DATA SYNTHESIS

Study-specific RRs were weighted by the inverse of their variance to obtain fixed- and random effects pooled estimates. The random effects RR of fractures was 1.34 (95% CI 1.24, 1.45) for benzodiazepines (23 studies), 1.60 (95% CI 1.38, 1.86) for antidepressants (16 studies), 1.54 (95% CI 1.24, 1.93) for non-barbiturate antiepileptic drugs (13 studies), 2.17 (95% CI 1.35, 3.50) for barbiturate antiepileptic drugs (five studies), 1.59 (1.27, 1.98) for antipsychotics (12 studies), 1.15 (95% CI 0.94, 1.39) for hypnotics (13 studies) and 1.38 (95% CI 1.15, 1.66) for opioids (six studies). For non-specified psychotropic drugs (10 studies), the pooled RR was 1.48 (95% CI 1.41, 1.59).

LIMITATIONS

Main concerns were the potential for residual confounding and for publication bias.

CONCLUSION

Globally, the increase in the risk of fractures among psychotropic drug users is moderate. Further research is needed, especially to examine high-risk populations and newer medications. Future studies should be prospective and emphasise control of confounding bias.

The effects of commonly prescribed drugs in patients with Alzheimer's disease on the rate of deterioration

BACKGROUND

Prescribed drugs in patients with Alzheimer's disease may affect the symptomatic progression of their disease, both positively and negatively.

AIM

To examine the effects of drugs on the progression of disease in a representative group of patients with Alzheimer's disease.

METHODS

Patients with the diagnosis of probable Alzheimer's disease were recruited from the community. The prescribed drugs taken by 224 patients (mean age 82.3 years) were recorded at initial assessment and then correlated in logistic regression analysis with progression of the disease, defined as an increase of one point or more in the Global Deterioration Scale over the next 12-month period.

RESULTS

Patients who were taking antipsychotic drugs and sedatives had a significantly higher risk of deterioration than those who were taking none (odds ratios (ORs) 2.74 (95% confidence interval (CI) 1.17 to 6.41) and 2.77 (95% CI 1.14 to 6.73), respectively). Higher risk of deterioration was observed in those who were taking both antipsychotic and sedative drugs together (OR 3.86 (95% CI 1.28 to 11.7). Patients taking drugs licensed for dementia, drugs affecting the renin-angiotensin system and statins had a significantly lower risk of deterioration than those who were not taking any of these drugs (ORs 0.49 (95% CI 0.25 to 0.97), 0.31 (95% CI 0.11 to 0.85) and 0.12 (95% CI 0.03 to 0.52), respectively).

CONCLUSION

Our findings have implications for both clinicians and trialists. Most importantly, clinicians should carefully weigh any potential benefits of antipsychotics and benzodiazepines, especially in combination, against the risk of increased decline. Researchers need to be aware of the potential of not only licensed drugs for dementia but also drugs affecting the renin-angiotensin system and statins in reducing progression in clinical trials.

Secondary insomnia in the primary care setting: review of diagnosis, treatment, and management

INTRODUCTION

Insomnia is associated with a number of medical and psychiatric disorders, including chronic pain and clinical depression. Until recently, it was assumed that effective treatment of the underlying medical condition would also correct the sleep disturbance. However, some evidence indicates that treatment of secondary or comorbid insomnia should be considered separately from, and perhaps in addition to, optimizing treatment of the primary condition.

METHODS

This article reviews the extant literature to examine the impact of secondary and comorbid insomnia on the patient, and on healthcare economics, in the primary care setting, and discusses current diagnostic and treatment approaches. A MEDLINE search was performed for literature published from 1980 to 2005, and retrieved randomized, controlled clinical trials and key review articles for the conditions most often accompanied by secondary insomnia: depression, chronic pain, and menopause/perimenopause. The search terms included those for commonly used pharmacologic treatments and behavioral therapy.

RESULTS

Due to the paucity of clinical trial data in secondary insomnia patients, physicians have had to rely on evidence derived from primary insomnia trials. These data indicate that hypnotic medications are effective in treating sleep onset insomnia. However, few of these agents are effective against the most commonly occurring insomnia symptom - poor sleep maintenance - and many are associated with problematic residual sedation. Nevertheless, the cost of not treating these insomnia symptoms is often greater than the treatment inadequacies. Physicians should thus consider treating what they perceive as secondary insomnia with one of the available forms of therapy.

CONCLUSION

Patients experiencing sleep problems associated with a potential medical or psychiatric primary condition would likely benefit from increased physician awareness of secondary insomnia and the subsequent increased attention to diagnosing and treating this prevalent condition. Recommendations for managing secondary or comorbid insomnia in the primary care setting are discussed.

Nocturnal giddiness in relation to nocturia and other symptoms and to medication in the elderly

The aim of this study was to evaluate the relation of nocturia, somatic diseases, symptoms, and medication to nocturnal giddiness in a group of elderly men and women. A questionnaire survey was undertaken among 10,216 elderly subjects. The mean (+/-S.D.) ages of the men and women were 73.0 +/- 6.0 and 72.6 +/- 6.7 years, respectively. Nocturnal giddiness was reported by 14.1% of the men and 9.1% of the women. Poor health was reported by 44.4% (P < 0.0001) of the men with nocturnal giddiness and by 14.0% of the men without, and among the women these figures were 45.5% and 20.0% (P < 0.0001), respectively. In a multiple logistic regression analysis significant independent correlates of nocturnal giddiness were: nocturnal micturition episodes >or=3 versus nocturia <or=2 (odds ratio [OR]: 1.6; 95% confidence interval [CI]: 1.1-2.3); married or cohabiting versus living alone (1.5; 1.1-2.0); age, 70-79 years versus <70 years (1.7; 1.2-2.3); age, >or=80 years versus <70 years (2.5; 1.7-3.6); eyesight, poor versus good (1.8; 1.4-2.4); hearing, poor versus good (1.4; 1.1-1.9); pain in the cervical spine (2.1; 1.5-2.8); spasmodic chest pain (1.5; 1.1-2.0); diabetes (1.6; 1.0-2.4); analgesics (1.8; 1.3-2.4); and diuretics (1.4; 1.1-21.8). Sex, irregular heartbeats, and sleep medication were deleted by the logistic model.

Benzodiazepines and risk of hip fractures in older people: a review of the evidence

A hip fracture epidemic is occurring in developed countries in association with population aging. The increasing number of people with a hip fracture has major implications for clinicians and health service managers. More importantly, a hip fracture is a devastating event in the life of an older person, as it often leads to loss of independence and death. Identification of risk factors for hip fracture is an essential first step towards prevention. The use of psychotropic medications is an established risk factor for hip fracture. The purpose of this article is to systematically review epidemiological studies of the relationship between use of benzodiazepines and risk of hip fracture and, then, to see how the findings of these studies fit with what is known about the pharmacology of benzodiazepines. Eleven primary epidemiological studies were identified. The results of these studies were not consistent; however, the inconsistency appeared to be almost entirely explained by research design. The studies that did not show an association between increased hip fracture risk and benzodiazepine use were nearly all hospital-based case-control studies, a type of study that often lacks validity because of the difficulty of finding an appropriate control group. After excluding the hospital-based case-control studies, all but one of the remaining seven studies found that use of benzodiazepines was associated with an increased risk of hip fracture that varied between 50% and 110%. The only higher quality study that did not find an association between benzodiazepine use and hip fracture was also the only study conducted entirely in nursing homes. There was no evidence that the risk of hip fracture differed between short- and long-acting benzodiazepines. People using higher doses of benzodiazepines and those who had recently started using benzodiazepines were at the highest risk of hip fracture. In very old people, there was some preliminary evidence that benzodiazepines that undergo oxidation in the liver may be associated with a higher risk of hip fracture than other benzodiazepines. The epidemiological evidence strongly suggests that the use of benzodiazepines by older people increases their risk of hip fracture by at least 50%. The benefits of benzodiazepines for older people are unclear. Given the high morbidity and mortality of hip fracture, it can be concluded that older people should rarely be prescribed benzodiazepines and that many older people already taking these drugs should have them withdrawn under appropriate supervision.

Benzodiazepines and hip fractures in elderly people: case-control study

OBJECTIVE

To determine whether benzodiazepines are associated with an increased risk of hip fracture.

DESIGN

Case-control study.

PARTICIPANTS

All incident cases of hip fracture not related to traffic accidents or cancer in patients over 65 years of age. 245 cases were matched to 817 controls.

SETTING

Emergency department of a university hospital.

MAIN OUTCOME MEASURES

Exposure to benzodiazepines and other potential risk or protective factors or lifestyle items.

RESULTS

The use of benzodiazepines as determined from questionnaires, medical records, or plasma samples at admission to hospital was not associated with an increased risk of hip fracture (odds ratio 0.9, 95% confidence interval 0.5 to 1.5). Hip fracture was, however, associated with the use of two or more benzodiazepines, as determined from questionnaires or medical records but not from plasma samples. Of the individual drugs, only lorazepam was significantly associated with an increased risk of hip fracture (1.8, 1.1 to 3.1).

CONCLUSION

Except for lorazepam, the presence of benzodiazepines in plasma was not associated with an increased risk of hip fracture. The method used to ascertain exposure could influence the results of case-control studies.

Benzodiazepines with different half-life and falling in a hospitalized population: The GIFA study. Gruppo Italiano di Farmacovigilanza nell'Anziano

In recent years, the use of benzodiazepines has been recognized as an independent risk factor for falls among the elderly. To evaluate the role of different types of benzodiazepines in determining falls in a hospitalized geriatric population, we conducted a prospective study among 7908 patients consecutively admitted in 58 clinical centers of the Gruppo Italiano di Farmacovigilanza nell'Anziano (GIFA), during an 8-month observation period (1991 and 1993). Over 70% of the patients were older than 65 years, 50% were women, and 23. 6% had a benzodiazepine prescription during hospital stay. The number of patients who experienced one or more falls during follow-up was 174 (2.2%). Sixty falls occurred among patients taking benzodiazepines (3.2%) and 114 (1.9%) among those who did not use benzodiazepines; the crude odds ratio for users versus non-users was 1.7 (95% CI 1.2-2.3). Multivariate logistic regression analysis showed that benzodiazepines with very short (OR 1.9; CI 1.03-3.3) and short half-life (OR 1.8; CI 1.2-2.8) were positively associated with falls during hospital stay. Patients who used other psychotropic agents (OR 2.3; CI 1.7-3.4), antidiabetic agents (OR 1. 5; CI 1.03-2.2), patients with presence of cognitive impairment (OR 1.6; CI 1.08-2.3), high level of comorbidity (OR 1.7; CI 1.05-2.9), more advanced age (>80 years, OR 2.7; CI 1.5-4.7) and those who stayed in the hospital for 17 days or more (OR 2.1; CI 1.4-3.3) were also at a greater risk. These findings suggest that benzodiazepines with short and very short half-life are an important and independent risk factor for falls and their prescription to elderly hospitalized patients should be carefully evaluated.

Sedative, hypnotic, and antianxiety medication use in an aging cohort over ten years: a racial comparison

OBJECTIVES

Prescriptions of sedatives, hypnotics, and antianxiety medications have decreased over the past 15 years. However, racial differences have not been well investigated in controlled analyses.

DESIGN

A prospective cohort study.

SETTINGS AND PARTICIPANTS

The authors analyzed data from a community-based, biracial cohort of older adults (n = 4,000 at baseline) followed for 10 years to determine sociodemographic and health characteristics associated with the use of these medications between 1986 and 1996.

MAIN OUTCOME MEASURES

Information about sedative, hypnotic, and antianxiety medication use and demographic and health characteristics was obtained from a race-stratified, probability-based sample of black and white community-dwelling older adults in the Piedmont region of North Carolina during four in-person interviews spanning 10 years. Descriptive statistics were calculated. Logistic regression was used for the final models.

RESULTS

A total of 13.3% of the subjects were taking these medications in 1986, with the frequency of use declining only to 11.8% in 1996 despite the cohort aging 10 years. Correlates of use at baseline were female gender, white race, depressive symptoms, poor self-rated health, impaired physical function, and health services use. These correlates persisted for each of the three follow-up waves of the survey. In 1996, the odds for being white and using these medications was 4.70 in controlled analyses.

CONCLUSIONS

Despite the overall decline in the use of sedative, hypnotics, and antianxiety agents in the general population in recent years, over the 10 years of this survey, an aging cohort continued to use these medications at a frequency greater than the general population and did not demonstrate a significant decline in use. Factors unrelated to health status, specifically being white, were among the strongest correlates of use throughout the years of follow-up.

The epidemiology of osteoporosis. Practical implications for patient care

The new definition of osteoporosis moves this disorder from a disease of fractures to a disease of fracture risks. Like blood lipids and blood pressure, bone mineral density is now viewed as a predictor of possible problems. Through careful history taking and physical examination, primary care physicians can identify patients in whom intervention is likely to prevent the anguish of broken bones and lost mobility. In this article, Drs Goddard and Kleerekoper discuss the new diagnostic criteria and what they mean for your patients.