A Clinical Study of the Cognitive Effects of Benzodiazepines in Psychogeriatric Patients

The effect of second-generation antidepressant treatment on the attention and mental processing speed of patients with major depressive disorder: A meta-analysis study with structural equation models

Major depressive disorder (MDD) has been linked to attention and mental processing speed deficits that can be improved after pharmacological treatment. However, it is unclear whether a class of antidepressants is more effective than others to ameliorate these deficits in MDD. Additionally, the possible effects of clinical and demographic variables on improving MDD attention and processing speed deficits after antidepressant treatment are unknown. We aimed to study the possible neuropsychological effects of second-generation antidepressant classes on the attention and processing speed of MDD patients and the potential influences of clinical and demographic variables as moderators of these effects using a meta-analytic approach. Twenty-five papers were included in our study. A structural equation model meta-analysis was performed. The improvement of attention and processing speed after pharmacological treatment is clinically relevant but incomplete. Selective serotonin reuptake inhibitors (SSRIs) and dual inhibitors are the drugs causing the greatest improvement in the processing speed of MDD patients. Antidepressant class is an important variable linked to processing speed improvement after MDD treatment. However, the degree of improvement in both cognitive functions is strongly influenced by some clinical and demographic variables of depressed patients, such are age and education of the MDD patients, the duration of the antidepressant treatment, and the depression status of the patients.

THE EFFECT OF SECOND-GENERATION ANTIDEPRESSANT TREATMENT ON THE EXECUTIVE FUNCTIONS OF PATIENTS WITH MAJOR DEPRESSIVE DISORDER: A META-ANALYSIS STUDY WITH STRUCTURAL EQUATION MODELS

Major depressive disorder (MDD) has been linked to executive functions (EF) deficits that can be improved after pharmacological treatment, but it is unclear whether there is a class of antidepressants that is more effective than others to ameliorate these deficits in MDD. Additionally, the possible effects of clinical and demographic variables on the improvement of MDD EF deficits after pharmacological treatment are currently unknown. Our aim was to study the possible neuropsychological effects of second-generation antidepressant classes on the EF of MDD patients and the potential influence of clinical and demographic variables as moderators of these effects through a meta-analytic approach. Twenty-one papers were included in our study. A structural equation model meta-analysis was performed. The improvement of EF after pharmacological treatment is clinically relevant, but it is incomplete. This effect is influenced by age and years of education of the patients. Selective serotonin reuptake inhibitors (SSRIs) and dual inhibitors are the drugs causing the greatest improvement in EF of MDD patients. Antidepressant class is an important variable linked to EF improvement after MDD treatment, but the degree of improvement in these cognitive functions is strongly influenced by some clinical and demographic variables of patients with depression.

Association between prescribed central nervous system depressant drugs, comorbidity and cognition among hospitalised older patients: a cross-sectional study

OBJECTIVES

Central nervous system depressants (CNSDs) such as opioids, benzodiazepine and Z-hypnotics are commonly used. However, CNSDs may influence cognitive function, especially in older hospitalised patients with comorbidities. The aim was to examine the association between CNSD use and cognitive function in older patients. We assessed global and domain specific cognitive function, among hospitalised older patients, including covariates for comorbidity, anxiety and depression.

DESIGN

Cross-sectional hospital-based study.

SETTINGS

Data was collected consecutively from inpatients at somatic wards of a general university hospital.

PARTICIPANTS

Older patients between 65 and 90 years with/without CNSD use for ≥4 weeks.

OUTCOME MEASURES

The main outcome was cognitive function assessed by Cognistat. Secondary outcomes were routine clinical tests in the wards (mini-mental state examination (MMSE), trail making test (TMT) A and B, and clock drawing tests). Analyses were bivariate and multiple linear regression, adjusted for age, gender, and education. Covariates were comorbidity, depression and anxiety scores.

RESULTS

The main result indicated that CNSD users (n=100) had (β=-3.4, 95% CI 6.27 to -0.58, p=0.017) lower Cognistat score than non-users (n=146), adjusted for age, gender, education, anxiety and depression, but not significant when including covariate for comorbidity (β= -2.50 - 5.45; -0.46, p=0.097). Comorbidity was associated with cognitive function (β=-0.77, 95% CI -1.22 to -0.14, p=0.014). Cognistat subdimensions associated with CNSD use were language (p=0.017) and calculation (p=0.003). In clock drawing test, users had lower scores than non-users (β=-0.80, 95% CI 1.24 to -0.36, p=0.004), but no significant difference was found with MMSE and TMT A or B. Z-hypnotics were associated with reduced cognitive function.

CONCLUSION

Among older hospitalised patients, global cognition and specific cognitive functions were associated with long-term use of CNSD medication as well as with somatic comorbidity.

TRIAL REGISTRATION NUMBER

NCT03162081, 22 May 2017.

On the conundrum of cognitive impairment due to depressive disorder in older patients

Objectives

Depressive symptoms and cognitive impairment often concur in older persons. Differentiating the cause of cognitive impairment in older persons with Depressive Disorder (DD) from other diseases such as Alzheimer’s Disease (AD) is challenging. The goal of this study was to characterize cognitive impairment in older persons with DD.

Design

Cross-sectional retrospective observational clinical cohort study using patient records from 2014 to 2018.

Setting

Gerontopsychiatric services of Ulm University at Bezirkskrankenhaus Günzburg serving as primary psychiatric care institution and tertiary referral center for psychiatric care for older persons.

Partcipants

DD was diagnosed according to ICD-10 criteria. When indicated by the medical history or neuropsychological assessment further diagnostic procedures were initiated. Cerebrospinal fluid (CSF) tap was routinely the first additional procedure. If patients did not consent to CSF tap or contraindications were present, ¹⁸F-fluordesoxyglucose-PET (FDG-PET) or Amyloid-PET (Am-PET) were performed.

Materials and methods

Extensive neuropsychological test battery to assess cognitive profile.

Results

457 subjects were diagnosed with DD (DD-all; age 50–94; 159 males, 298 females). Biomarkers were assessed in 176 persons; in 90 of these subjects AD-biomarkers were negative (DD-BM-; age 54–89; 40 males, 50 females), and in 86 subjects at least one biomarker was compatible with AD (DD-BM+; age 60–90; 31 males, 55 females). Cognitive performance was below healthy controls (HC; n = 56; age 50–80; 30 males, 26 females) for all groups of patients with DD. With case-control matching of HC and DD-BM- we find that executive functions are impaired in about one out of three and delayed recall in about two out of three patients with DD.

Conclusion

Cognitive impairment is frequent in older persons with DD. Cognitive profile in older patients with DD without and with biomarkers of AD is not distinguishable. Therefore, cognitive impairment due to DD should be diagnosed after exclusion of comorbid AD.

Is Long-Term Benzodiazepine Use a Risk Factor for Cognitive Decline? Results of a Systematic Review

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.

The Effects of Benzodiazepine Use and Abuse on Cognition in the Elders: A Systematic Review and Meta-Analysis of Comparative Studies

OBJECTIVE

Benzodiazepines (BZD) are one of the most frequently prescribed drugs worldwide. However, the cognitive effects of benzodiazepines in the elderly are highly debated. This systematic review and meta-analysis aims to explore the following two questions in the elderly population: (i) Do BZD lead to any impairments in cognitive functions in elderly users? and (ii) Which specific cognitive domains are most affected by BZD use and abuse?

METHODS

First, we performed a literature search following the PRISMA guidelines. Electronic databases, including PubMed, PsycINFO, EMBASE, Cochrane Library, and Web of Science were searched until May 14^th, 2020. After selecting the relevant articles, we integrated the results of the selected studies with a standardized cognitive classification method. Next, we performed meta-analyses with the random-effects model on the cognitive results. Finally, we specifically examined the cognitive impairments of BZD in the abuse subgroup.

RESULTS

Of the included studies, eight of the thirteen had meta-analyzable data. Compared to the controls, elderly BZD users had significantly lower digital symbol test scores (n=253; SMD: -0.61, 95% CI: -0.91 to 0.31, I² = 0%, p < 0.0001). There was no significant difference in Mini-Mental State Examination, Auditory Verbal Learning Test, and Stroop Color and Word Test scores between BZD users and controls. According to the subgroup analyses, BZD abusers performed significantly worse than controls in Mini-Mental State Examination (n=7726; SMD: -0.23, 95% CI: -0.44 to -0.03, I² = 86%, p = 0.02), while there was no significant difference between the regular BZD users and the controls (n=1536; SMD: -0.05, 95% CI: -0.59 to 0.48, I² = 92%, p =0.85).

CONCLUSION

In the elderly population, the processing speed (digital symbol test scores) was significantly impaired in BZD users; global cognition (Mini-Mental State Examination scores) was significantly impaired in BZD abusers but not in BZD regular users. This study provides insight into the factors that interact with BZD cognitive effects, such as aging, testing tools, and abuse. Clinicians should be cautious when prescribing BZD for the elderly.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, identifier CRD42019124711.

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.

Drug interactions with dementia-related pathophysiological pathways worsen or prevent dementia

Many risk factors are known to induce or precipitate dementia. Drugs acting via different mechanisms can modulate cognitive performance and exert either beneficial or deleterious effects on cognition through functional or neuropathological mechanisms. This review discusses the association between several classes of drugs and cognitive impairment and dementia risk. These drugs can be divided into drugs targeting CNS disorders (e.g., anticholinergic drugs, antiepileptics, antipsychotics, benzodiazepines, and opioids) and drugs targeting non‐CNS disorders (e.g., antidiabetics, antihypertensives, proton pump inhibitors, and statins). Furthermore, we sought to highlight the pharmacological mechanisms underlying their possible detrimental or beneficial effects on cognition. Anticholinergic and antiepileptic drugs were excluded from this review because their effects on cognition are well known. Studies investigating benzodiazepines have revealed an increased risk of dementia. Conclusions on dementia risk or cognitive impairment regarding opioids and antipsychotic drugs are difficult to draw. These different classes appear to impair cognition not by a single clear mechanism of action specific to each class but by several relatively interdependent and interconnected mechanisms (e.g., impaired neurotransmission, neuroinflammation, neuronal death, oxidative stress, or interactions with dementia‐related pathways). The dementia risk initially associated with the use of proton pump inhibitors might have been overestimated. In contrast, statins, antihypertensive medications, and antidiabetics could potentially decrease the risk of dementia and cognitive impairment by acting in ways opposite to the mechanisms cited above.

Linked Articles

This article is part of a themed section on Therapeutics for Dementia and Alzheimer's Disease: New Directions for Precision Medicine. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v176.18/issuetoc

Clinical impact of potentially inappropriate medications during hospitalization of acutely ill older patients with multimorbidity

OBJECTIVE

To identify potentially inappropriate medications (PIMs), to compare drug changes between geriatric and other medical wards, and to investigate the clinical impact of PIMs in acutely hospitalized older adults.

SETTING AND SUBJECTS

Retrospective study of 232 home-dwelling, multimorbid older adults (aged ≥75 years) acutely admitted to Vestfold Hospital Trust, Norway.

MAIN OUTCOME MEASURES

PIMs were identified by Norwegian general practice (NORGEP) criteria and Beers' 2012 criteria. Clinical correlates were laboratory measures, functional and mental status, physical frailty, and length of stay.

RESULTS

Mean (SD) age was 86 (5.7) years, and length of stay was 6.5 (4.8) days. During the stay, the mean number of drugs used regularly changed from 7.8 (3.6) to 7.9 (3.6) (p = 0.22), and drugs used pro re nata (prn) changed from 1.4 (1.6) to 2.0 (1.7) (p < 0.001). The prevalence of any PIM changed from 39.2% to 37.9% (p = 0.076), while anticholinergics and benzodiazepines were reduced significantly (p ≤ 0.02). The geriatric ward reduced drug dosages (p < 0.001) and discontinued PIMs (p < 0.001) significantly more often than other medical wards. No relations between number of PIMS and clinical outcomes were identified, but the concomitant use of ≥3 psychotropic/opioid drugs was associated with reduced hand-grip strength (p ≤ 0.012).

CONCLUSION

Hospitalization did not change polypharmacy or PIMs. Drug treatment was more appropriate on the geriatric than other medical wards. No clinical impact of PIMs was observed, but prescribers should be vigilant about concomitant prescription of ≥3 psychotropics/opioids.

KEY POINTS

Acute hospitalization of older patients with multimorbidity did not increase polypharmacy or potentially inappropriate medications. Prescription of anticholinergics and benzodiazepines was significantly reduced. The geriatric ward reduced drug dosages and discontinued potentially inappropriate medications more frequently than the other medical wards.