Oxidative and nonoxidative benzodiazepines and the risk of femur fracture. The Systematic Assessment of Geriatric Drug Use Via Epidemiology Study Group

Benzodiazepines and Z-Drugs: An Updated Review of Major Adverse Outcomes Reported on in Epidemiologic Research

Various adverse events resulting from, or associated with, benzodiazepine and/or Z-drug use have been extensively reported on and discussed in great detail within the biomedical literature. It is widely accepted that motor vehicle accidents and falls leading to fractures in older adults are major adverse events that have been shown to occur more frequently in users of sedative-hypnotic medication, especially of the benzodiazepine and related Z-drug variety. However, the last few years have seen increasing reports in the literature raising the issue of benzodiazepine and Z-drug exposure in the development of other serious medical issues including dementia, infections, respiratory disease exacerbation, pancreatitis, and cancer. This article provides an overview and interpretation on the current state of evidence regarding each of these associations and proposes what gaps in the evidence for drug-exposure–harm associations need to be addressed in the future for the purpose of evaluating causality of harm as it relates to these drugs.

Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study

OBJECTIVE

To study the association between benzodiazepine prescribing patterns including dose, type, and dosing schedule and the risk of death from drug overdose among US veterans receiving opioid analgesics.

DESIGN

Case-cohort study.

SETTING

Veterans Health Administration (VHA), 2004-09.

PARTICIPANTS

US veterans, primarily male, who received opioid analgesics in 2004-09. All veterans who died from a drug overdose (n=2400) while receiving opioid analgesics and a random sample of veterans (n=420,386) who received VHA medical services and opioid analgesics.

MAIN OUTCOME MEASURE

Death from drug overdose, defined as any intentional, unintentional, or indeterminate death from poisoning caused by any drug, determined by information on cause of death from the National Death Index.

RESULTS

During the study period 27% (n=112,069) of veterans who received opioid analgesics also received benzodiazepines. About half of the deaths from drug overdose (n=1185) occurred when veterans were concurrently prescribed benzodiazepines and opioids. Risk of death from drug overdose increased with history of benzodiazepine prescription: adjusted hazard ratios were 2.33 (95% confidence interval 2.05 to 2.64) for former prescriptions versus no prescription and 3.86 (3.49 to 4.26) for current prescriptions versus no prescription. Risk of death from drug overdose increased as daily benzodiazepine dose increased. Compared with clonazepam, temazepam was associated with a decreased risk of death from drug overdose (0.63, 0.48 to 0.82). Benzodiazepine dosing schedule was not associated with risk of death from drug overdose.

CONCLUSIONS

Among veterans receiving opioid analgesics, receipt of benzodiazepines was associated with an increased risk of death from drug overdose in a dose-response fashion.

Effects of drug pharmacokinetic/pharmacodynamic properties, characteristics of medication use, and relevant pharmacological interventions on fall risk in elderly patients

BACKGROUND

Falls among the elderly are an issue internationally and a public health problem that brings substantial economic and quality-of-life burdens to individuals and society. Falls prevention is an important measure of nursing quality and patient safety. Numerous studies have evaluated the association of medication use with fall risk in elderly patients. However, an up-to-date review has not been available to summarize the multifaceted pharmaceutical concerns in the prevention of medication-related falls.

MATERIALS AND METHODS

Relevant literature was identified by performing searches in PubMed, Web of Science, and the Cochrane Library, covering the period until February 2014. We included studies that described an association between medications and falls, and effects of drug pharmacokinetic/pharmacodynamic properties, characteristics of medication use, and pharmacological interventions on fall risk in elderly patients. The full text of each included article was critically reviewed, and data interpretation was performed.

RESULTS

Fall-risk-increasing drugs (FRIDs) include central nervous system-acting agents, cough preparations, nonsteroidal anti-inflammatory drugs, anti-Alzheimer's agents, antiplatelet agents, calcium antagonists, diuretics, α-blockers, digoxin, hypoglycemic drugs, neurotoxic chemotherapeutic agents, nasal preparations, and antiglaucoma ophthalmic preparations. The degree of medication-related fall risk was dependent on one or some of the following factors: drug pharmacokinetic/pharmacodynamic properties (eg, elimination half-life, metabolic pathway, genetic polymorphism, risk rating of medications despite belonging to the same therapeutic class) and/or characteristics of medication use (eg, number of medications and drug-drug interactions, dose strength, duration of medication use and time since stopping, medication change, prescribing appropriateness, and medication adherence). Pharmacological interventions, including withdrawal of FRIDs, pharmacist-conducted clinical medication review, and computerized drug alerts, were effective in reducing fall risk.

CONCLUSION

Based on the literature review, clear practical recommendations for clinicians to prevent falls in the elderly included making a list of FRIDs, establishing a computerized alert system for when to e-prescribe FRIDs, seeking an alternative drug with lower fall risk, withdrawing FRIDs if clinically indicated, taking pertinent cautions when the use of FRIDs cannot be avoidable, paying attention to prescribing appropriateness, simplifying the medication regimen, strengthening pharmacist-conducted clinical medication review, ensuring the label of each FRID dispensed contains a corresponding warning sign, being careful when medication change occurs, enhancing medication adherence, and mandating for periodic reassessment of potential risk associated with the patient's medication regimen. Further studies should be conducted in this area, such as investigating whether medication reconciliation and improving medication adherence could decrease the rate of falls.

Association between use of benzodiazepines and risk of fractures: a meta-analysis

Benzodiazepines (BZDs) are some of the most commonly prescribed drugs in the world. It has been shown that BZD use could be associated with increased fracture risk. However, studies on the use of BZDs and fracture risk have yielded inconsistent results. Results from the present meta-analysis show that BZD use is associated with a moderate and clinically significant increase in the risk of fractures.

INTRODUCTION

The relationship between the use of BZDs and fracture risk has been neither well identified nor summarized. This meta-analysis reports on the use of BZDs, especially short-acting BZDs, and their correlation with a moderate and clinically significant increase in fracture risk. This analysis will provide evidence for clinicians to consider fracture risk when prescribing BZDs among the elderly population. This study was conducted to determine whether people who take BZDs are at an increased fracture risk.

METHODS

A systematic search of studies published through January 2013 was conducted using MEDLINE, EMBASE, OVID, and ScienceDirect. Case-control and cohort studies that assessed the relationship between BZD use and the risk of fractures were identified. Literature searches, study selections, methodological assessments, and data mining were independently conducted by two reviewers. Disagreements were resolved by consensus. STATA 12.0 software was used for the meta-analysis. Random effects models were used for pooled analysis due to heterogeneity among the studies.

RESULTS

There were 25 studies, including 19 case-control studies and 6 cohort studies, that met the inclusion criteria. Overall, the results of the meta-analysis indicated that BZD use was associated with a significantly increased fracture risk (relative risk (RR) = 1.25; 95% confidence intervals (CI), 1.17-1.34; p < 0.001). Increased fracture risk associated with BZD use was observed in participants aged ≥65 years old (RR = 1.26; 95% CI, 1.15-1.38; p < 0.001). When only hip fractures were included as the outcome measure, the RR increased to 1.35. However, subgroup meta-analyses showed that there was no significant association between BZD use and fracture risk in Eastern countries (RR = 1.27; 95% CI, 0.76-2.14; p = 0.362) as well as between long-acting BZD use and risk of fractures (RR = 1.21; 95% CI, 0.95-1.54; p = 0.12). After accounting for publication bias, we observed that the overall association between BZD use and fracture risk to be slightly weaker (RR = 1.21; 95% CI, 1.13-1.30) but still significant.

CONCLUSION

The results of this meta-analysis demonstrate that the use of BZD, especially short-acting BZD, is associated with a moderate and clinically significant increase in fracture risk. However, large prospective studies that minimize selection bias are necessary to determine a more accurate fracture risk associated with BZD use.

Potential impact of benzodiazepine use on the rate of hip fractures in five large European countries and the United States

Benzodiazepine use increases the risk of falls and has been associated with an increased risk of hip fractures. Our aim was to estimate the possible population impact of the use of benzodiazepines on the rate of hip fracture in France, Germany, Italy, Spain, the United Kingdom, and the United States. We conducted a literature review to estimate the pooled relative risk (RR) for hip fractures and use of benzodiazepines. Prevalence rates of benzodiazepine use in 2009 were calculated for each country using the IMS MIDAS database and three public databases in Denmark, the Netherlands, and Norway. Both the RR and prevalence rates were used for calculation of population attributable risks (PARs) of hip fractures associated with benzodiazepine use. The literature review showed an increased risk of hip fractures in benzodiazepine users (RR = 1.4, 95 % CI 1.2-1.6). Rate of benzodiazepine use showed considerable differences between countries, ranging from 4.7 % to 22.3 % of population ever in a 1-year period. These are reflected in results for the PARs; estimated attributions of benzodiazepines to the rate of hip fractures were 1.8 %, 95 % CI 1.1-2.6 (Germany); 2.0 %, 95 % CI 1.2-2.8 (United Kingdom); 5.2 %, 95 % CI 3.2-7.3 (Italy); 7.4 %, 95 % CI 4.5-10.0 (France); 8.0 %, 95 % CI 4.9-11.0 (United States); and 8.2 %, 95 % CI 5.1-12.0 (Spain). PAR estimates suggest that the potential attribution of benzodiazepine use on the population rate of hip fractures in the five specified European countries and the United States varies between 1.8 % and 8.2 %. During the next phase of the IMI-PROTECT study, a comparison with individual patient data will show whether this approach is valid.

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.

The Role of Medications in Predicting Activity Restriction Due to a Fear of Falling

Objectives: To examine the role of medication use and other factors in predicting activity restriction due to a fear of falling (AR/FF). Methods: Older adults were assessed twice with the interRAI Community Health Assessment and the Berg Balance Scale (BBS). The main outcome was limiting going outdoors due to an AR/FF. Medications were recorded by trained assessors. Results: Participants ( n = 441) had a mean age of 80.3 ( SD = 7.1) years, most were aged 65+ (96.8%) and 29.3% reported activity restriction. Taking nervous system active or cardiovascular medications was associated with AR/FF. In a multivariate model, the main predictors were having 3+ comorbid health conditions, lower (i.e., worse) scores on the BBS, having difficulty with climbing stairs, and having a visual impairment. Discussion: Modifiable risk factors, related to functional impairments, such as difficulties with balance and vision, appear to be more important predictors than medications.

Alternatives for Potentially Inappropriate Medications in the Elderly Population: Treatment Algorithms for Use in the Fleetwood Phase III Study

OBJECTIVE

To provide estimates of the prevalence of potentially inappropriate medications used in eligible nursing facilities, to describe the development of evidence-based treatment algorithms for recommending safer alternative treatments to potentially inappropriate medications, and to provide the actual treatment algorithms developed for the Fleetwood Phase III study.

DESIGN

Literature review, cross-sectional design.

SETTING

Thirty North Carolina nursing facilities eligible for Fleetwood Phase III.

PATIENTS, PARTICIPANTS

Algorithms developed for use by all pharmacists in the long-term care pharmacy serving the intervention facilities site for the Fleetwood Phase III study.

INTERVENTIONS

Pharmacists are prospectively intervening directly with the prescriber to recommend a safer alternative to inappropriate medications using the standardized treatment algorithms developed for the study.

MAIN OUTCOME MEASURE(S)

Prevalence of potentially inappropriate medications used among residents and the development of 14 treatment algorithms suggesting appropriate alternatives to inappropriate medications.

RESULTS

The percentage of potentially inappropriate medications used ranged from 0% to 13.2% at baseline in March 2002. We also found that evidence-based treatment algorithms were well received by consultant pharmacists at the intervention sites of the Fleetwood Phase III study.

CONCLUSION

We have provided prevalence rates of potentially inappropriate medication use in nursing homes and developed treatment algorithms for pharmacists to use when making clinical recommendations regarding safer alternatives to potentially inappropriate medications in the elderly population. We are in the process of evaluating the effect of pharmacists' prospective interventions by using these standardized evidence-based treatment algorithms to reduce the prevalence of inappropriate medication use in intervention facilities.

Medication as a risk factor for falls: critical systematic review

BACKGROUND

Falls in older people are associated with poor prognosis. Medication use is a potential cause of falls. Our aim was to systemically review all original articles examining medication use as a risk factor for falls or fall-related fractures in people aged >/=60 years.

METHODS

We searched English articles in Medline (1996-2004) indexed under "falls" or "accidental falls" and "pharmaceutical preparations" or specific groups of drugs. We excluded studies not meeting the age criterion, not controlled with nonusers of target medicines or nonfallers, or with no clear definition of target medication.

RESULTS

Twenty-eight observational studies and one randomized controlled trial met the inclusion criteria. The number of participants ranged from 70 to 132,873. The outcome measure was a fall in 22 studies and a fracture in 7 studies. The main group of drugs associated with an increased risk of falling was psychotropics: benzodiazepines, antidepressants, and antipsychotics. Antiepileptics and drugs that lower blood pressure were weakly associated with falls.

CONCLUSIONS

Central nervous system drugs, especially psychotropics, seem to be associated with an increased risk of falls. The quality of observational studies needs to be improved, for many appear to lack even a clear definition of a fall, target medicines, or prospective follow-up. Many drugs commonly used by older persons are not systematically studied as risk factors for falls.

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

BACKGROUND

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

PURPOSE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA SYNTHESIS

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

LIMITATIONS

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

CONCLUSION

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

Measuring change in activities of daily living in nursing home residents with moderate to severe cognitive impairment

Background

The objective of this study was to assess the responsiveness of the Minimum Data Set Activities of Daily Living (MDS-ADL) Scale to change over time by examining the change in physical function in adults with moderate to severe dementia with no comorbid illness who had been resident in a nursing home for over 90 days.

Methods

Longitudinal data were collected on nursing home residents with moderate (n = 7001) or severe (n = 4616) dementia in one US state from the US national Minimum Data Set (MDS). Severity of dementia was determined by the MDS Cognitive Performance Scale (CPS). Physical function was assessed by summing the seven items (bed mobility, transfer, locomotion, dressing, eating, toilet use, personal hygiene) on the MDS activities of daily living (ADL) Long Form scale. Mean change over time of MDS-ADL scores were estimated at three and six months for residents with moderate (CPS score of 3) and severe (CPS score of 4 or 5) dementia.

Results

Physical function in residents with moderate cognitive impairment deteriorated over six months by an average of 1.78 points on the MDS-ADL Long Form scale, while those with severe cognitive impairment declined by an average of 1.70 points. Approximately one quarter of residents in both groups showed some improvement in physical function over the six month period. Residents with moderate cognitive impairment experienced the greatest deterioration in early-loss and mid-loss ADL items (personal hygiene, dressing, toilet use) and residents with severe cognitive impairment showed the greatest deterioration in activities related to eating, a late loss ADL.

Conclusion

The MDS-ADL Long Form scale detected clinically meaningful change in physical function in a large cohort of long-stay nursing home residents with moderate to severe dementia, supporting its use as a research tool in future studies.

Neugebrauch von Benzodiazepinen und das Risiko einer proximalen Femurfraktur

Benzodiazepines appear to increase the incidence of hip fractures. Their role as a time-dependent risk factor remains unclear. We therefore conducted a case-crossover study to determine whether the new use of benzodiazepines is associated with a rise in hip fractures. We analysed 49 months of the statutory health insurance Gmünder Ersatzkasse (GEK) and enrolled all first hip fractures. The index date was the day of hospital admission. Exposure to new use of benzodiazepines was compared within the five periods preceding the index date. Out of 1630 subjects, 223 (13.7%) had at least one prescription of benzodiazepines in the preceding 150 days before the index date, 74 (4.5%) of them as a first prescription. The average age of the population was 79.8 years (SD: 7.7). Odds ratio (OR) of hip fracture was highest during the initial 5 days of new use (OR: 3.43; 95% CI 1.15-10.20) and then declined to a non-significant OR of 1.59 (95% CI 0.96-2.63) after 30 days. In conclusion, the start of a new benzodiazepine is associated with an increased risk of hip fractures. However, the population attributable risk (PAR) and, therefore, the percentage of preventable events is small (PAR: 0.55%; 95% CI 0.05-1.06%).

Use of Benzodiazepines and Benzodiazepine-Related Drugs among 223 Patients with an Acute Hip Fracture in Finland

BACKGROUND AND OBJECTIVE

CNS drugs are a risk factor for falls and fractures among older people. Our aim was to describe the use of benzodiazepines and benzodiazepine-related drugs among patients admitted to two Finnish hospitals as a result of an acute hip fracture, and to analyse the concordance of benzodiazepine findings from different data sources.

PATIENTS AND METHODS

We studied the use of benzodiazepines and benzodiazepine-related drugs by (i) asking the patient or his/her relatives about his/her use of hypnotics; (ii) checking the patient's medical records; and (iii) analysing for the presence of benzodiazepines in serum and urine. Blood and urine samples were taken at admission. Detection of benzodiazepines in serum and urine was achieved by the fluorescence polarisation method. Concordance in benzodiazepine findings between medical records and laboratory results was estimated by calculating the degree of agreement (kappa) and described graphically using a Venn diagram.

RESULTS

A total of 223 patients were enrolled in the study. Of these, 71% were women. The mean age of women was 80.5 years (SD: 10) and of men, 73 years (SD: 12) [p < 0.0001]. Thirty percent of the patients reported that they used hypnotics. Benzodiazepine in serum or urine was detected in 83 (37%) patients. Over half of the patients coming from residential homes (53%) and institutions (54%) were benzodiazepine-positive. For home dwellers the proportion of patients that were benzodiazepine-positive was 29%. In 48% (40/83) of the benzodiazepine-positive patients, the type of benzodiazepine could not be identified because of a lack of drug records regarding benzodiazepines. A total of 113 (51%) patients used benzodiazepines or benzodiazepine-related drugs when both laboratory results and medical drug records were taken into account. Thirty-nine percent of these patients were home dwellers, 69% came from residential care and 76% from institutional care. The concordance between medical records and laboratory results expressed as overlap area was 32% in men and 59% in women, 38% in community-dwelling patients, 63% in residential home patients, and 68% in patients from institutions.

CONCLUSION

Half of patients with an acute hip fracture used benzodiazepines or benzodiazepine-related drugs. The highest prevalences were found in institutional and residential care where it should be well known that the use of CNS drugs increases the risk of hip fracture. Concordance of benzodiazepine findings was moderate in all patients and poorest among men. Concordance was poorer among home dwellers than among those living in residential homes and institutions. Analysing benzodiazepine in serum seems to be the most reliable method for ascertaining benzodiazepine exposure. This laboratory test could be performed routinely when the elderly patient is admitted to hospital because of a fall or, at least, in case of hip fracture. Then, if needed, the patient should be informed about the risks of benzodiazepine use, and further falls and fractures could be prevented.

Patterns and correlates of benzodiazepine use in the French general population

OBJECTIVE

To investigate the prevalence of current use of benzodiazepines (BZDs) and related drugs in the French general population and factors associated with this use.

METHODS

National cross-sectional telephone survey conducted between 25 April 2001 and 8 May 2001 in a representative sample of non-institutionalized adults of BZD use and duration, prescriber specialty, socio-demographic data and mood and anxiety disorders, using a structured diagnostic interview.

RESULTS

The prevalence of current use of BZD was 7.5%. It was higher among women (9.7%) than men (5.2%). It increased with age and was higher in the jobless (10.9). Duration of BZD use was more than 6 months in 75.9% of users and increased with age. Of the 711 (17.7%) subjects with at least one mood or anxiety disorder, 122 (17%) used BZD compared with 180 (5.5%) of the 3296 subjects without mood or anxiety disorders. In multivariate analysis, factors associated with BZD use were age [odds ratio (OR): 3.6; 95% confidence interval (CI) 2.0-5.6], 6.5 (4.1-10.3) and 10.9 (6.9-17.1), respectively, for ages 35-44 years, 45-59 years and over 60 years compared with below 34 years, female gender (OR: 1.7; 95% CI 1.3-2.1), anxiety only (OR: 2.2; 95% CI 1.5-3.2), mood disorder only (OR: 4.4; 95% CI 2.7-7.1) or both mood and anxiety disorders (OR: 8.8; 95% CI 5.9-12.6).

CONCLUSION

Despite precautions, warnings and attempts to limit use, there remains a high proportion of long-term BZD users in the general French population, especially in the elderly. Our findings add to the weight of opinion that messages concerning proper use of BZDs certainly need to be clarified and amplified.

Residual effects of hypnotics: epidemiology and clinical implications

The risk of "hangover" effects, e.g. residual daytime sleepiness and impairment of psychomotor and cognitive functioning the day after bedtime administration, is one of the main problems associated with the use of hypnotics. However, the severity and duration of these effects varies considerably between hypnotics and is strongly dependent on the dose administered. This article reviews epidemiological evidence on the effect of hypnotics on patients' risk for accidents such as traffic accidents, falls and hip fractures (i.e. end-points for residual effects). Information on the duration and severity of residual effects of 11 hypnotics (flunitrazepam, flurazepam, loprazolam, lormetazepam, midazolam, nitrazepam, temazepam, triazolam, zaleplon, zolpidem and zopiclone) was derived from expert ratings, a meta-analysis and actual driving studies. Epidemiological studies show that the risks of an accident increase with increasing half-life of the hypnotic, but that the use of hypnotics with a short half-life, such as triazolam, zopiclone and zolpidem, can also be associated with increased risks. A summary of results from experimental studies should enable prescribing clinicians to compare residual effects of the various hypnotics at different doses and select the one considered most favourable in this respect for the individual patient. This information should also enable them to inform patients more adequately about the likelihood and duration of residual effects of a specific hypnotic dose.

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

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

High daily doses of benzodiazepines among Quebec seniors: prevalence and correlates

BACKGROUND

Use of high daily doses of benzodiazepines is generally contraindicated for seniors. While both patient and physician factors may influence the use of high daily doses, previous research on the effect of patient factors has been extremely limited. The objectives of this study were to determine the one year prevalence of use of high daily doses of benzodiazepines, and examine physician and patient correlates of such use among Quebec community-dwelling seniors.

METHODS

Patient information for 1423 community-dwelling Quebec seniors who participated in the Canadian Study of Health and Aging was linked to provincial health insurance administrative data bases containing detailed information on prescriptions received and prescribers.

RESULTS

The standardized one year period prevalence of use of high daily doses of benzodiazepines was 7.9%. Use of high daily doses was more frequent among younger seniors and those who had reported anxiety during the previous year. Patients without cognitive impairment were more likely to receive high dose prescriptions from general practitioners, while those with cognitive impairment were more likely to receive high dose prescriptions from specialists.

CONCLUSION

High dose prescribing appears to be related to both patient and physician factors.