Progressive trends in the prevalence of benzodiazepine prescribing in older people in Ontario, Canada

Melatonin Prescribing in Assisted Living

OBJECTIVES

Aging is associated with sleep problems, which are common among assisted living (AL) residents. More than 40% of residents have insomnia, and almost 70% have a sleep disturbance of some kind. Melatonin to treat sleep disorders has become common among older adults, but its use in AL is unknown, which is concerning because melatonin may have side effects and interfere with other medications. The purpose of this study was to determine the prevalence and correlates of melatonin prescribing in AL, to inform whether changes in care may be indicated.

DESIGN

Cross-sectional chart abstracts and interviews.

SETTINGS AND PARTICIPANTS

Data were collected in 250 randomly selected AL communities among 5777 residents across 7 states in the United States and weighted to an estimated 4043 communities and 152,719 residents.

METHODS

Charts of residents were abstracted, and AL administrators and health care supervisors were interviewed to obtain information related to case-mix, staffing, and attitudes regarding psychoactive medications. Weighted analyses primarily examined the association of melatonin prescribing with community- and resident-level characteristics.

RESULTS

Melatonin was prescribed in 82% of communities, more commonly in those that had a registered nurse or licensed practical nurse on site (+7%, P = .027), and whose health care supervisor was more favorable toward nonpharmacologic practices (+18%, P = .010). On average, 9% of residents were prescribed melatonin, with prescriptions being more common among those diagnosed with dementia (+24%, P = .004); a psychiatric disorder, especially an anxiety disorder (+43%, P = .007); having behavioral expressions; and taking other psychotropics. Coprescribing was common, especially with antidepressants (OR 2.64, 95% CI 1.99, 3.48; P < .001).

CONCLUSIONS AND IMPLICATIONS

This study is the first to examine melatonin prescribing in AL, and finds it to be common. Such use may be appropriate if it is as a more suitable replacement for hypnotics. The fact that use varies by organizational characteristics suggests practices may be modifiable. Research examining benefits and side effects of melatonin, overall and in relation to other medications, is indicated to promote better care for AL residents.

The factors associated with inappropriate prescription patterns of benzodiazepines and related drugs among patients with dementia

BACKGROUND

It has been emphasised that benzodiazepines and related drugs (BZDRs) should be used cautiously in people with dementia. The aim of this study was to identify factors associated with inappropriate prescription patterns of BZDRs including polypharmacy, long-term treatment and high doses among patients with dementia taking BZDRs.

METHODS

This was a retrospective chart review study of patients with dementia who were treated at the study hospital. The date that the patient was issued a catastrophic illness certificate from the National Health Insurance Administration was used as the index date. Medical records of the 2-year period after the index date were reviewed.

RESULTS

A total of 308 patients with dementia were included in this study. Among them, 151 (49.0%) received at least one prescription of BZDRs. After adjusting for covariates, psychiatric comorbidities (adjusted odds ratio (aOR) = 4.74, 95% CI = 1.75-12.81), history of past suicidal behaviour (aOR = 4.25, 95% CI = 1.40-12.88) and long-term treatment with BZDRs (aOR = 3.38, 95% CI = 1.11-10.27) were associated with polypharmacy of BZDRs. Age (aOR = 1.05, 95% CI = 1.0-1.11) and polypharmacy (aOR = 3.57, 95% CI = 1.23-10.32) were associated with long-term treatment. Living with family (aOR = 3.33, 95% CI = 1.32-9.79) and fewer psychiatric admissions to the study hospital (aOR = 0.56, 95% CI = 0.36-0.86) were associated with treatment with high doses of BZDRs.

CONCLUSIONS

Treatment with BZDRs is prevalent in patients with dementia. Inappropriate prescription patterns of BZDRs are not uncommon in these patients and may be interlinked.

Socioeconomic status and benzodiazepine and Z-drug prescribing: a cross-sectional study of practice-level data in England

BACKGROUND

Benzodiazepines and Z-drugs (such as zopiclone) are widely prescribed in primary care. Given their association with addiction and dependence, understanding where and for whom these medications are being prescribed is a necessary step in addressing potentially harmful prescribing.

OBJECTIVE

To determine whether there is an association between primary care practice benzodiazepine and Z-drug prescribing and practice population socioeconomic status in England.

METHODS

This was a cross-sectional study. An aggregated data set was created to include primary care prescribing data for 2017, practice age and sex profiles and practice Index of Multiple Deprivation (IMD) scores-a marker of socioeconomic status. Drug doses were converted to their milligram-equivalent of diazepam to allow comparison. Multiple linear regression was used to examine the association between IMD and prescribing (for all benzodiazepines and Z-drugs in total, and individually), adjusting for practice sex (% male) and older age (>65 years) distribution (%).

RESULTS

Benzodiazepine and Z-drug prescribing overall was positively associated with practice-level IMD score, with more prescribing in practices with more underserved patients, after adjusting for age and sex (P < 0.001), although the strength of the association varied by individual drug. Overall, however, IMD score, age and sex only explained a small proportion of the overall variation in prescribing across GP practices.

CONCLUSION

Our findings may, in part, be a reflection of an underlying association between the indications for benzodiazepine and Z-drug prescribing and socioeconomic status. Further work is required to more accurately define the major contributors of prescribing variation.

Benzodiazepine Prescribing in People with Chronic Obstructive Pulmonary Disease: Clinical Considerations

Benzodiazepines, available clinically for almost six decades, are still one of the most widely prescribed classes of medication. The proportion of the population prescribed benzodiazepines increases with age, and harms also increase with age. The prevalence of prescribing in people > 85 years of age is as high as one in three, including in people with chronic obstructive pulmonary disease (COPD). The prevalence of COPD also increases with age. In COPD, indications cited for prescribing a benzodiazepine include anxiety, sleep disorders, or chronic breathlessness. Each of these symptoms is prevalent in the population with COPD, especially later in the course of the illness. For anxiety and insomnia, there is evidence to support short-term use, with little robust evidence to support prescribing for the symptomatic reduction of chronic breathlessness. People prescribed benzodiazepines are more likely to experience drowsiness or somnolence, exacerbations of their COPD, and respiratory tract infections. Furthermore, the longer people take benzodiazepines, the more likely they will become dependent on them. Prescribing patterns vary internationally but prescriptions of longer-acting benzodiazepines are declining in favour of shorter-acting compounds. Other evidence-based therapies that can more safely treat these problematic symptoms are available. For people already taking benzodiazepines, there are a number of interventions that have been shown to reduce the rate of prescribing. For people with COPD and not taking a benzodiazepine, but with symptoms where there is evidence of benefit, clinicians should weigh carefully the potential net benefit and prescribe at the lowest dose for the briefest time possible.

The association between benzodiazepine use and falls, and the impact of sleep quality on this association: data from the TILDA study

BACKGROUND

Benzodiazepines (BZD) are associated with adverse effects, particularly in older adults.

AIM

This study assesses the association between BZD use and falls, and the impact of sleep quality on this association, in community dwelling adults aged over 50.

DESIGN

Cross-sectional analysis of data from wave 1 of The Irish Longitudinal Study on Ageing.

METHODS

Participants were classed as BZD users or non-users and asked if they had fallen in the last year, and whether any falls were unexplained. Sleep quality was assessed via self-reported trouble falling asleep, daytime somnolence and early-rising. Logistic regression assessed for an association between BZD use and falls, and the impact of sleep quality on this association was assessed by categorizing based on BZD use and sleep quality variables.

RESULTS

Of 8175 individuals, 302 (3.69%) reported taking BZDs. BZD use was associated with falls, controlling for confounders [Odds Ratio (OR) 1.40; 1.08, 1.82; P-value 0.012]. There was no significant association between BZDs and unexplained falls, controlling for confounders [OR 1.41; 95% Confidence Interval (CI) 0.95, 2.10; P-value 0.09]. Participants who use BZDs and report daytime somnolence (OR 1.93; 95% CI 1.12, 3.31; P-value 0.017), early-rising (OR 1.93; 95% CI 1.20, 3.11; P-value 0.007) or trouble falling asleep (OR 1.83; 95% CI 1.12, 2.97; P-value 0.015), have an increased odds of unexplained falls.

CONCLUSION

BZD use is associated with falls, with larger effect size in those reporting poor sleep quality in community dwelling older adults. Appropriate prescription of medications such as BZDs is an important public health issue.

Is the Long-Term Use of Benzodiazepines Associated With Worse Cognition Performance in Highly Educated Older Adults?

Background: Benzodiazepines (BZD) are common medications for sedative, hypnotic, and anxiolytic that are especially prevalent in older adults. Previous studies have shown that BZD use could impair users' cognition, significantly affecting their quality of life. Past research has shown that higher education might play a protective role in the process of cognitive decline. Very few studies had examined the cognitive effects of BZD on highly educated older adults. The study aimed to explore how cognitive functions would be affected by benzodiazepines among highly educated older adults. Method: 140 older adults with an average education period of 14.8 years were included in this study. The subjects were divided into three separate groups, the long-term BZD users (≥180 days), short-term BZD users (<180 days), and non-users. Demographics and cognitive assessments for the three groups were analyzed using the analysis of variance (ANOVA), the chi-squared test, and the analysis of covariance (ANCOVA). To examine the association between BZD use and cognition a multiple linear aggression approach was used. Result: All three groups were significantly different from each other when looking at executive functioning in the Trail Making Test B (TMT-B). Compared to the control group, short-term BZD users showed significant defects in TMT-B time (p = 0.002) and TMT-B errors (p < 0.001); long-term BZD users showed significant defect on TMT-B time (p = 0.041). Compared to short-term BZD users, long-term BZD users showed significant merit on TMT-B errors (p = 0.001). No significant differences were found in other cognitive tasks that reflected general cognition, verbal memory, language fluency, and visual memory. After adjusting for demographic, increased BZD use over time was positively associated with scores for the revised Brief Visuospatial Memory Test (r = 0.377, p = 0.012). Conclusion: BZD use may be significantly associated with worse executive functioning in highly educated older adults. However, there is no association between the duration of BZD use and increased cognitive deficits in highly educated older adults. This study identified future experimental directions including potential longitudinal studies, within-subject studies comparing mood disorder patients' cognitive performance before and after onset of BZD use, and between-subject studies that directly compare BZD's effect on subjects with the same baseline of cognitive functioning.

Psychiatric and physical outcomes of long-term use of lithium in older adults with bipolar disorder and major depressive disorder: A cross-sectional multicenter study

OBJECTIVE

Although lithium is widely used in current practice to treat bipolar disorder (BD) and treatment-resistant major depressive disorder (MDD) among older adults, little is known about its efficacy and tolerability in this population, which is generally excluded from randomized clinical trials. The objective of this study was to evaluate the efficacy and tolerability of long-term use of lithium among older adults with BD and MDD.

METHOD

Data from the Cohort of individuals with Schizophrenia and mood disorders Aged 55 years or more (CSA) were used. Two groups of patients with BD and MDD were compared: those who were currently receiving lithium versus those who were not. The effects of lithium on psychiatric (i.e., depressive symptoms severity, perceived clinical severity, rates of psychiatric admissions in the past-year), geriatric (overall and cognitive functioning) and physical outcomes (i.e., rates of non-psychiatric medical comorbidities and general hospital admissions in the past-year) were evaluated. All analyses were adjusted for age, sex, duration of disorder, diagnosis, smoking status, alcohol use, and use of antipsychotics, antiepileptics or antidepressants.

RESULTS

Among the 281 older participants with BD or MDD, 15.7% were taking lithium for a mean duration of 12.5(SD = 11.6) years. Lithium use was associated with lower intensity of depressive symptoms, reduced perceived clinical global severity and lower benzodiazepine use (all p < 0.05), without being linked to greater rates of medical comorbidities, except for hypothyroidism.

LIMITATIONS

Data were cross-sectional and data on lifetime history of psychotropic medications was not assessed.

CONCLUSION

Our results suggest that long-term lithium use may be efficient and relatively well-tolerated in older adults with BD or treatment-resistant MDD.

Anticholinergic and sedative drug burden in community-dwelling older people: a national database study

OBJECTIVES

The Drug Burden Index (DBI) tool quantifies individual exposure to anticholinergic and sedative medications. The DBI has been internationally validated against adverse health outcomes in older people. DBI exposure has not been reported in the Irish older population. This study aimed to: (1) develop a list of drugs with clinically significant anticholinergic and/or sedative effects (DBI medications) relevant to Ireland; (2) examine, using the DBI formula, the prevalence of exposure to DBI medications in Irish older people and (3) explore patient factors associated DBI exposure.

DESIGN

A cross-sectional national pharmacy claims database study.

SETTING

Community setting using the General Medical Services (GMS) scheme pharmacy claims database maintained by the Health Service Executive Primary Care Reimbursement Services.

PARTICIPANTS

Irish older individuals (aged ≥65 years) enrolled in the GMS scheme and dispensed at least one prescription item in 2016 (n=428 516).

MAIN OUTCOME MEASURES

Prevalence of exposure to DBI medications and patient factors associated with DBI exposure.

RESULTS

282 874 (66%) of the GMS population aged ≥65 years were exposed to at least one DBI medication in 2016. Prevalence of exposure to DBI medications was significantly higher in females than males (females 71.6% vs males 58.7%, adjusted OR 1.65, 95% CI 1.63 to 1.68). Prevalence of DBI exposure increased progressively with the number of chronic drugs used, rising from 42.7% of those prescribed 0-4 chronic drugs to 95.4% of those on ≥12 chronic drugs (adjusted OR 27.8, 95% CI 26.7 to 29.0). The most frequently used DBI medications were codeine/paracetamol combination products (20.1% of patients), tramadol (11.5%), zopiclone (9.5%), zolpidem (8.5%), pregabalin (7.9%) and alprazolam (7.8%).

CONCLUSIONS

The majority of older people in Ireland are exposed to medications with anticholinergic and/or sedative effects, particularly females and those with multiple comorbidities. The high use of low-dose codeine/paracetamol combination products, Z-drugs and benzodiazepines, suggests there are opportunities for deprescribing.

Benzodiazepine prescription in Ontario residents aged 65 and over: a population-based study from 1998 to 2013

BACKGROUND

Although commonly used in anxiety and insomnia, recent guidelines recommend caution when prescribing benzodiazepines in the elderly. Here we examined rates of benzodiazepine prescribing to older adults in Ontario, Canada from 1998 to 2013 and impact of legislation that made prescribing regulations more strict.

METHOD

Annual benzodiazepine prescription rates for Ontario residents aged 65 and over were examined using the Ontario Drug Benefit database which captures all publicly funded prescriptions. Since most drugs, including benzodiazepines, are funded for residents aged ⩾65, data are essentially population-based. Weighted least squares regression methods were used to examine trends in prescribing rates (all benzodiazepines, anxiolytics, hypnotics, short- and long-acting drugs and individual drugs) from 1998 to 2013 for all Ontario residents aged ⩾65 and by sex and 5-year age bands. Impact on monthly prescribing rates of legislative changes (November 2011) which aimed to promote appropriate prescribing and dispensing practices for controlled substances, including requiring prescribers to record specified information, was assessed by constructing an interrupted time-series model.

RESULTS

Benzodiazepines were prescribed to 23.2% of the 1,412,638 Ontario residents aged ⩾65 in 1998, declining to 14.9% of 2,057,899 residents aged ⩾65 in 2013 (p < 0.001 for trend). Rates were significantly greater throughout in older age bands (p < 0.001) and 1.54-1.62 times greater in females than males (p < 0.001). Lorazepam was the most prescribed benzodiazepine throughout, but rates declined from 11.4% in 1998 to 8.5% in 2013. Diazepam rates fell from 2.3% to 0.7%. However, clonazepam prescription rates increased until 2011, 1.7-fold overall. After the November 2011 legal changes, downward shifts were observed in total benzodiazepine prescription rates and for each drug individually. The step function, conditional on covariates, suggested benzodiazepine rates after November 2011 were 2.89 per 1000 (p < 0.001) below rates observed previously, representing a relative reduction of 4.8% compared to the year before the intervention.

CONCLUSION

Benzodiazepine prescribing rates declined markedly in this population from 1998 to 2013. Targeted legislation may have reduced rates, but the effect, although statistically significant, was small.

Benzodiazepine Use and Cognitive Decline in Elderly With Normal Cognition

Benzodiazepine (BZD) use may be associated with dementia. However, differing opinions exist regarding the effect of BZDs on long-term changes in cognition. We evaluated the association between BZD use and cognitive decline in the elderly with normal cognition from the National Alzheimer's Disease Coordinating Center's Uniform Data Set. The study exposure, BZD use, was classified 2 ways: any-use [reported BZD use at a minimum of 1 Alzheimer's disease center (ADC) visit] and always-use (reported BZD use at all ADC visits). The reference group included participants without any declared BZD use at any Alzheimer's Disease Center (ADC) visit. The main outcome measures were Clinical Dementia Rating Sum of Boxes score and Mini-Mental State Examination score. We observed a decline in cognitive status over time in the 2 comparison groups. All participants who reported taking BZDs had poorer cognitive performance at all visits than nonusers. However, cognitive decline was statistically similar among all participants. We found no evidence of an association between BZD use and cognitive decline. The poor cognitive performance in BZD users may be due to prodromal symptoms caused by preclinical dementia processes.

Prescription of Sedative Drugs During Hospital Stay: A Swiss Prospective Study

BACKGROUND

In recent years, the number of prescriptions for sedative drugs has increased significantly, as has their long-term use. Moreover, sedative use is frequently initiated during hospital stays.

OBJECTIVES

This study aimed to describe new prescriptions of sedative drugs during hospital stays and evaluate their maintenance as discharge medication.

METHODS

This observational prospective study took place in an internal medicine ward of a Swiss hospital over a period of 3 months in 2014. Demographic (age, sex, diagnosis, comorbidities) and medication data [long-term use of sedative drugs, new regular or pro re nata ('as needed') prescriptions of sedative drugs, drug-related problems] were collected. Sedative medications included: benzodiazepines, Z-drugs, antihistamines, antidepressants, neuroleptics, herbal drugs, and clomethiazole. McNemar's test was used for comparison.

RESULTS

Of 290 patients included, 212 (73%) were over 65 years old and 169 (58%) were women; 34% (n = 98) were using sedative drugs long term before their hospital stay, and 44% (n = 128) had a prescription for sedative drugs at discharge-a 10% increase (p < 0.05). Sedative drugs were newly prescribed to 37% (n = 108) of patients during their stay. Among these, 37% (n = 40) received a repeat prescription at discharge. Over half of the sedative drugs were prescribed within 24 h of admission. Drug-related problems were detected in 76% of new prescriptions, of which 90% were drug-drug interactions.

CONCLUSION

This study showed that hospital stays increased the proportion of patients who were prescribed a sedative drug at discharge by 10% (absolute increase). These prescriptions may generate long-term use and expose patients to drug-related problems. Promoting alternative approaches for managing insomnia are recommended.

Long-term sedative use among community-dwelling adults: a population-based analysis

BACKGROUND

Chronic use of benzodiazepines and benzodiazepine-like sedatives (z-drugs) presents substantial risks to people of all ages. We sought to assess trends in long-term sedative use among community-dwelling adults in British Columbia.

METHODS

Using population-based linked administrative databases, we examined longitudinal trends in age-standardized rates of sedative use among different age groups of community-dwelling adults (age ≥ 18 yr), from 2004 to 2013. For each calendar year, we classified adults as nonusers, short-term users, or long-term users of sedatives based on their patterns of sedative dispensation. For calendar year 2013, we applied cross-sectional analysis and estimated logistic regression models to identify health and socioeconomic risk factors associated with long-term sedative use.

RESULTS

More than half (53.4%) of long-term users of sedatives in British Columbia are between ages 18 and 64 years (young and middle-aged adults). From 2004 to 2013, long-term sedative use remained stable among adults more than 65 years of age (older adults) and increased slightly among young and middle-aged adults. Although the use of benzodiazepines decreased during the study period, the trend was offset by equal or greater increases in long-term use of z-drugs. Being an older adult, sick, poor and single were associated with increased odds of long-term sedative use.

INTERPRETATION

Despite efforts to stem such patterns of medication use, long-term use of sedatives increased in British Columbia between 2004 and 2013. This increase was driven largely by increased use among middle-aged adults. Future deprescribing efforts that target adults of all ages may help curb this trend.

Benzodiazepine Misuse in the Elderly: Risk Factors, Consequences, and Management

Benzodiazepine (BZD) inappropriate use (i.e., misuse and overuse) is a worldwide public health problem. Despite current knowledge about increased sensitivity to side effects in the elderly, that should lead to more caution, only a third of BZD prescriptions in this age group are considered appropriate. The most frequent inadequate situations are excessive duration and/or dosage of a medical prescription or self-medication, especially in a context where it would be contraindicated, e.g., long-acting BZD in the elderly. Polypharmacy and comorbidities are major risk factors. Consequences of BZD inappropriate use are falls, delirium and other cognitive dysfunction, acute respiratory failure, car accidents, dependence, and withdrawal symptoms. An emerging concern is a potentially increased risk of dementia. Contrary to most clinicians' belief, discontinuation of chronic BZD use in elderly patients is feasible, with adequate psychotherapeutic or pharmacological strategies, and can lead to long-term abstinence. Brief cognitive therapy mostly relies on psychoeducation and motivational enhancement and is particularly useful in this context. Further research is needed, notably in three areas: (1) assessing the impact of public health programs to prevent BZD inappropriate use in the elderly, (2) developing alternative strategies to treat anxiety and insomnia in elderly patients, and (3) exploring the association between chronic BZD use and dementia.

Trends in prescribing of sedative-hypnotic medications in the USA: 1993-2010

PURPOSE

Non-benzodiazepine receptor agonists (nBZRAs) were developed as an alternative to benzodiazepines (BZDs) to treat insomnia. Little is known about how the introduction of nBZRAs influenced trends in BZD prescribing. We examined BZD and nBZRA prescribing trends from 1993 to 2010.

METHODS

We used the National Ambulatory Medical Care Survey to examine 516,118 patient visits between 1993 and 2010. We categorized visits as BZD, nBZRA, or BZD + nBZRA visits based on medications prescribed in each visit and applied linear probability regression models to assess trends in visits.

RESULTS

Increases were observed in proportions of visits that were BZD (2.6% in 1993 to 4.4% in 2010, p < 0.001) and nBZRA (0% to 1.4%, p < 0.001). Increases in BZD visits were primarily after 2002, with prescribing in the preceding years remaining relatively stable. We also found increases in BZD + nBZRA visits (0% to 0.4%, p < 0.001). Among patients with sleep disorders, there was an increase in nBZRA visits (2.3% to 13.7%, p < 0.001), and decline in BZD visits (23.5% to 10.8%, p = 0.015). Just under a third (30.8%) of any sedative-hypnotic visits were for adults aged 65+ years, among whom increases in BZD, nBZRA, and BZD + nBZRA visits were observed across the study period.

CONCLUSIONS

There were increases in prescribing of nBZRAs between 1993 and 2010. Increases in prescribing of BZDs were also observed, especially after 2002. The introduction of nBZRAs likely resulted in declines in BZD prescribing among those with a sleep disorder, but not other groups. Delivery of behavioral treatments should be encouraged to avert adverse outcomes associated with sedative-hypnotic use. Copyright © 2015 John Wiley & Sons, Ltd.

Changing Pattern of Sedative Use in Older Adults: A Population-Based Cohort Study

BACKGROUND

Benzodiazepine medications have well-documented side effects, and their prescription rates in older adults have been declining. Trazodone and quetiapine are medications with sedative properties when used at low doses and are commonly used off-label for sleep or behavioral symptoms in older adults.

OBJECTIVE

Our objective was to describe the shifting patterns of sedative prescription in older adults over time by comparing changes in benzodiazepine, trazodone, and quetiapine dispensing between community and long-term care settings.

METHODS

We conducted a population-based serial cross-sectional study to compare the patterns of sedative dispensing (specifically, benzodiazepines, trazodone, and quetiapine) to individuals aged ≥66 years between 1 January 2002 and 31 March 2013 in Ontario, Canada. We compared rates of use between long-term care and community settings and used linear regression models to characterize the magnitude and direction of the rate of change in sedative use by age, sex, and dementia status.

RESULTS

The dispensing of trazodone and quetiapine increased over time, and this coincided with a decrease in benzodiazepine dispensing. This pattern was particularly apparent in the oldest cohort and in those with dementia. Benzodiazepines, trazodone, and quetiapine were associated with high rates of psychotropic polypharmacy. Overall trends were similar in long-term care and the community.

CONCLUSIONS

While benzodiazepine prescribing is declining among older adults in Ontario over time, there is a corresponding shift towards low-dose, off-label prescribing of trazodone and quetiapine and psychotropic polypharmacy. These prescribing trends highlight sedative substitution and reinforce the need to confirm efficacy and safety of this practice.

Benzodiazepine and z-hypnotic prescribing for older people in primary care: a cross-sectional population-based study

BACKGROUND

Overall prescribing of benzodiazepines and z-hypnotics (B&Zs) has slowly reduced over the past 20 years. However, long-term prescribing still occurs, particularly among older people, and this is at odds with prescribing guidance.

AIM

To compare prescribing of B&Zs between care home and non-care home residents ≥65 years old.

DESIGN AND SETTING

Cross-sectional population-based study in primary care in Scotland.

METHOD

National patient-level B&Z prescribing data, for all adults aged ≥65 years, were extracted from the Prescribing Information System (PIS) for the calendar year 2011. The PIS gives access to data for all NHS prescriptions dispensed in primary care in Scotland. Data were stratified by health board, residential status, sex, and age (65-74, 75-84, and ≥85 years). To minimise disclosure risk, data from smaller health boards were amalgamated according to geography, thereby reducing the number from 14 to 10 areas.

RESULTS

A total of 17% (n = 879 492) of the Scottish population were aged ≥65 years, of which 3.7% (n = 32 368) were care home residents. In total, 12.1% (n = 106 412) of older people were prescribed one or more B&Z: 5.9% an anxiolytic, 7.5% a hypnotic, and 1.3% were prescribed both. B&Zs were prescribed to 28.4% (9199) of care home and 11.5% (97 213) of non-care home residents (relative risk = 2.88, 95% CI = 2.82 to 2.95, P<0.001). Estimated annual B&Z exposure reduced with increasing age of care home residents, whereas non-care home residents' exposure increased with age.

CONCLUSION

B&Zs were commonly prescribed for older people, with care home residents approximately three times more likely to be prescribed B&Zs than non-care home residents. However, overall B&Z exposure among non-care home residents was found to rise with increasing age.

Consumo de ansiolíticos benzodiazepínicos: uma correlação entre dados do SNGPC e indicadores sociodemográficos nas capitais brasileiras

Resumo O objetivo do artigo é conhecer a distribuição e a frequência de consumo de ansiolíticos benzodiazepínicos, bem como avaliar a correlação entre consumo e características demográficas, epidemiológicas, econômicas e sociais. Estudo ecológico tendo como unidade amostral as 27 capitais brasileiras. A coleta de dados foi executada através do banco da Anvisa, para a dispensação do Alprazolam, Bromazepam, Clonazepam, Diazepam e Lorazepam, de 2010 a 2012, do Censo Demográfico 2010 (IBGE), Datasus e da pesquisa Demografia Médica. A análise estatística descritiva e a de regressão linear múltipla foram realizadas para análise dos dados. A região Norte possui as capitais com menores médias de consumo desses medicamentos e o Sudeste as mais elevadas. O consumo médio para a população de todas as capitais foi de 3,60 DHD. O Alprazolam é o mais dispensado pelas farmácias e drogarias particulares, com média de 2,00 DHD para as capitais. A análise de regressão linear múltipla demonstrou que 76% da variância do consumo foi explicada pela variação da densidade demográfica (β = 0,310 p = 0,045) e percentual de médicos (β = 0,507 p = 0,016). O consumo de ansiolíticos de meia vida curta vem crescendo ao longo dos anos, principalmente nas capitais de maior densidade demográfica e concentração de médicos.

Dependence, misuse, and beliefs regarding use of hypnotics by elderly psychiatric patients taking zolpidem, estazolam, or flunitrazepam

INTRODUCTION

To examine the prevalence rates and correlates of dependence on, misuse of, and beliefs regarding use of hypnotics in elderly psychiatric patients with long-term use of zolpidem, estazolam, or flunitrazepam.

METHODS

A total of 139 psychiatric outpatients 65 or more years of age who used zolpidem, estazolam, or flunitrazepam for at least 3 months were studied. The levels of hypnotic dependence and beliefs regarding hypnotic use (necessity and concern) were assessed. Three patterns of hypnotic misuse in the past 1 month were also explored. The correlates of high dependence, misuse, and unfavorable attitude and high concern toward hypnotic use were examined using logistic regression analyses.

RESULTS

A total of 28.8%, 7.9%, 12.2%, and 22.3% of participants reported high dependence on, misuse of, unfavorable attitude toward, and high concern toward hypnotic use, respectively. Males were more likely to report unfavorable attitude toward hypnotic use than females. Elders with significant depression were more likely to report high concern toward hypnotic use than those without significant depression. Elders with high concern toward hypnotic use were more likely to report high dependence on hypnotics than those with low concern. Elders with significant depression and taking zolpidem were more likely to misuse hypnotics than those without significant depression and taking estazolam or flunitrazepam, respectively.

DISCUSSION

Clinicians should monitor the possibility of dependence on and misuse of hypnotics among elderly psychiatric patients who had the correlates identified in this study.

Use of benzodiazepines and association with falls in older people admitted to hospital: a prospective cohort study

BACKGROUND

Hypnosedatives are commonly prescribed for anxiety and sleep problems. Changes in pharmacokinetics and pharmacodynamics of benzodiazepines (BZDs) during ageing may increase their potential to cause adverse outcomes.

OBJECTIVE

This study aimed to investigate the use of BZDs in acute care settings and explore their association with falls.

METHODS

A prospective cohort study was undertaken of patients aged over 70 years consecutively admitted to 11 acute care hospitals in Australia. Data were collected using the interRAI Acute Care assessment tool. Falls were recorded prospectively (in hospital) and retrospectively (in the 90 days prior to admission).

RESULTS

Of 1,412 patients, 146 (10.3 %) were taking BZDs at admission and 155 (11.3 %) at discharge. Incidence rates of in-hospital fallers for users and non-users of BZDs were not statistically different [incidence rate ratio 1.03, 95 % confidence interval (CI) 0.58-1.82]. There was also no significant association between benzodiazepine use at admission and history of falls in the previous 90 days compared with non-users. However, patients on diazepam were significantly more likely to have a history of falls than all other benzodiazepine users (70.8 vs. 36.1 %; p = 0.002), particularly when compared with oxazepam users (70.8 vs. 25.0 %; p < 0.001). Adjusting for confounders, use of diazepam at admission was positively associated with a history of falls compared with all other benzodiazepine users (odds ratio 3.0; 95 % CI 1.1-8.5; p = 0.036).

CONCLUSIONS

Different BZDs may vary in their propensity to predispose to falls, with diazepam having the strongest association. The selection of particular BZDs for older patients should be carefully evaluated.

Patterns of benzodiazepine and antidepressant use among middle-aged adults. the Brazilian longitudinal study of adult health (ELSA-Brasil)

BACKGROUND

Antidepressant and benzodiazepine medicines are widely prescribed in high-income countries. Our aim was to investigate and describe clinical and demographic characteristics of their use in a large cohort from a middle-income country.

METHODS

Participants (n=15,105) from the Brazilian Health Longitudinal Study (ELSA-Brasil), a civil servant cohort from six different sites in Brazil were asked about antidepressant and benzodiazepine use. The Clinical Interview Schedule-Revised was used for psychiatric assessment. Sociodemographic and clinical data were also collected.

RESULTS

Current use of antidepressant and benzodiazepine medicines was respectively reported by 6.87% and 3.88% of participants. These numbers were higher in major depression-MDD (16.5% and 13.9%), generalized anxiety disorder-GAD (14% and 9.5%) and any mental disorder (11.7% and 7.8%). The use of antidepressant and benzodiazepine was directly associated with clinical comorbidities and psychiatry diagnosis. In addition, older age was associated with benzodiazepine use and more years of schooling, with antidepressant use. Finally, the use of these medicines was strongly associated (odds ratio=8.48, p<0.001).

LIMITATIONS

Our cohort does not include younger adults (18-34 years), although it includes older (65-75 years) participants.

DISCUSSION

Antidepressant and benzodiazepine use in Brazil is lower than in high-income countries. We found that factors such as age and education level were associated with the use of these medicines, whereas MDD and GAD were poor predictors of psychopharmacotherapy use, suggesting misuse/overuse of psychopharmacotherapy among individuals without psychiatric illness and underuse among those with psychiatric conditions in Brazil.

Do Benzodiazepines Still Deserve a Major Role in The Treatment of Psychiatric Disorders? A Critical Reappraisal

Discovered 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.

[Impact of benzodiazepine dependence on the use of health services: study of the health of seniors]

BACKGROUND

The use of benzodiazepines is common among seniors. This consumption can cause an addiction whose criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition revised (DSM-IV-TR) do not always apply to the situation of the elderly. This research seeks to examine the link between the feeling of benzodiazepine dependence and the use of health services by seniors. A secondary objective is to describe the use of benzodiazepines among seniors living in the community.

METHOD

Data derive from a survey conducted in Quebec in 2005-2006 from a representative sample of 707 Francophones aged 65 and over living in the community. The feeling of benzodiazepine dependence was measured by a composite variable incorporating two questions inspired by the DSM-IV-TR. The use of health services was measured through the cumulative impact of consultation with health care professionals during a 12- month period.

RESULTS

Older adults consumed a total of 745 benzodiazepines, including 117 (16.5%) which had a half-long life. The proportion of seniors who reported a feeling of dependence on benzodiazepines was estimated at 35.1 %. These seniors did not significantly make further use of health services for their addiction to benzodiazepines.

CONCLUSION

The results of this study suggest that the use of benzodiazepines among seniors in Quebec is far from optimal. Moreover, the perceived need in addiction is not a significant factor in inducing seniors to use health services for the management of addiction. There is, therefore, a need for research to better understand the barriers associated with the use of health services by seniors addicted to benzodiazepines.

Assessing the cumulative effects of exposure to selected benzodiazepines on the risk of fall-related injuries in the elderly

BACKGROUND

The use of benzodiazepines is associated with increased risk of fall-related injuries in the elderly. However, it is unclear if the risks vary across the products and how they depend on the pattern of use and dosage. Specifically, the possibility of cumulative effects of past benzodiazepine use has not been thoroughly investigated.

METHODS

We used the administrative database for a cohort of 23,765 new users of benzodiazepines, aged 65 years and older, in Quebec, Canada, between 1990 and 1994. The associations between the use of seven benzodiazepines and the risk of fall-related injuries were assessed using several statistical models, including a novel weighted cumulative exposure model. That model assigns to each dose taken in the past a weight that represents the importance of that dose in explaining the current risk of fall.

RESULTS

For flurazepam, the best-fitting model indicated a cumulative effect of doses taken in the last two weeks. Uninterrupted use of flurazepam in the past months was associated with a highly significant increase in the risk of fall-related injuries (HR = 2.83, 95% CI: 1.45-4.34). The cumulative effect of a 30-day exposure to alprazolam was 1.27 (1.13-1.42). For temazepam, the results suggested a potential withdrawal effect.

CONCLUSIONS

Mechanisms affecting the risk of falls differ across benzodiazepines, and may include cumulative effects of use in the previous few weeks. Thus, benzodiazepine-specific analyses that account for individual patterns of use should be preferred over simpler analyses that group different benzodiazepines together and limit exposure to current use or current dose.

Benzodiazepines revisited--will we ever learn?

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.

Psychotropic drug use in relation to mental disorders and institutionalization among 95-year-olds: a population-based study

BACKGROUND

The prevalence of psychotropic drug use is high among the elderly, but research on how psychotropic drugs are used among individuals aged 90 years and older is limited. An increased knowledge on this topic may contribute to improved prescribing patterns in this vulnerable population. The aim of this study was to assess the use of psychotropic drugs in relation to mental disorders and institutionalization among 95-year-olds and to identify use of potentially inappropriate psychotropic drugs.

METHODS

All 95-year-olds born in 1901-1903 living in nursing homes or community settings in Gothenburg, Sweden were invited to participate. The response rate was 65% and 338 95-year-olds were examined (263 women, 75 men). Psychotropic drug use in relation to mental disorders and institutionalization was assessed. Information on drug use was collected primarily from multi-dose drug dispensing lists. Participants were examined by trained psychiatrists using the Comprehensive Psychopathological Rating Scale and a battery of cognitive tests. Dementia, depression, anxiety and psychotic disorders were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R).

RESULTS

Sixty percent of the 95-year-old participants used psychotropic drugs; hypnotics were most common (44%). Potentially inappropriate psychotropics were observed in one third (33%). Antidepressants were used by 7% of the participants without dementia who fulfilled criteria for a depressive disorder, while 56% used hypnotics and 30% used anxiolytics.

CONCLUSIONS

The high prevalence of psychotropic drug use and the nonspecific nature of these treatments among 95-year-olds indicate a need for improvement in prescribing patterns.

Sedative medication use: prevalence, risk factors, and associations with body mass index using population-level data

STUDY OBJECTIVES

To estimate the prevalence of and identify sociodemographic risk factors for sedative medication use in the general Canadian population, and to examine the association between sedative medication use and body mass index (BMI).

DESIGN

Cross-sectional study

SETTING

Canadian population

PARTICIPANTS

Participants from the 1994-2003 Canadian national health surveys, the National Population Health Survey (NPHS) and the Canadian Community Health Survey (CCHS). For the 2003 CCHS, n = 134,072, ages 12-80+ years.

INTERVENTIONS

Not applicable

MEASUREMENTS AND RESULTS

The overall prevalence of sedative medication use in Canada in 2003 was 5.5%, having more than doubled since 1994. Notable rises in sedative medication use have occurred among men, non-elderly, and obese individuals. After adjusting for potential sociodemographic and health status confounders, including psychiatric comorbidities, the odds of sedative use were significantly greater among morbidly obese (BMI ≥ 35 kg/m(2)) men (OR = 1.89, 95%CI = 1.02-3.53) and underweight (BMI < 18.5 kg/m(2)) women (OR = 2.11, 95%CI = 1.26-3.53).

CONCLUSIONS

The use of sedative medications has substantially risen among the general Canadian population, and among particular population subgroups. The greater odds of sedative medication use found among morbidly obese men may reflect the presence of underlying obstructive sleep apnea, which may in turn serve to explain in part the known relationship between sedative medications and mortality. The increase in sedative medications coupled with their known adverse health associations raises potential public health concerns.

The additive effects of alcohol and benzodiazepines on driving

OBJECTIVES

To examine the relationship between the combination of alcohol and benzodiazepines and the risk of committing an unsafe driver action.

METHODS

We used data from the Fatality Analysis Reporting System (1993-2006) on drivers aged 20 or older who were tested for both alcohol and drugs. Using a case-control design, we compared drivers who had at least one unsafe driver action (UDA; e.g., weaving) recorded in relation to the crash (cases) to drivers who did not (controls).

RESULTS

Drivers who tested positive for intermediate- and long-acting benzodiazepines in combination with alcohol had significantly greater odds of a UDA compared to those under the influence of alcohol alone, up to blood alcohol concentrations (BACs) of 0.08 and 0.05 g/100 ml, respectively. The odds of a UDA with short-acting benzodiazepines combined with alcohol were no different than for alcohol alone.

CONCLUSIONS

This study demonstrates that the combination of alcohol and benzodiazepines can have detrimental effects on driving beyond those of alcohol alone. By describing these combined effects in terms of BAC equivalencies, this study also allows for the extrapolation of simple, concrete concepts that communicate risk to the average benzodiazepine user.

Elderly and drugs: risks and necessity of rational use

In recent decades, the world has undergone a demographic transformation with a rapid growth of the elderly population, resulting in an increased demand for funds to maintain their health and drug consumption. Pharmacokinetic and pharmacodynamic changes occurring in the elderly can interfere directly in the adverse effects of drugs and increase the risk of intoxication. In addition, there are external factors interfering with the pharmacotherapy of the elderly, such as inappropriate use and the lack of access to information. Many therapeutic classes of drugs should be used with caution or avoided in the elderly population, such as anti-inflammatory and some anti-hypertensive drugs, diuretics and digitalis. If not managed carefully, these medicines can affect the safety and quality of life in the elderly. Thus, the aim of this review was to identify drugs that should be used with caution in elderly patients in order to avoid intoxication and/or adverse drug events.

Discontinuing Benzodiazepine Therapy: An Interdisciplinary Approach at a Geriatric Day Hospital

Background:

Despite the known adverse effects of benzodiazepines, elderly people commonly use these drugs over long periods to treat insomnia and anxiety. This qualitative study was conducted to examine the experiences of patients and care providers in a geriatric day hospital (GDH) as patients participated in a benzodiazepine tapering process, to identify the components and processes of the benzodiazepine tapering intervention, and to begin exploring how they influence patient outcomes.

Methods:

The study was conducted in a GDH in a Canadian city. Data were gathered from a discussion group and from individual semistructured interviews with 13 health care providers and 5 patients. Charts were reviewed to gather demographic data and confirm provider activities. A reflexive approach was conducted whereby each care provider reviewed and modified the role description created from information provided during his or her interview. Themes were determined through constant comparative analysis of transcripts, which included 5 meetings of the research team.

Results:

The tapering of benzodiazepines at the GDH was effected primarily by 3 people: the physician, the pharmacist and the nurse. Other members of the interdisciplinary team were not always aware of which patients were tapering their benzodiazepine therapy, but they supported patients in a variety of ways. The patients included in this analysis were willing to taper their benzodiazepines and did not consider the experience significant in any way.

Conclusion:

The health care provider roles, processes and tools described here could be replicated in other environments to assist patients who are tapering benzodiazepine therapy. Further research is needed to understand the interrelationships of all components of GDH care to determine their relative importance in facilitating behaviour change related to benzodiazepine tapering.

Usage of benzodiazepines: A review

Abstract Purpose. The use of benzodiazepines remains a source of controversy. Some prescribers believe that they are beneficial and espouse their use; others regard their risk:benefit ratio as too adverse for any but occasional use. This review considers these viewpoints based on the appropriate literature. Survey. The recent English-language literature relating to this topic was surveyed. The publications proved too heterogeneous for a formal meta-analysis, so a descriptive review is provided. Overview. Surveys of benzodiazepine use provide data mainly from the UK, Europe and North America. Prescribing patterns varied widely but long-term usage is common and sometimes the norm. Conclusions. Long-term prescription of benzodiazepines still takes place despite general warnings from the medical and other professions and drug regulatory bodies that long-term use is unjustified both from the lack of a systemic database establishing such efficacy and a large literature documenting the risks of long-term usage, such as dependence. The young and the old are particularly at risk. Continued monitoring is essential, but the regulatory authorities may need to take a more active role in curbing such undesirable practice.

Effectively detect dependence on benzodiazepines among community-dwelling seniors by asking only two questions

Consumption of benzodiazepines (BZDs) is common among seniors. When used over a long period of time, BZDs can induce dependence. The present study aimed to equip nurses with valid screening questions for detecting BZD dependence among seniors, applicable to clinical practice and based on the DSM-IV-TR version. A random sample of 707 BZD users aged 65 years and over was screened for BZD dependence using the DSM-IV-TR criteria for substance dependence. To predict a diagnosis of BZDs dependence, sensitivity and specificity were computed for each pair of items. Results showed that an affirmative answer to 'Have you try to stop taking this medication?' and 'Over the past 12 months, have you noticed any decrease in the effect of this medication?' led to a sensitivity of 97.1% and a specificity of 94.9% to detect BZD dependence. Asking these two simple questions can be easily integrated into clinical practice and have considerable potential for identifying cases of BZD dependence.

Patterns in the use of benzodiazepines in British Columbia: examining the impact of increasing research and guideline cautions against long-term use

OBJECTIVE

We examined changes in patterns of benzodiazepine use in British Columbia over a period of increasing evidence of harms associated with long-term use.

METHODS

Using linked administrative databases for the years 1996 and 2006, we performed logistic regression to examine how socio-economic and health factors affect the likelihood of benzodiazepine use and long-term use, and to test for changes in rates of use and long-term use over time.

RESULTS

In 2006, 8.4% of British Columbians used benzodiazepines, 3.5% long-term. Use was positively related with being female, lower income, older, and of poorer health status. Long-term use was positively associated with being in the lowest income quintile, of poorest health, and over the age of 65. While the rate of long-term use decreased from 1996 to 2006 for those over age 70, it increased in middle-aged populations.

CONCLUSIONS

Our results suggest, despite increased awareness of and cautions regarding risks associated with long-term use of benzodiazepines, rates of potentially inappropriate use have changed very little over a decade. Given that early use of benzodiazepines is positively associated with later long-term use, policies targeting populations younger than conventionally studied (i.e. those under age 65) may be needed to decrease rates of long-term use.

Trends of the potentially inappropriate medication consumption over 10 years in older adults in the East of France

PURPOSE

To describe the trends of potentially inappropriate medication (PIM) use in older adults from 1995 to 2004 in the East of France, by using the 1997 Beers criteria and its French update, and to assess risk factors for this PIM use.

METHODS

We carried out a repeated cross-sectional study using data collected among people aged >/=65 years, examined in the Center for Preventive Medicine. Studied variables were socio-demographic, clinical data, medication consumption and the self-health status. Joinpoint regression analysis was used to estimate the temporal changes in PIM rate.

RESULTS

30 683 participants were included. 51.2% were women. The mean age was 70.1 +/- 4.3 years [65-99]. The annual overall rate of PIM use decreased significantly during the study period. These rates range from 14.9% in 1995 to 9.0% in 2004 according the Beers criteria (-3.4% per year) and from 33.5% in 1995 to 19.3% in 2004 according to the French update criteria (-3.6% per year). The annual rate of medication users increased during the same period (+0.75% per year). The risk of PIM consumption increased with age, number of drugs and frequency of the visits to the physician (OR = 1.26 [1.18-1.35]). This risk was also higher among women (OR = 1.29 [1.18-1.40]), elderly living alone (OR = 1.09 [1.02-1.17]) and with those with low education level (OR = 1.19 [1.02-1.38]).

CONCLUSION

This study shows a decrease in PIM consumption. Despite an increase of drug use in the elderly, an improving of the quality of this consumption remains possible.

A population based study on health conditions associated with the use of benzodiazepines among older adults (The Bambuí Health and Aging Study)

The aim of this study was to assess the health conditions and use of health services among elderly users of benzodiazepines. The study was carried out in the city of Bambuí in Minas Gerais State, Brazil. Of 1,742 inhabitants aged over 60, 1,419 participated in the study. Information about benzodiazepine and the use of other medications was obtained by means of interviews and checking medication packaging. After adjustments for confounding variables, benzodiazepine remained significantly associated with poorer self reported health (prevalence ratio = 1.94 and 2.04 for reasonable and bad/very bad health, respectively), common mental disorders (1.33), myocardial infarction (1.42), number of doctor visits in the previous 12 months (1.90 and 2.24 for 2-3 and 4+ visits, respectively) and concomitant use of other medications (1.84 and 1.83 for 2-4 and 5+ medications). The results showed that the factors associated with the use of benzodiazepine were similar to those observed in the elderly in higher income countries. The concomitant use of benzodiazepines and two or more medications was highly prevalent (59.5%), characterizing a situation of risk, which deserves attention as a public health problem.

Inappropriate medication use and risk of falls--a prospective study in a large community-dwelling elderly cohort

Background

Explicit criteria for determining potentially inappropriate medication consumption in elderly were elaborated by Beers et al. These lists have been used worldwide to evaluate medical prescriptions but there is little epidemiologic evidence demonstrating negative consequences of inappropriate medication use. It has been reported that some drugs could increase the risk of falls, which are a frequent and serious problem in elderly population. We aimed to evaluate the association between the use of potentially inappropriate medications and the risk of falls.

Methods

The 3C Study is a multicentre prospective cohort study conducted in France with 4 years of follow-up. Non-institutionalized men and women aged 65 years or over (N = 6343) were randomly selected from electoral rolls. Data on socio-demographic, medical characteristics and medication use (based on self-reports and data from the national healthcare insurance) were collected. Use of inappropriate medication for elderly was defined from established criteria. Data about falls were collected at the two follow-up examinations (2 years and 4 years after baseline). The association between the exposure to inappropriate medications and the risk of falls was evaluated using multivariate models (Cox model and logistic regression).

Results

32% of subjects reported inappropriate medication use at baseline and 29% at least two of the three examinations; 22% had fallen 2 times or more during follow-up. Overall, inappropriate medication users had an increased risk of falling. This increase was mainly due to the use of long-acting benzodiazepines (adjusted odds ratio (OR) = 1.4, 95% confidence interval: [1.1–1.8], in both occasional and regular users), other inappropriate psychotropics (adjusted OR = 1.7 [1.7–2.7] in regular users), or medication with anticholinergic properties (adjusted OR = 1.6 [1.2–2.1] in regular users). Neither occasional, nor regular use of short- or intermediate-acting benzodiazepines was associated with an increased risk of falling. Further analysis in long-acting benzodiazepines users did not show any dose-effect relation between the number of prescriptions filled over a 3-year period and the risk of falling.

Conclusion

Our study showed that use of inappropriate medications was associated with an increased risk of falling in elderly persons. This increase was mainly due to long-acting benzodiazepines and other inappropriate psychotropics, and to medications with anticholinergic properties.