1
|
Sundermann EE, Saloner R, Rubtsova A, Nguyen AL, Letendre S, Moore RC, Cherner M, Ma Q, Marquine MJ. The association between benzodiazepine use and greater risk of neurocognitive impairment is moderated by medical burden in people with HIV. J Neurovirol 2022. [PMID: 35389174 DOI: 10.1007/s13365-022-01076-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 03/12/2022] [Accepted: 03/23/2022] [Indexed: 11/22/2022]
Abstract
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.
Collapse
|
2
|
Affiliation(s)
- Lauren L Orefice
- Department of Molecular Biology, Massachusetts General Hospital, and Department of Genetics, Harvard Medical School, Boston, MA 02114, USA.
| |
Collapse
|
3
|
Polles AG, Williams MK, Phalin BR, Teitelbaum S, Merlo LJ. Neuropsychological impairment associated with substance use by physicians. J Neurol Sci 2020; 411:116714. [DOI: 10.1016/j.jns.2020.116714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/05/2019] [Accepted: 01/29/2020] [Indexed: 10/25/2022]
|
4
|
Kaufmann CN, Moore AA, Bondi MW, Murphy JD, Malhotra A, Hart LA. Association Between the Use of Non-benzodiazepine Hypnotics and Cognitive Outcomes: A Systematic Review. Curr Sleep Med Rep 2020; 6:11-20. [PMID: 33457189 DOI: 10.1007/s40675-020-00163-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Purpose of Review Adverse effects of sedative-hypnotic medications on cognition are concerning. Past studies have examined benzodiazepine (BZD) use and cognitive outcomes; however, few studies have examined newer non-BZD hypnotic agents (nBHs; e.g. zolpidem). This systematic review examined observational studies assessing the association between nBH use and cognitive outcomes. Recent Findings Five studies met eligibility requirements and were included in the review. Most studies did not find an association between nBH use and dementia diagnosis; however, we found no studies assessing other cognitive outcomes such as cognitive performance (e.g., word recall tasks). Characterization of nBH use mostly consisted of incident new use; one study assessed nBH dosing; none examined duration of use. Studies included were of strong quality. Summary This review found no association between nBH use and dementia diagnosis, although there is a need for more research on more cognitive outcomes and nBH use patterns.
Collapse
Affiliation(s)
- Christopher N Kaufmann
- Division of Geriatrics and Gerontology, Department of Medicine, University of California San Diego School of Medicine, La Jolla, CA.,Division of Preventive Medicine, Department of Family Medicine and Public Health, University of California San Diego School of Medicine, La Jolla, CA
| | - Alison A Moore
- Division of Geriatrics and Gerontology, Department of Medicine, University of California San Diego School of Medicine, La Jolla, CA.,Department of Psychiatry, University of California San Diego School of Medicine, La Jolla, CA
| | - Mark W Bondi
- Department of Psychiatry, University of California San Diego School of Medicine, La Jolla, CA.,Veterans Affairs San Diego Healthcare System, La Jolla, CA
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego School of Medicine, La Jolla, CA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego School of Medicine, La Jolla, CA
| | - Laura A Hart
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
| |
Collapse
|
5
|
Nader D, Gowing L. Is Long-Term Benzodiazepine Use a Risk Factor for Cognitive Decline? Results of a Systematic Review. J Addict 2020; 2020:1569456. [PMID: 32047702 DOI: 10.1155/2020/1569456] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 12/24/2019] [Indexed: 12/17/2022]
Abstract
Background and Aims Benzodiazepines have been widely used for long periods of time despite their adverse effects. The acute effects on cognition are well established. However, less is known about the long-term effects. This study critically reviewed existing evidence of the association between long-term exposure to benzodiazepines and risk of cognitive decline in adults. Methods A systematic review with narrative synthesis was conducted. PubMed and PsycINFO databases were searched using combinations of keywords related to “benzodiazepines” and “cognitive function” from database inception to 12 February 2018 to identify prospective longitudinal studies. The records were evaluated for relevance according to the inclusion and exclusion criteria. Results Fourteen studies involving 2145 long-term benzodiazepine users were included. Meta-analysis was not undertaken because the combined result would not be meaningful as the included studies differed in several key aspects such as frequency and duration of benzodiazepine use, follow-up periods, cognitive domains, cognitive tests, scoring systems, and statistical analysis. The definition of long-term benzodiazepine use was problematic in all the studies. The exposure was determined by measures which were assumed to represent the whole period in-between the follow-ups. Only 3 of the 14 studies provided support for an association between long-term benzodiazepine use and cognitive decline with a small to medium effect size. However, these three studies used different methods to assess the strength of this association. Global cognitive functioning, verbal memory, intelligence, psychomotor speed, and speed of processing were the cognitive domains affected which also varied across these three studies. Conclusions Little evidence of an association between long-term benzodiazepine use and a higher risk of cognitive decline among the general adult population was found. However, discrepancies among the results and inconsistencies regarding the cognitive domains affected and methodological limitations prevent definite conclusions. Therefore, future research with prospective studies specially designed would be of great value.
Collapse
|
6
|
Orefice LL, Mosko JR, Morency DT, Wells MF, Tasnim A, Mozeika SM, Ye M, Chirila AM, Emanuel AJ, Rankin G, Fame RM, Lehtinen MK, Feng G, Ginty DD. Targeting Peripheral Somatosensory Neurons to Improve Tactile-Related Phenotypes in ASD Models. Cell 2019; 178:867-886.e24. [PMID: 31398341 PMCID: PMC6704376 DOI: 10.1016/j.cell.2019.07.024] [Citation(s) in RCA: 123] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/06/2019] [Accepted: 07/11/2019] [Indexed: 12/23/2022]
Abstract
Somatosensory over-reactivity is common among patients with autism spectrum disorders (ASDs) and is hypothesized to contribute to core ASD behaviors. However, effective treatments for sensory over-reactivity and ASDs are lacking. We found distinct somatosensory neuron pathophysiological mechanisms underlie tactile abnormalities in different ASD mouse models and contribute to some ASD-related behaviors. Developmental loss of ASD-associated genes Shank3 or Mecp2 in peripheral mechanosensory neurons leads to region-specific brain abnormalities, revealing links between developmental somatosensory over-reactivity and the genesis of aberrant behaviors. Moreover, acute treatment with a peripherally restricted GABAA receptor agonist that acts directly on mechanosensory neurons reduced tactile over-reactivity in six distinct ASD models. Chronic treatment of Mecp2 and Shank3 mutant mice improved body condition, some brain abnormalities, anxiety-like behaviors, and some social impairments but not memory impairments, motor deficits, or overgrooming. Our findings reveal a potential therapeutic strategy targeting peripheral mechanosensory neurons to treat tactile over-reactivity and select ASD-related behaviors.
Collapse
Affiliation(s)
- Lauren L Orefice
- Department of Neurobiology, Harvard Medical School, 220 Longwood Avenue, Boston, MA 02115, USA; Howard Hughes Medical Institute, Harvard Medical School, 220 Longwood Avenue, Boston, MA 02115, USA
| | - Jacqueline R Mosko
- Department of Neurobiology, Harvard Medical School, 220 Longwood Avenue, Boston, MA 02115, USA; Howard Hughes Medical Institute, Harvard Medical School, 220 Longwood Avenue, Boston, MA 02115, USA
| | - Danielle T Morency
- Department of Neurobiology, Harvard Medical School, 220 Longwood Avenue, Boston, MA 02115, USA; Howard Hughes Medical Institute, Harvard Medical School, 220 Longwood Avenue, Boston, MA 02115, USA
| | - Michael F Wells
- McGovern Institute for Brain Research, Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, 43 Vassar Street, Cambridge, MA 02139, USA
| | - Aniqa Tasnim
- Department of Neurobiology, Harvard Medical School, 220 Longwood Avenue, Boston, MA 02115, USA; Howard Hughes Medical Institute, Harvard Medical School, 220 Longwood Avenue, Boston, MA 02115, USA
| | - Shawn M Mozeika
- Department of Neurobiology, Harvard Medical School, 220 Longwood Avenue, Boston, MA 02115, USA; Howard Hughes Medical Institute, Harvard Medical School, 220 Longwood Avenue, Boston, MA 02115, USA
| | - Mengchen Ye
- Department of Neurobiology, Harvard Medical School, 220 Longwood Avenue, Boston, MA 02115, USA; Howard Hughes Medical Institute, Harvard Medical School, 220 Longwood Avenue, Boston, MA 02115, USA
| | - Anda M Chirila
- Department of Neurobiology, Harvard Medical School, 220 Longwood Avenue, Boston, MA 02115, USA; Howard Hughes Medical Institute, Harvard Medical School, 220 Longwood Avenue, Boston, MA 02115, USA
| | - Alan J Emanuel
- Department of Neurobiology, Harvard Medical School, 220 Longwood Avenue, Boston, MA 02115, USA; Howard Hughes Medical Institute, Harvard Medical School, 220 Longwood Avenue, Boston, MA 02115, USA
| | - Genelle Rankin
- Department of Neurobiology, Harvard Medical School, 220 Longwood Avenue, Boston, MA 02115, USA; Howard Hughes Medical Institute, Harvard Medical School, 220 Longwood Avenue, Boston, MA 02115, USA
| | - Ryann M Fame
- Department of Pathology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Maria K Lehtinen
- Department of Pathology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Guoping Feng
- McGovern Institute for Brain Research, Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, 43 Vassar Street, Cambridge, MA 02139, USA
| | - David D Ginty
- Department of Neurobiology, Harvard Medical School, 220 Longwood Avenue, Boston, MA 02115, USA; Howard Hughes Medical Institute, Harvard Medical School, 220 Longwood Avenue, Boston, MA 02115, USA.
| |
Collapse
|
7
|
Crowe SF, Stranks EK. The Residual Medium and Long-term Cognitive Effects of Benzodiazepine Use: An Updated Meta-analysis. Arch Clin Neuropsychol 2017; 33:901-911. [DOI: 10.1093/arclin/acx120] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 11/13/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Simon F Crowe
- School of Psychology and Public Health, La Trobe University, Victoria, Australia
| | - Elizabeth K Stranks
- School of Psychology and Public Health, La Trobe University, Victoria, Australia
| |
Collapse
|
8
|
Silva-Rodríguez J, García-Varela L, López-Arias E, Domínguez-Prado I, Cortés J, Pardo-Montero J, Fernández-Ferreiro A, Ruibal Á, Sobrino T, Aguiar P. Impact of benzodiazepines on brain FDG-PET quantification after single-dose and chronic administration in rats. Nucl Med Biol 2016; 43:827-834. [DOI: 10.1016/j.nucmedbio.2016.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 09/02/2016] [Accepted: 09/07/2016] [Indexed: 02/08/2023]
|
9
|
Dell’osso B, Lader M. Do Benzodiazepines Still Deserve a Major Role in The Treatment of Psychiatric Disorders? A Critical Reappraisal. Eur Psychiatry 2013; 28:7-20. [DOI: 10.1016/j.eurpsy.2011.11.003] [Citation(s) in RCA: 145] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Revised: 11/07/2011] [Accepted: 11/11/2011] [Indexed: 01/01/2023] Open
Abstract
AbstractDiscovered in the late 1950s by Leo Sternbach, the first benzodiazepine (BZD) chlordiazepoxide was followed by several congeners, which rapidly constituted one of the largest and most widely prescribed classes of psychotropic compounds. After 50 years, BZDs are still routinely utilized not only in psychiatry but, more generally, in the whole of medicine. Despite their high therapeutic index which makes BZDs safer than other compounds like barbiturates, as well as their rapidity of onset, psychiatrists and family physicians are well aware about the controversy that surrounds the wide use – often not adequately based on scientific evidence – of BZDs in many psychiatric disorders. In this overview of international treatment guidelines, systematic reviews and randomized clinical trials, the aim was to provide a critical appraisal of the current use and role of BZDs in psychiatric disorders and their disadvantages, with specific emphasis on anxiety and affective disorders, sleep disorders, alcohol withdrawal, violent and aggressive behaviours in psychoses, and neuroleptic-induced disorders. In addition, specific emphasis has been given to the extent of usage of BZDs and its appropriateness through the assessment of available international surveys. Finally, the entire spectrum of BZD-related adverse effects including psychomotor effects, use in the elderly, paradoxical reactions, tolerance and rebound, teratologic risk, dependence, withdrawal and abuse issues was examined in detail.
Collapse
|
10
|
Kitajima R, Miyamoto S, Tenjin T, Ojima K, Ogino S, Miyake N, Fujiwara K, Funamoto Y, Arai J, Tsukahara S, Ito Y, Tadokoro M, Anai K, Kaneda Y, Yamaguchi N. Effects of tapering of long-term benzodiazepines on cognitive function in patients with schizophrenia receiving a second-generation antipsychotic. Prog Neuropsychopharmacol Biol Psychiatry 2012; 36:300-6. [PMID: 22122880 DOI: 10.1016/j.pnpbp.2011.11.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 11/12/2011] [Accepted: 11/14/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND The high use of long-term benzodiazepines (BZDs) with second-generation antipsychotics (SGAs) has been identified as an important issue in the treatment of schizophrenia in Japan. The aim of this study was to evaluate the effects of gradual reduction or discontinuation of daytime BZD use on cognitive function and quality of life (QOL) in patients with chronic schizophrenia receiving an SGA. METHODS Thirty schizophrenic patients who had received an SGA with concomitant BZDs for at least 3 months were enrolled. Before and 4 weeks after tapering of daytime BZDs, the Brief Assessment of Cognition in Schizophrenia Japanese-language version (BACS-J) and the Schizophrenia Quality of Life Scale Japanese-language version (SQLS-J) were administered. Clinical evaluation also included the Positive and Negative Syndrome Scale (PANSS). To compare for practice effects on the BACS-J, 10 patients with chronic schizophrenia were assessed without tapering BZDs. RESULTS BZDs were reduced or discontinued safely in most patients, and no emergent withdrawal symptoms were observed. Significant improvements were shown in verbal memory, working memory, and composite score, as measured by the BACS-J without practice effects. In addition, the motivation/energy score on the SQLS-J, the negative symptoms and total scores on the PANSS significantly improved after tapering BZDs. CONCLUSION Reduction or discontinuation of long-term daytime use of BZDs may be warranted in patients with schizophrenia treated with SGAs, as it may improve cognitive function, subjective QOL, and psychiatric symptoms with no significant adverse effects.
Collapse
Affiliation(s)
- Rei Kitajima
- Department of Neuropsychiatry, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Vinkers CH, Olivier B. Mechanisms Underlying Tolerance after Long-Term Benzodiazepine Use: A Future for Subtype-Selective GABA(A) Receptor Modulators? Adv Pharmacol Sci 2012; 2012:416864. [PMID: 22536226 DOI: 10.1155/2012/416864] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Revised: 10/10/2011] [Accepted: 11/02/2011] [Indexed: 01/01/2023] Open
Abstract
Despite decades of basic and clinical research, our understanding of how benzodiazepines tend to lose their efficacy over time (tolerance) is at least incomplete. In appears that tolerance develops relatively quickly for the sedative and anticonvulsant actions of benzodiazepines, whereas tolerance to anxiolytic and amnesic effects probably does not develop at all. In light of this evidence, we review the current evidence for the neuroadaptive mechanisms underlying benzodiazepine tolerance, including changes of (i) the GABA(A) receptor (subunit expression and receptor coupling), (ii) intracellular changes stemming from transcriptional and neurotrophic factors, (iii) ionotropic glutamate receptors, (iv) other neurotransmitters (serotonin, dopamine, and acetylcholine systems), and (v) the neurosteroid system. From the large variance in the studies, it appears that either different (simultaneous) tolerance mechanisms occur depending on the benzodiazepine effect, or that the tolerance-inducing mechanism depends on the activated GABA(A) receptor subtypes. Importantly, there is no convincing evidence that tolerance occurs with α subunit subtype-selective compounds acting at the benzodiazepine site.
Collapse
|
12
|
Kleykamp BA, Griffiths RR, McCann UD, Smith MT, Mintzer MZ. Acute effects of zolpidem extended-release on cognitive performance and sleep in healthy males after repeated nightly use. Exp Clin Psychopharmacol 2012; 20:28-39. [PMID: 21928913 PMCID: PMC3280925 DOI: 10.1037/a0025237] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The extended-release formulation of zolpidem (Ambien CR) is approved for the treatment of insomnia without a treatment duration limit. Acutely zolpidem impairs performance, and no research to date has examined whether tolerance develops to these performance impairments during nighttime awakening. The present double-blind, placebo-controlled study examined whether tolerance develops to zolpidem-induced acute performance impairment after repeated (22-30 days) nightly use. Effects of bedtime administration of zolpidem extended-release (ZOL; 12.5 mg) were tested on a battery of performance measures assessed during a forced nighttime awakening in 15 healthy male volunteers who completed overnight polysomnographic recording sessions in our laboratory at baseline and after approximately a month of at-home ZOL. As expected, bedtime ZOL administration was associated with changes in sleep architecture and impairments across all performance domains during nighttime testing (psychomotor function, attention, working memory, episodic memory, metacognition) with no residual next morning impairment. Tolerance did not develop to the observed ZOL-related impairments on any outcome. Possible evidence of acute abstinence effects after discontinuation of ZOL was observed on some performance and sleep outcomes. Overall, these findings suggest that performance is significantly impaired during nighttime awakening even after a month of nightly ZOL administration, and these impairments could significantly impact safety should nighttime awakening require unimpaired functioning (e.g., driving; combat-related activities in the military).
Collapse
Affiliation(s)
| | - Roland R Griffiths
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Una D McCann
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Michael T Smith
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Miriam Z Mintzer
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| |
Collapse
|
13
|
Abstract
AIMS To re-examine various aspects of the benzodiazepines (BZDs), widely prescribed for 50 years, mainly to treat anxiety and insomnia. It is a descriptive review based on the Okey Lecture delivered at the Institute of Psychiatry, King's College London, in November 2010. METHODS A search of the literature was carried out in the Medline, Embase and Cochrane Collaboration databases, using the codeword 'benzodiazepine(s)', alone and in conjunction with various terms such as 'dependence', 'abuse', etc. Further hand-searches were made based on the reference lists of key papers. As 60,000 references were found, this review is not exhaustive. It concentrates on the adverse effects, dependence and abuse. RESULTS Almost from their introduction the BZDs have been controversial, with polarized opinions, advocates pointing out their efficacy, tolerability and patient acceptability, opponents deprecating their adverse effects, dependence and abuse liability. More recently, the advent of alternative and usually safer medications has opened up the debate. The review noted a series of adverse effects that continued to cause concern, such as cognitive and psychomotor impairment. In addition, dependence and abuse remain as serious problems. Despite warnings and guidelines, usage of these drugs remains at a high level. The limitations in their use both as choice of therapy and with respect to conservative dosage and duration of use are highlighted. The distinction between low-dose 'iatrogenic' dependence and high-dose abuse/misuse is emphasized. CONCLUSIONS The practical problems with the benzodiazepines have persisted for 50 years, but have been ignored by many practitioners and almost all official bodies. The risk-benefit ratio of the benzodiazepines remains positive in most patients in the short term (2-4 weeks) but is unestablished beyond that time, due mainly to the difficulty in preventing short-term use from extending indefinitely with the risk of dependence. Other research issues include the possibility of long-term brain changes and evaluating the role of the benzodiazepine antagonist, flumazenil, in aiding withdrawal.
Collapse
Affiliation(s)
- Malcolm Lader
- Addiction Research Centre, Institute of Psychiatry, King's College London, London, UK.
| |
Collapse
|
14
|
Abstract
OBJECTIVE To summarize the literature on the available pharmacotherapy for insomnia and the adverse cognitive effects of those options in persons with traumatic brain injury (TBI). DESIGN Ovid/MEDLINE databases were searched by using the following key words: "brain injury," "sleep initiation and maintenance disorders," "hypnotics and sedatives," "benzodiazepines," "trazodone," and "neuronal plasticity." RESULTS The reviewed literature consistently reported that benzodiazepines and atypical gamma-aminobutyric acid (GABA) agonists result in cognitive impairment when plasma levels are at their peak. Evidence of residual effects on cognition was reported for benzodiazepines but was seen less often in atypical GABA agonists. However, evidence has also been presented that GABA agonists have adverse effects on neuroplasticity, raising concerns about their use in patients recovering from TBI. CONCLUSIONS Use of benzodiazepines in TBI has been discouraged and some authors also advocate caution in prescribing atypical GABA agonists. Alternate treatments including trazodone and a newer class of agents, melatonin agonists, are highlighted, along with the limited data available addressing the use of these medications in TBI. Finally, suggestions are offered for further research, especially on topic related to neural plasticity and functional recovery.
Collapse
|
15
|
van Rijswijk E, Lucassen P, van De Lisdonk E, Zitman F, van Weel C. Do co-existing psychosocial problems influence the prescription of psychotropic medication in depressive and anxiety disorders? Eur J Gen Pract 2009; 12:37-9. [PMID: 16945871 DOI: 10.1080/13814780600757294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
16
|
Abstract
The objective of this review was to assess the benefits and risks of medication withdrawal in older people as documented in published trials of medication withdrawal. This was done by systematic review of the evidence from clinical trials of withdrawal of specific classes of medications in patient populations with a mean age of >or=65 years. We identified all relevant articles published between 1966 and 2007 initially through electronic searches on PubMed and manual searches of review articles. Numerous search terms related to the withdrawal of medication in older people were utilized. Clinical trials identified were reviewed according to predetermined inclusion/exclusion criteria. Only trials that focused on the withdrawal of specific classes of medication were included. Thirty-one published studies (n = 8972 subjects) met the inclusion criteria, including four randomized and placebo-controlled studies (n = 448 subjects) of diuretic withdrawal, nine open-label and prospective observational studies (n = 7188 subjects) of withdrawal of antihypertensives (including diuretics), 16 studies (n = 1184 patients) of withdrawal of sedative, antidepressant, cholinesterase inhibitor and antipsychotic medications, and 1 study each of withdrawal of nitrates and digoxin. These studies were of heterogeneous study design, patient selection criteria and follow-up. Withdrawal of diuretics was maintained in 51-100% of subjects and was unsuccessful primarily when heart failure was present. Adverse effects from medication withdrawal were infrequently encountered. After withdrawal of antihypertensive therapy, many subjects (20-85%) remained normotensive or did not require reinstatement of therapy for between 6 months and 5 years, and there was no increase in mortality. Withdrawal of psychotropic medications was associated with a reduction in falls and improved cognition. In conclusion, there is some clinical trial evidence for the short-term effectiveness and/or lack of significant harm when medication withdrawal is undertaken for antihypertensive, benzodiazepine and psychotropic agents in older people.
Collapse
Affiliation(s)
- Shoba Iyer
- Centre for Education and Research on Ageing, Concord RG Hospital and University of Sydney, Sydney, New South Wales, Australia
| | | | | | | |
Collapse
|
17
|
Abstract
Psychotropic medications are widely used in older adults and may cause neurocognitive deficits. Older adults are at increased risk of developing adverse effects because of age-related pharmacodynamic and pharmacokinetic changes. This article provides a comprehensive review of the undesirable, and at times beneficial, effects of psychotropic medications. The review covers a wide range of medications that impair executive function, memory, and attention, as well as a much smaller group of medications that lead to improved neurocognitive function. Some of the most commonly used psychotropic medications in older adults, namely, antidepressants, sedatives, and hypnotics, are among the drugs that most consistently lead to cognitive impairments. Medications with anticholinergic properties almost invariably lead to neurocognitive dysfunction, despite symptom improvement. The neurocognitive costs and benefits of psychiatric medications should be considered in the context of disease treatment in older adults.
Collapse
Affiliation(s)
- John O Brooks
- Palo Alto Veterans Affairs Health Care System and Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA.
| | | |
Collapse
|
18
|
Dièye AM, Sy AN, Sy GY, Diallo AA, Diarra M, Ndiaye M, Faye B. [Prescription of benzodiazepines by general practitioners in the private sector of Dakar: survey on knowledge and attitudes]. Therapie 2007; 62:163-8. [PMID: 17582318 DOI: 10.2515/therapie:2007018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate knowledge and attitudes of general practitioners of the private sector, in Dakar, concerning prescription of benzodiazepines, in order to make, possibly, recommendations for their rational use. METHOD A survey was done in 2005 with a representative sample of 55 medical doctors. Medical doctors filled in the questionnaire which focused on the main benzodiazepines' indications, those prescribed and their rules of prescription. RESULTS The main indications were anxiety, convulsions, epilepsy and insomnia and the benzodiazepines prescribed in first intention were prazepam against anxiety and insomnia and diazepam against convulsions and epilepsy. Practically 17% of medical doctors ignored the existence of limited period of benzodiazepine use and 70.9% of medical doctors considered their training on benzodiazepines insufficient. CONCLUSION These results show the necessity to base continuous training for these general practitioners on the pharmacology of benzodiazepines.
Collapse
Affiliation(s)
- Amadou Moctar Dièye
- Laboratoire de Pharmacologie, Faculté de Médecine, de Pharmacie et d'Odonto-Stomatologie, Université Cheikh Anta Diop de Dakar, Dakar-Fann, Sénégal
| | | | | | | | | | | | | |
Collapse
|
19
|
Abstract
The rational use of pharmacological treatment in generalized anxiety disorders is still a matter of debate due to the uncertainties concerning the nature, diagnostic criteria and target-symptoms of this frequent and potentially invalidating disorder. If benzodiazepines may still be prescribed for a limited amount of time (i.e. 6 to 12 weeks) due to the fluctuating nature of generalized anxiety, the chronic evolution of this disorder in most patients often justifies the long-term prescription of serotoninergic (5-HT) or dual-action (5HT-NA) antidepressants and sometimes of 5HT-la partial agonists like buspirone. Imipramine, a tricyclic antidepressant was the first to demonstrate its efficacy in carefully selected patients; however, due to the side-effects of this molecule recent guidelines based on controlled clinical trials, suggest to use either serotonergic antidepressants (SSRIs) or venlafaxine as a first-line treatment of generalized anxiety disorders. Because of its pharmacological profile buspirone remains however a useful option in patients with cognitive or addictive problems, especially alcoholics. If most SSRIs have demonstrated efficacy over placebo, head to head comparisons remain limited except for escitalopram which appear better tolerated than paroxétine in this indication. More recently, an anticonvulsant, pregabaline also demonstrated its efficacy in several clinical trials but the symptomatic profile of generalized anxiety patients likely to respond to this GABA analog compared to other psychotropic treatments remain to be established. The traditional use of other psychotropic agents such as hydroxyzine, an H1 histaminergic receptor antagonist, is only supported by limited scientific data; this is also the case of sedative typical antipsychotics which benefit/risk ratio should be carefully evaluated before being prescribed to generalized anxiety patients resistant to other psychotropic agents. However, the possible use of atypical antipsychotics with a better tolerance profile than the typical ones in this indication is presently under investigation in several countries. At last it is important to realize that most clinical trials in this field only include patients with non-comorbid generalized anxiety and that their conclusion may not always be generalizable to most psychiatric patients who are usually characterized by a high rate of comorbidity. In this population the indication of specific pharmacological treatments should rely on a careful evaluation of the patients drug treatment history, of the duration, evolution and functional consequences of their symptoms and of the nature of their possible comorbidity. The treatment of resistant generalized anxiety disorders remains a question for future research but the use of imipramine or sedative antipsychotics could be an option when other treatments have failed to induce any improvement.
Collapse
Affiliation(s)
- J-P Boulenger
- Service Universitaire de Psychiatrie Adulte et INSERM U-888, CHU de Montpellier (Université Montpellier 1), Hôpital La Colombière, 39, avenue Charles Flahault, 34295 Montpellier cedex 5, France
| | | |
Collapse
|
20
|
Mintzer MZ, Griffiths RR. A triazolam/amphetamine dose-effect interaction study: dissociation of effects on memory versus arousal. Psychopharmacology (Berl) 2007; 192:425-40. [PMID: 17342474 DOI: 10.1007/s00213-007-0726-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2006] [Accepted: 01/24/2007] [Indexed: 10/23/2022]
Abstract
RATIONALE In addition to producing robust memory impairment, benzodiazepines also induce marked sedation. Thus, it is possible that the observed amnestic effects are secondary to more global sedative effects and do not reflect a specific primary benzodiazepine effect on memory mechanisms. OBJECTIVE The objective was to use the nonspecific stimulant d-amphetamine to dissociate the sedative and memory-impairing effects of the benzodiazepine triazolam. MATERIALS AND METHODS Single oral doses of placebo, triazolam alone (0.25, 0.50 mg/70 kg), d-amphetamine sulfate alone (20, 30 mg/70 kg), and triazolam (0.25, 0.50 mg/70 kg) and d-amphetamine sulfate (20, 30 mg/70 kg) conjointly (at all dose combinations) were administered to 18 healthy adult participants across nine sessions in a double-blind, staggered-dosing, crossover design. In addition to standard data analyses, analyses were also conducted on z-score standardized data, enabling effects to be directly compared across measures. RESULTS Relative to the sedative measures, the memory measures generally exhibited a pattern of less reversal of triazolam's effects by d-amphetamine. The memory measures ranged in degree of reversal such that the most reversal was observed for reaction time on the n-back working memory task, and the least reversal was observed for accuracy on the Sternberg working memory task, with most measures showing an overall pattern of partial reversal. CONCLUSIONS Benzodiazepines have specific effects on memory that are not merely a by-product of the drugs' sedative effects, and the degree to which sedative effects contribute to the amnestic effects varies as a function of the particular memory process being assessed.
Collapse
Affiliation(s)
- Miriam Z Mintzer
- Department of Psychiatry and Behavioral Sciences, Behavioral Biology Research Center, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA.
| | | |
Collapse
|
21
|
Gittos MW. Toward a better understanding of depression and anxiety: the involvement of stress and tryptophan hydroxylase activation. Drug Dev Res 2007. [DOI: 10.1002/ddr.20143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
22
|
Affiliation(s)
- Melinda J. Barker
- La Trobe University, Australia
- School of Psychological Science, La Trobe University, VIC, 3086, Australia
| | - Martin Jackson
- La Trobe University, Australia
- School of Psychological Science, La Trobe University, VIC, 3086, Australia
| | - Kenneth M. Greenwood
- La Trobe University, Australia
- School of Psychological Science, La Trobe University, VIC, 3086, Australia
| | - Simon F. Crowe
- La Trobe University, Australia
- School of Psychological Science, La Trobe University, VIC, 3086, Australia
| |
Collapse
|
23
|
Abstract
The amnestic effects of benzodiazepines are well documented on a variety of memory tasks. However, prospective memory (PM), or remembering to execute an action at a future time, has not been studied previously. This study examined the effect of diazepam on word list recall, PM, sustained attention, and subjective ratings of arousal. Forty-eight healthy participants, aged 19-35, received an average of 0.19 mg/kg oral diazepam or placebo in a double-blind manner. Retrospective memory and PM were assessed by free recall of unrelated word lists and by instructing participants to request a hidden belonging at the end of the session, respectively. Sustained attention was measured by multiple trials of a digit cancellation task, and subjective arousal was assessed by self-ratings of drowsiness. Diazepam impaired performance on all measures, including PM. Reduced PM performance was associated with decreased subjective arousal in the diazepam group but was unrelated to sustained attention. This is the first report of the effects of benzodiazepines on prospective remembering, and further supports the view that the arousal/attentional system is composed of partially independent subsystems that have differential relationships to memory.
Collapse
Affiliation(s)
- Jill B Rich
- Department of Psychology, York University, 4700 Keele Street, Toronto, Ontario, Canada M3J 1P3.
| | | | | |
Collapse
|
24
|
Oude Voshaar RC, Krabbe PFM, Gorgels WJMJ, Adang EMM, van Balkom AJLM, van de Lisdonk EH, Zitman FG. Tapering off benzodiazepines in long-term users: an economic evaluation. Pharmacoeconomics 2006; 24:683-94. [PMID: 16802844 DOI: 10.2165/00019053-200624070-00007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Discontinuation of benzodiazepine usage has never been evaluated in economic terms. This study aimed to compare the relative costs and outcomes of tapering off long-term benzodiazepine use combined with group cognitive behavioural therapy (TO+CBT), tapering off alone (TOA) and usual care. METHOD A randomised controlled trial was conducted, incorporating a cost-effectiveness analysis from a societal as well as a pharmaceutical perspective. The cost of intervention treatment, prescribed drugs, healthcare services, productivity loss, and patients' costs were measured using drug prescription data and cost diaries. Costs were indexed at 2001 prices. The principal outcome was the proportion of patients able to discontinue benzodiazepine use during the 18-month follow-up. A secondary outcome measure was quality of life (Health Utility Index Mark III [HUI-3] and the Medical Outcomes Study 36-item Short-Form Health Survey [SF-36]). RESULTS A total of 180 patients were randomised to one of TO+CBT (n = 73), TOA (n = 73) or usual care (n = 34). Intervention treatment costs were an average of 172.99Euro per patient for TO+CBT and 69.50Euro per patient for TOA. Both treatment conditions significantly reduced benzodiazepine costs during follow-up compared with usual care. The incremental cost-effectiveness ratios (ICERs) showed that, for each incremental 1% successful benzodiazepine discontinuation, TO+CBT cost 10.30-62.53Euro versus usual care, depending on the study perspective. However, TO+CBT was extendedly dominated or was dominated by TOA. This resulted in ICERs of 0.57Euro, 10.21Euro and 48.92Euro for TOA versus usual care from the limited pharmaceutical, comprehensive pharmaceutical and societal perspective, respectively. CONCLUSIONS TO+CBT and TOA both led to a reduction in benzodiazepine costs. However, it remains uncertain which healthcare utilisation has a causal relationship with long-term benzodiazepine consumption or its treatment. Although the ICERs indicated better cost effectiveness for TOA than for TO+CBT, the differences were relatively small. The addition of group CBT to tapering off had no clinical or economic advantages. Extrapolation of our data showed that the investment in TOA was paid back after 19 months when corrected for treatment gain with usual care.
Collapse
Affiliation(s)
- Richard C Oude Voshaar
- Department of Psychiatry, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
25
|
|
26
|
|
27
|
Abstract
Benzodiazepines are the most frequently prescribed antianxiety drugs in the elderly. Despite their usefulness and safety in the younger population, there is concern about the rationale for their use in the elderly. Studies of the therapeutic use of benzodiazepines in the elderly are rare. Elderly females with co-morbid medical and psychiatric conditions and who are taking multiple medications form the group most frequently prescribed benzodiazepines among the elderly, and the group most likely to experience side effects. Age-related pharmacokinetic and pharmacodynamic changes increase the potential for certain side effects in the elderly. Significant adverse effects that may be associated with benzodiazepine use in the elderly include falls, cognitive impairment, sedation, and impairment of driving skills, all of which are particularly related to the long half-life of benzodiazepines. Long-term use of benzodiazepines should be discouraged because of the risk of dependence, which is a serious problem in the elderly. Unrecognised and untreated benzodiazepine dependence can lead to serious medical complications.
Collapse
Affiliation(s)
- Subramoniam Madhusoodanan
- Department of Psychiatry, St. John's Episcopal Hospital, South Shore, 327 Beach 19th Street, Far Rockaway, New York, USA.
| | | |
Collapse
|
28
|
Barker MJ, Greenwood KM, Jackson M, Crowe SF. An evaluation of persisting cognitive effects after withdrawal from long-term benzodiazepine use. J Int Neuropsychol Soc 2005; 11:281-9. [PMID: 15892904 DOI: 10.1017/S1355617705050332] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2004] [Revised: 07/22/2004] [Indexed: 11/07/2022]
Abstract
Twenty participants with self-reported long-term benzodiazepine use (mean 108 months) who had previously withdrawn from medication (mean 42 months) were administered a battery of neuropsychological tests. Each long-term user was case matched for age, sex, and education to two control participants who reported never taking benzodiazepines (those with and those without anxiety). The results indicated that long-term benzodiazepine use may lead to impairments in the areas of verbal memory, motor control/performance, and nonverbal memory but not visuospatial skills and attention/concentration. The length of abstinence (> 6 months) indicates that these impairments persist well beyond cessation of benzodiazepine use. However, observed impairments in the area of nonverbal memory were not solely attributable to benzodiazepine use and may be influenced by the elevated anxiety levels present in both the case and the anxious control group.
Collapse
|
29
|
Gorgels WJMJ, Oude Voshaar RC, Mol AJJ, van de Lisdonk EH, van Balkom AJLM, van den Hoogen HJM, Mulder J, Breteler MHM, Zitman FG. Discontinuation of long-term benzodiazepine use by sending a letter to users in family practice: a prospective controlled intervention study. Drug Alcohol Depend 2005; 78:49-56. [PMID: 15769557 DOI: 10.1016/j.drugalcdep.2004.09.001] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2004] [Revised: 07/21/2004] [Accepted: 09/13/2004] [Indexed: 11/18/2022]
Abstract
Minimal intervention strategies to decrease long-term benzodiazepine use have not yet been evaluated in large primary care based studies with a blinded control condition and a long follow-up period. The purpose of this study was to assess the effects of a letter with a discontinuation advice sent to long-term benzodiazepine users in family practice followed by an evaluation consultation offer. The experimental group consisted of 2425 long-term benzodiazepine users, 1707 of whom were addressed by a discontinuation letter and an evaluation consultation offer. The control group consisted of 1821 long-term users. Primary endpoints were the number of prescribed daily dosages (PDD) and the percentage of subjects without prescription (quitters). At 21 months a reduction in benzodiazepine prescription of 26% was observed in the experimental group, versus 9% in the control group (PDD difference=12.5; 95%-ci: 8.2-16.8). In the experimental group 13% and in the control group 5% of the study completers were benzodiazepine prescription free through the full follow-up period (RR=2.6; 95%-ci: 2.0-3.4). The percentage of quitters at short-term (6 months) was 24% in the experimental group versus 12% in the control group (RR=2.1; 95%-ci: 1.8-2.4). It is concluded that this intervention strategy steadily reduces long-term benzodiazepine use in family practice.
Collapse
Affiliation(s)
- Wim J M J Gorgels
- Department of General Practice and Family Medicine, University Medical Centre St. Radboud, Nijmegen, The Netherlands.
| | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Abstract
We investigated the effects of lorazepam, a benzodiazepine, on the allocation of study time, memory, and judgment of learning, in a cognitive task where the repetition of word presentation was manipulated. The aim was to assess whether lorazepam would affect the learning processes and/or whether the participants would be aware of the amnesic difficulty. A total of 30 healthy volunteers participated in the study, 15 of whom received a capsule containing the lorazepam drug (0.038 mg/kg) and 15 a placebo capsule. First, the accuracy of delayed judgments of learning (JOL) was measured in both groups. For the JOL ratings, results showed that all the participants benefited from word repetition. Although the overall performance was lower in the lorazepam than in the placebo group, the accuracy of the JOL ratings was preserved by the drug. Second, all the participants benefited from the repetition of learning, although the performances of the lorazepam-treated subjects remained lower than those of the placebo participants. The repetition of learning had an effect on JOL in both groups. Finally, the time spent learning each (allocation study time) pair of words was measured. For the placebo group, results revealed that study time decreased significantly with the frequency of presentation. For the lorazepam group, no effect of presentation frequency was found. Overall, our findings suggest that the lorazepam drug has a differential effect on the monitoring and the control processes involved in a learning task. The implications of these findings are discussed within the theoretical framework of metacognition.
Collapse
Affiliation(s)
- Marie Izaute
- Laboratoire de Psychologie Sociale de la Cognition (LAPSCO-UMR 6024 CNRS), Universite Blaise Pascal, Clermont-Ferrand Cedex, France
| | | |
Collapse
|
31
|
Abstract
Résumé
Des études effectuées chez une population de volontaires sains en administration unique indiquent que les benzodiazépines (BZD) sont connues pour induire des déficits en mémoire. Cette population étudiée ne correspond toutefois pas avec celle qui consomme régulièrement ces substances soit les personnes âgées. Peu d’études ont été faites auprès de cette population cible afin de déterminer l’impact des BZD sur leur mémoire. Par contre, il existe des évidences suggérant aussi qu’il existe des conséquences importantes sur le fonctionnement de la mémoire des personnes âgées qui prennent des BZD. Les données actuelles vont même jusqu’à suggérer que les BZD exacerbent les déficits de mémoire chez les personnes âgées. Cela pourrait même constituer un facteur de risque précipitant le déclin cognitif et augmentant ainsi le risque de développer une démence.
Collapse
Affiliation(s)
- France Quevillon
- Université du Québec à Montréal, Centre de recherche Fernand-Seguin, Hôpital Louis-H. Lafontaine
| | - Marc-André Bédard
- Université du Québec à Montréal, Centre de recherche Fernand-Seguin, Hôpital Louis-H. Lafontaine
| |
Collapse
|
32
|
Abstract
INTRODUCTION While benzodiazepines are the most widely used psychotropic drugs, there are relatively few studies that have examined deficits in cognitive functioning after long-term use. The literature that is available is difficult to interpret due to conflicting results as well as a variety of methodological flaws. OBJECTIVE To systematically evaluate and integrate the available research findings to determine the effect of long-term benzodiazepine use on cognitive functioning using meta-analytical techniques. METHODS Thirteen research studies that employed neuropsychological tests to evaluate cognitive performance after long-term use of benzodiazepine medication met inclusion criteria. The neuropsychological tests employed in these 13 studies were each categorised as measuring one of 12 cognitive domains. Separate effect sizes were calculated for each of the 12 cognitive categories. Each study was only allowed to contribute one effect size to each cognitive category by averaging together the effect sizes from the same study if more than one type of test was used to measure a particular category. This strategy resulted in equal weight being given to each study per category, regardless of the number of tests in that category. RESULTS The overall mean number of patients who were benzodiazepine users was 33.5 (SD +/- 28.9) and the mean number of controls was 27.9 (SD +/- 19.6). The duration of benzodiazepine use ranged from 1 to 34 (mean 9.9) years. Long-term benzodiazepine users were consistently more impaired than controls across all cognitive categories examined, with effect sizes ranging in magnitude from -1.30 to -0.42. The mean weighted effect size was -0.74 (SD +/- 0.25). None of the effect sizes had 95% CIs that spanned zero and, therefore, all of these effects were significant and different to zero. CONCLUSION Moderate-to-large weighted effect sizes were found for all cognitive domains suggesting that long-term benzodiazepine users were significantly impaired, compared with controls, in all of the areas that were assessed. However, this study has several limitations, one being that it includes a relatively small number of studies. Further studies need to be conducted; ideally, well designed, controlled studies that thoroughly investigate certain areas of cognitive functioning and present data in such a way so as to be amenable to inclusion in a meta-analysis. Incorporating the information from these studies into a larger meta-analysis would allow for a more thorough and statistically sound investigation of the effects of moderator variables. The observation that long-term benzodiazepine use leads to a generalised effect on cognition has numerous implications for the informed and responsible prescription of these drugs.
Collapse
Affiliation(s)
- Melinda J Barker
- School of Psychological Science, La Trobe University, Bundoora, Victoria, Australia
| | | | | | | |
Collapse
|
33
|
|
34
|
Abstract
BACKGROUND There have been few general population studies of the effects of psychotropic treatment on cognitive functioning in the elderly. Current evidence based on studies with numerous procedural shortenings supports the notion of the detrimental effect. OBJECTIVES To examine changes in a wide range of specific cognitive abilities across time in a general population sample in order to establish a relationship between psychotropic drug use and cognitive performance, and to estimate to what extent such cognitive changes may be attributable to psychotropic use or other factors, notably age and co-morbidity. METHOD We analysed the data from the Eugeria longitudinal study of cerebral ageing. Three hundred and seventy two subjects (263 female and 109 male) were visited at their place of residence and given a computerized cognitive examination. Depressive symptomatology and depressive episodes were defined according to ICD-9 criterias and medication use were established. Four categories of psychotropic consumers was differentiated. Using a logistic regression model, comparisons were made between consumers and non-consumers. RESULTS A significant positive effect in chronic consumers was found on tests of secondary memory (delayed verbal recall: Odds Ratio (OR)=1.22; 95% Confidence Intervals (CI) [1.04-1.43]; p=0.013) and this effect is principally attributable to antidepressants with significant effects being shown for both verbal (OR=1.59; 95%CI [1.18-2.14]; p=0.002) and visual recall (OR=1.51; 95%CI [1.05-2.16]; p=0.025). No effect is found for benzodiazepines. CONCLUSIONS Contrary to the common belief that psychotropic drug use has a detrimental effect on cognitive function of elderly people, even long term use is seen to be benign. We attest to the positive effects of antidepressant therapy on secondary memory.
Collapse
Affiliation(s)
- Jacques Allard
- Sherbrooke Geriatric University Institute, Sherbrooke, Quebec, Canada.
| | | | | |
Collapse
|
35
|
Abstract
It is well-documented that benzodiazepine sedative/hypnotics produce robust dose-dependent memory-impairing effects. However, benzodiazepines also induce marked sedation, as reflected in changes in observer and subjective ratings of arousal and impaired psychomotor performance. Thus, it is possible that the observed amnestic effects are secondary to more global sedative effects, and do not reflect a specific, primary, benzodiazepine effect on memory mechanisms. This study was designed to use the non-specific stimulant d-amphetamine to dissociate the sedative and memory-impairing effects of the benzodiazepine triazolam. Across four sessions, 20 healthy adult volunteers received via oral capsule administration placebo, 0.25 mg/70 kg triazolam alone, 20 mg/70 kg d-amphetamine sulfate alone, and triazolam (0.25 mg/ 70 kg) and d-amphetamine (20 mg/70 kg) conjointly, in a double-blind, staggered dosing, cross-over design. d-Amphetamine significantly reversed the effects of triazolam on all participant rating and psychomotor performance-based measures of sedative effects, and selectively reversed the memory-impairing effects of triazolam on some measures (e.g. working memory assessed by a 2-back task, episodic memory assessed by free recall, metamemory), but not others (e.g. working memory assessed by a digit recall task, episodic memory assessed by recognition memory). Results suggest that benzodiazepines do have specific effects on memory that are not merely a by-product of the drugs' sedative effects, and that the degree to which sedative effects contribute to the amnestic effects may vary as a function of the particular memory process being assessed. In addition to enhancing the understanding of the mechanisms underlying benzodiazepine-induced amnesia, these results may also contribute to a better understanding of the complex relationship between specific memory processes and level of arousal.
Collapse
Affiliation(s)
- Miriam Z Mintzer
- Department of Psychiatry and Behavioral Sciences, Behavioural Biology Research Center, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA.
| | | |
Collapse
|
36
|
Abstract
This study examined the potential for cognitive morbidity associated with the long-term use of benzodiazepine (BZ) sedative-hypnotics in a sample of healthy older adults. Tests of memory, attention and processing speed were conducted prior to and 1 month after drug discontinuation for 25 BZ-users and at similar intervals for 26 healthy control subjects. After controlling for differences in affective status between BZ-users and controls, there were no significant group differences in cognitive performance. However, BZ-users showed greater gains on tests of attention and speed of processing at repeat testing compared with controls this improvement was not attributable to a change in affective status. These findings suggest that there may be subtle and reversible effects of long-term BZ use on speed-dependent tasks in older adults. However, the magnitude of these effects is quite small and may be of little clinical significance in the healthy elderly.
Collapse
Affiliation(s)
- Mary Pat McAndrews
- Department of Psychology, Toronto Western Hospital and University of Toronto, Canada.
| | | | | | | | | | | |
Collapse
|
37
|
Petrovic M, Mariman A, Warie H, Afschrift M, Pevernagie D. Is there a rationale for prescription of benzodiazepines in the elderly? Review of the literature. Acta Clin Belg 2003; 58:27-36. [PMID: 12723259 DOI: 10.1179/acb.2003.58.1.004] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Benzodiazepines (BZDs) constitute the most widely used symptomatic treatment of insomnia and anxiety. Many of these drugs are associated with adverse effects, such as daytime sedation and dependence with continued use. There is a concern about the rationale for and extent of benzodiazepine (BZD) use in the elderly. The sedation due to BZD use is a main risk factor for falls and other accidents. Impaired cognitive function with continuous use appears to be a major side effect. There is a general awareness that BZD use is inappropriate in many patients, and therefore discontinuation should be recommended whenever possible. Moreover, long-term use of these drugs should be actively discouraged. Although no unanimous recommendations concerning the optimal duration of the withdrawal process exist, BZDs may easily be withdrawn during a short period in most patients who are habituated to a low dose, if an initial phase with dose reduction and psychological support are provided. Alternative approaches involve sleep hygiene guidelines, behavioural treatment and psychotherapy tailored to the needs of the individual patient.
Collapse
Affiliation(s)
- M Petrovic
- Service of Internal Medicine, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium.
| | | | | | | | | |
Collapse
|
38
|
Bastien CH, Fortier-Brochu E, Rioux I, LeBlanc M, Daley M, Morin CM. Cognitive performance and sleep quality in the elderly suffering from chronic insomnia. Relationship between objective and subjective measures. J Psychosom Res 2003; 54:39-49. [PMID: 12505554 DOI: 10.1016/s0022-3999(02)00544-5] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The objective of the present study was to evaluate the relationship between objective and subjective sleep quality and objective and subjective evaluation of cognitive performance in older adults suffering of chronic insomnia (using or not benzodiazepines, BZs) or self-reported good sleepers. METHODS Three groups of participants 55 years and older were evaluated: 20 insomnia sufferers using BZs chronically, 20 drug-free insomnia sufferers and 20 good sleepers. Objective sleep (PSG) and subjective sleep (sleep diaries, SD) were measured. Objective measures of cognitive performance (attention/concentration, verbal/visual memory, executive function and psychomotor speed) and subjective perception of daily performance were evaluated. RESULTS Correlational analysis revealed that objective and subjective measures of daytime performance are differentially related to sleep quality for the three groups. An objective good night of sleep is associated with better cognitive performance in good sleepers and drug-free individuals. On the other hand, the impression of having slept well is related to better cognitive performance in good sleepers and chronic insomnia sufferers using BZs. CONCLUSION Daytime performance and sleep quality are related, but differently so for a good sleeper, an insomnia sufferer without treatment, or one using BZs to alleviate sleep difficulties.
Collapse
Affiliation(s)
- Célyne H Bastien
- Ecole de Psychologie and Centre d'Etude des Troubles du Sommeil, Université Laval, Ste-Foy, Québec, Canada G1K 7P4.
| | | | | | | | | | | |
Collapse
|
39
|
Abstract
Several cross-sectional studies have found cognitive impairment in subjects taking benzodiazepines for long periods. However, it is not known whether long-term use of benzodiazepines accelerates cognitive decline in the elderly. The authors addressed this issue in a follow-up study of 1,389 people aged 60 to 70 years recruited from the electoral rolls of the city of Nantes (Epidemiology of Vascular Aging study). Data on cognitive functioning (five cognitive tests), depressive symptoms (Center for Epidemiologic Studies-Depression Scale), anxiety symptoms (Spielberger Inventory Scale), use of psychotropics and other drugs, and tobacco and alcohol consumption were collected at baseline, 2-year, and 4-year examinations. People reporting to take benzodiazepines at one, two and three examinations were classified as episodic, recurrent, and chronic users, respectively. Among the 1,176 subjects (85%) who participated in the three examinations, the proportions of episodic, recurrent, and chronic users were 10%, 6%, and 7%, respectively. Chronic users of benzodiazepines had a significantly higher risk of cognitive decline in the global cognitive test (Mini Mental State Examination) and the two attention tests than nonusers (Mini Mental State Examination: odds ratio [OR] [95% confidence interval (CI)] = 1.9 [1.0-3.5]; Digit Symbol Substitution test: OR [95% CI] = 2.7 [1.6-4.7]; Trail Making test, part B: OR [95% CI] = 2.1 [1.2-3.7]). Overall, episodic and recurrent users had lower cognitive scores than nonusers, but differences were not statistically significant. These results were independent of age, sex, education, alcohol and tobacco use, anxiety and depression scores, and use of psychotropic drugs other than benzodiazepines. The findings suggest that long-term use of benzodiazepines is risk factor of increased cognitive decline in the elderly.
Collapse
Affiliation(s)
- Sabrina Paterniti
- Institut National de la Santé et de la Recherche Médicale, Paris, France.
| | | | | |
Collapse
|
40
|
Gladsjo JA, Rapaport MH, McKinney R, Auerbach M, Hahn T, Rabin A, Oliver T, Haze A, Judd LL. Absence of neuropsychologic deficits in patients receiving long-term treatment with alprazolam-XR for panic disorder. J Clin Psychopharmacol 2001; 21:131-8. [PMID: 11270908 DOI: 10.1097/00004714-200104000-00003] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Studies to date on the effects of benzodiazepines on neuropsychologic function have yielded conflicting data with respect to the type, severity, and duration of deficits that may be induced by these agents. As part of a placebo-controlled trial of alprazolam-XR (extended release) administered in combination with cognitive-behavioral therapy in patients with panic disorder, a battery of tests was used to measure neuropsychologic function. Thirty-eight outpatients were randomly assigned to receive either alprazolam-XR or placebo. Dosages were titrated up so that the alprazolam group (N = 18) received a mean dose of 4 mg/day (reduced in two patients because of sedative side effects). Neuropsychologic function after 6 weeks of therapy at the target dosage was compared with baseline assessments in each group. Both groups showed a statistically significant improvement from baseline to repeated assessments on measures of attention, executive functioning, psychomotor speed, and visual memory (p < 0.001); these gains were attributed to a practice effect. No significant changes were noted in measures of learning, verbal memory, or reaction time, and neither group showed any deterioration from baseline to retesting in any aspect of neuropsychologic function. These findings call into question the assumption that long-term benzodiazepine therapy produces significant neuropsychologic deficit in patients with diagnosed anxiety disorders.
Collapse
Affiliation(s)
- J A Gladsjo
- Department of Psychiatry, University of California, San Diego School of Medicine, La Jolla 92037, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
41
|
McAndrews MP, Kayumov L, Phillipson R, Shapiro CM. Self-report of memory and affective dysfunction in association with medication use in a sample of individuals with chronic sleep disturbance. Hum Psychopharmacol 2000; 15:583-587. [PMID: 12404610 DOI: 10.1002/hup.226] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Benzodiazepines produce memory disturbance after acute administration. It is not clear whether chronic use of benzodiazepines is hazardous to memory processes. Epidemiological data indicate that a large proportion (10-30 per cent) of individuals with sleep dysfunction take hypnotic aids for a year or longer. The purpose of the present study was to evaluate self-reported memory dysfunction in a sample of individuals who considered their sleep disturbance sufficiently severe to seek investigation in sleep clinics. It was hypothesized that individuals taking benzodiazepines for sleep would report greater perceived everyday memory failures than individuals taking other sleep aids or no medication. Questionnaires were given to 368 individuals referred into the study by investigators in six sleep disorders clinics. All respondents completed a lengthy (700-item) questionnaire, which included scales assessing memory difficulties, affective status and sleep disturbance. Respondents also reported any medication use for sleep problems and duration of use of the current drug. Information on medication use was reported by 289 participants. Fifty-six per cent of respondents reported using some form of psychoactive medication (antidepressants, benzodiazepines, Zopiclone). Twenty-two per cent reported using no medication. Analysis of covariance showed that these medications had no detectable effect on subjective memory difficulties during chronic use, F(4,226)=1.34, p=0.25. Copyright 2000 John Wiley & Sons, Ltd.
Collapse
Affiliation(s)
- Mary Pat McAndrews
- Department of Psychology, University Health Network, Toronto Western Hospital, Canada
| | | | | | | |
Collapse
|
42
|
Affiliation(s)
- P Tyrer
- Department of Public Mental Health, Imperial College of Science, Technology and Medicine, St Mary's Campus, Paterson Centre, London, UK
| |
Collapse
|
43
|
Rickels K, Lucki I, Schweizer E, García-España F, Case WG. Psychomotor performance of long-term benzodiazepine users before, during, and after benzodiazepine discontinuation. J Clin Psychopharmacol 1999; 19:107-13. [PMID: 10211911 DOI: 10.1097/00004714-199904000-00003] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Long-term (mean, 8 years) users of benzodiazepines (BZs) were administered a small battery of cognitive tests on three occasions (before BZ taper, and 5 and 12 weeks post taper) as part of their BZ discontinuation program. Ninety-six patients had 5-week and 77 patients had 12-week data. For taper successes, BZ-free status was confirmed by weekly BZ plasma level determinations. Age and education, as well as baseline test scores, were used as covariates for all data analyses. Patients who successfully tapered off BZ were able to complete symbol copying (SC) and digit symbol substitution (DSST) tasks faster than patients still taking BZ (p < 0.05). In addition, using an adjective check list, patients with taper success, i.e., BZ-free patients, reported lower levels of mental and physical sedation and higher levels of tranquilization (p < 0.05) than did patients still taking BZ. These results were confirmed in two multiple regression analyses with SC and DSST as the dependent variables. Higher baseline, younger age, and successful taper status (off BZ) were selected as significant independent predictors of SC and DSST scores. In summary, cognitive functions improved for many long-term BZ users after discontinuing their BZ intake.
Collapse
Affiliation(s)
- K Rickels
- Department of Psychiatry, University of Pennsylvania, Philadelphia 19104-2649, USA
| | | | | | | | | |
Collapse
|
44
|
Abstract
The prevalence of psychotropic medication consumption was assessed in the UK by surveying a representative sample of 4972 non-institutionalized individuals 15 years of age or older (participation rate, 79.6%). A questionnaire was administered over the telephone with the help of the Sleep-Eval Expert System. Topics covered included: type and name of medication, indication, dosage, duration of intake, and medical specialty of prescriber. Also collected were data pertaining to sociodemographics, physical illnesses, and DSM-IV mental disorders. Overall, 3.5% [95% CI: 3-4] of the sample reported current use of psychotropic medication. Consumption was higher among women [4.6% (3.8-5.4)] than men [2.3% (1.7-2.9)], and among the elderly (> or = 65 years of age). The distribution of psychotropics was: hypnotics 1.5%, antidepressants 1.1%, and anxiolytics 0.8%. The median duration of psychotropic intake was 52 weeks. General practitioners were the most common prescribers of psychotropics (over 80% for each class of drug). Nearly half the antidepressant users were diagnosed by the system with a DSM-IV anxiety disorder, and one-fifth the anxiolytic users with a depressive disorder. A marked improvement in sleep quality was reported by half the subjects using a psychotropic for sleep-enhancing purposes. Psychotropic users were more likely than non-users to report episodes of memory loss, vertigo, or anomia. Psychotropic medication consumption is lower and patterns of psychotropic prescription differ in the UK compared with other European and North American countries. Results suggest that physicians may not be sufficiently trained to deal with the overlap between general practice and psychiatry.
Collapse
Affiliation(s)
- M M Ohayon
- Centre de Recherche Philippe Pinel de Montréal, Québec, Canada
| | | | | | | |
Collapse
|
45
|
|
46
|
Habraken H, Soenen K, Blondeel L, Van Elsen J, Bourda J, Coppens E, Willeput M. Gradual withdrawal from benzodiazepines in residents of homes for the elderly: experience and suggestions for future research. Eur J Clin Pharmacol 1997; 51:355-8. [PMID: 9049574 DOI: 10.1007/s002280050213] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE A randomised, controlled clinical trial was performed to study the long-term effect of gradual withdrawal from benzodiazepines on the daily functioning of residents of homes for the elderly. The planned sample size was not achieved due to recruitment and follow-up problems. RESULTS The results in this small sample nevertheless suggest that gradual withdrawal from benzodiazepines is possible in residents of homes for the elderly, and that it can have a positive effect on their daily functioning. No major withdrawal symptoms were observed, although there was a decrease in sleep quality during withdrawal. CONCLUSION The findings are promising for further research, but researchers should anticipate the problems inherent in executing a trial with institutionalised elderly subjects.
Collapse
|
47
|
Streufert S, Satish U, Pogash R, Gingrich D, Landis JR, Lonardi L, Miller J, Severs W, Roache JD. Effects of Alprazolam on Complex Human Functioning1. J Appl Social Pyschol 1996. [DOI: 10.1111/j.1559-1816.1996.tb00105.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
48
|
Abstract
This review aims at providing a critical assessment of the effects of the most widely used benzodiazepine (flurazepam, flunitrazepam, temazepam, triazolam) and non-benzodiazepine (zopiclone and zolpidem) hypnotic drugs, based on the recording of polysomnographic variables. In the light of newly acquired neurophysiological data on the microstructure of sleep, this paper reconsiders the problem of insomnia and the current ideas on polysomnography and hypnotic drugs.
Collapse
Affiliation(s)
- L Parrino
- Istituto di Neurologia, Università degli Studi, Parma, Italy
| | | |
Collapse
|
49
|
Abstract
The long-term effects of benzodiazepines (BDZ) on psychomotor and cognitive functions were assessed in 28 out patients, users of low therapeutic doses of diazepam (13.6 ± 4.9 mg/day, range: 5-20 mg/day) for 5-20 years (10.1 ± 5.0 years). These patients' performance was compared with two control groups: 53 BDZ-free anxious out patients and 56 healthy volunteers. The three groups were similar in sex, age and education. BDZ chronic users were tested before and after short-term (3 weeks) and long-term discontinuation (at an average of 10 months). Performance of chronic users of BDZ was consistently worse than those of the control groups, suggesting an impairment in these patients on both psychomotor and cognitive functions. These were not related to either dose or cumulative exposure to BDZ, and were also independent of diagnosis and levels of anxiety and depression. Moreover, these deficits were persistent as their performance failed to improve after drug discontinuation.
Collapse
Affiliation(s)
- C Gorenstein
- Departamento de Farmacologia, Instituto de Ciências Biomédicas and LIM-23 Faculdade de Medicina
| | | | | | | |
Collapse
|