Problems and pitfalls in the use of benzodiazepines in the elderly

Computed Tomography Angiography (CTA) in Selected Scenarios with Risk of Possible False-Positive or False-Negative Conclusions in Diagnosing Brain Death

It is widely accepted that brain death (BD) is a diagnosis based on clinical examination. However, false-positive and false-negative evaluation results may be serious limitations. Ancillary tests are used when there is uncertainty about the reliability of the neurologic examination. Computed tomography angiography (CTA) is an ancillary test that tends to have the lowest false-positive rates. However, there are various influencing factors that can have an unfavorable effect on the validity of the examination method. There are inconsistent protocols regarding the evaluation criteria such as scoring systems. Among the most widely used different scoring systems the 4-point CTA-scoring system has been accepted as the most reliable method. Appropriate timing and/or Doppler pre-testing could reduce the number of possible premature examinations and increase the sensitivity of CTA in diagnosing cerebral circulatory arrest (CCA). In some cases of inconclusive CTA, the whole brain computed tomography perfusion (CTP) could be a crucial adjunct. Due to the increasing significance of CTA/CTP in determining BD, the methodology (including benefits and limitations) should also be conveyed via innovative electronic training tools, such as the BRAINDEXweb teaching tool based on an expert system.

The association between benzodiazepine use and greater risk of neurocognitive impairment is moderated by medical burden in people with HIV

Benzodiazepine use is linked to neurocognitive impairment (NCI) in the general population and people with HIV (PWH); however, this relationship may depend on age-related factors such as medical comorbidities, which occur at an elevated rate and manifest earlier in PWH. We retrospectively examined whether chronological age or medical burden, a clinical marker for aging, moderated the relationship between benzodiazepine use and NCI in PWH. Participants were 435 PWH on antiretroviral therapy who underwent neurocognitive and medical evaluations, including self-reported current benzodiazepine use. A medical burden index score (proportion of accumulated multisystem deficits) was calculated from 28 medical deficits. Demographically corrected cognitive deficit scores from 15 neuropsychological tests were used to calculate global and domain-specific NCI based on established cut-offs. Logistic regressions separately modeled global and domain-specific NCI as a function of benzodiazepine x age and benzodiazepine x medical burden interactions, adjusting for current affective symptoms and HIV disease characteristics. A statistically significant benzodiazepine x medical burden interaction (p = .006) revealed that current benzodiazepine use increased odds of global NCI only among those who had a high medical burden (index score > 0.3 as indicated by the Johnson–Neyman analysis), which was driven by the domains of processing speed, motor, and verbal fluency. No age x benzodiazepine interactive effects on NCI were present. Findings suggest that the relationship between BZD use and NCI among PWH is specific to those with greater medical burden, which may be a greater risk factor for BZD-related NCI than chronological age.

Traditional Chinese Medicine for Post-stroke Sleep Disorders: The Evidence Mapping of Clinical Studies

BACKGROUND AND PURPOSE

Recently, there are a number of clinical studies on traditional Chinese medicine (TCM) for post-stroke sleep disorders (PSSDs). This study aimed to map the current clinical studies and identify gaps to inform future study agendas.

METHODS

PubMed, Embase, Cochrane Library, and Chinese databases, including SinoMed, CNKI, and Wanfang, were searched for clinical studies on PSSDs treated with TCM from their inception to September 2021. Evidence sources, number of studies, types of PSSDs, intervention categories, effectiveness, and quality assessment were graphically displayed.

RESULTS

The evidence map involved 810 clinical studies, of which the earliest report was dated back to 1993, and an advanced growth of the whole evidence was observed in 2012. Randomized controlled trials (RCTs) were the most common type of study design (78.15%), and post-stroke insomnia was the most common type of sleep disorders (65.80%). The benefits of Chinese herbal medicine (CHM) and acupuncture therapies for post-stroke insomnia have been widely reported in RCTs (81.60% and 75.38%, respectively). However, the benefits of CHM interventions were assessed using a global approach rather than being based on a specific formula, and the highest level of evidence supporting the effectiveness of acupuncture therapies was of low methodological quality. In addition, evidence from primary studies was insufficient in the areas of TCM for post-stroke sleep-related breathing disorders (SBDs) and Chinese mind-body exercises for post-stroke insomnia.

CONCLUSIONS

PSSDs treated with TCM have been widely assessed in clinical studies. For better evidence translation, clinical trials on specific CHM interventions and high-quality systematic reviews on acupuncture for post-stroke insomnia should be conducted. For a better solution to clinical questions, TCM on SBDs after stroke and the benefits of Chinese mind-body exercises for post-stroke insomnia should be explored in future clinical studies.

Frailty and potentially inappropriate medications using the 2019 Beers Criteria: findings from the Australian Longitudinal Study on Women's Health (ALSWH)

BACKGROUND

Frailty is an essential consideration with potentially inappropriate medications (PIMs), especially among older women.

AIMS

This study determined the use of potentially inappropriate medications according to frailty status using the Beers Criteria 2019, identified medications that should be flagged as potentially inappropriate and harmful depending on individual health factors, and determined the association between frailty and PIMs, adjusted for characteristics associated with PIMs.

METHODS

This prospective longitudinal study included 9355 participants aged 77-82 years at baseline (2003). Frailty was measured using the FRAIL (fatigue, resistance, ambulation, illness and loss of weight) scale. Generalised estimating equations using log-binomial regressions determined the association between frailty and risk of using PIMs.

RESULTS

Among participants who were frail and non-frail at baseline, the majority used ≥ 3 PIMs (74.2% and 58.5%, respectively). At 2017, the proportion using ≥ 3 PIMs remained constant in the frail group (72.0%) but increased in the non-frail group (66.0%). Commonly prescribed medications that may be potentially inappropriate in both groups included benzodiazepines, proton-pump inhibitors and non-steroidal anti-inflammatory drugs, and risperidone was an additional contributor in the non-frail group. When adjusted for other characteristics, frail women had a 2% higher risk of using PIMs (RR 1.02; 95% CI 1.01, 1.03).

CONCLUSION

Given that the majority of frail women were using medications that may have been potentially inappropriate, it is important to consider both frailty and PIMs as indicators of health outcomes, and to review the need for PIMs for women aged 77-96 years who are frail.

Post-injury benzodiazepine and opioid use among older adults involved in road traffic crashes: A Swedish register-based longitudinal study

AIM

Psychotropic drugs like opioids and benzodiazepines are prescribed for traumas resulting from road traffic crashes and the risk of developing an addiction deserves consideration. This study aims to shed light on how the consumption of those drugs evolves over time among older road traffic injury (RTI) victims.

METHODS

We conducted a nationwide Swedish register-based longitudinal study to identify trajectories of post-RTI psychotropic drug use. All individuals aged 50 years and older who had a hospital visit for an RTI from 2007 to 2015 were followed up during a 2-year period; those who used the drugs prior to the RTI were excluded. Trajectories were identified by performing latent class trajectory analysis on drug dispensation data for opioids and benzodiazepines separately (66 034 and 66 859 adults, respectively, in total).

RESULTS

Three trajectories were identified for opioids and four for benzodiazepines. The largest group in both instances included people with no-use/minimal use throughout the follow-up (81.3% and 92.8%). "Sporadic users" were more frequent among users of opioids (16.7%) than benzodiazepines (4.3%), whereas "chronic users" were found in similar proportions (2.0% and 1.8%). "Delayed chronic use" characterized the fourth group of benzodiazepine users (1.0%).

CONCLUSION

Several trajectories of psychotropic drug use were identified after RTI, from limited to chronic. Although chronic use was uncommon, a better understanding of the factors likely to increase that risk is warranted given the seriousness of the problem.

Prevalence of psychoactive substance use among acutely hospitalised patients in Oslo and Moscow: a cross-sectional, observational study

OBJECTIVES

The use of psychoactive prescription medication is increasing in the general population. This is a cause for concern, particularly among the elderly, where physiological changes related to senescence increase the risk for adverse effects. While previous studies regarding psychoactive substance use have generally been population based, we sought to determine the frequency of such use among acutely hospitalised patients.

SETTING

Two emergency departments (EDs), one in Oslo and one in Moscow, admitting patients to Departments of Internal Medicine.

PARTICIPANTS

5583 patients aged ≥18 years participated, distributed evenly between genders and study locations. Patients unable to give informed consent were excluded. The study sites did not admit patients with surgical conditions and/or injuries.

PRIMARY AND SECONDARY OUTCOMES

The presence of psychoactive substances was determined through blood analysis using liquid chromatography-mass spectrometry. Secondary outcomes comprised demographic data (including age, gender, employment and marital status), degree of psychological distress, concurrent alcohol use, and self-reported alcohol, psychoactive drug and illicit substance use.

RESULTS

32.3% in Oslo and 12% in Moscow were positive for one or more psychoactive medicinal drugs (benzodiazepines, z-hypnotics, opioids or barbiturates). In Oslo, medicinal drug use was associated with being aged 61 to 70 years (OR 2.40, 95% CI 1.61 to 3.58) compared with 18 to 40 years, and psychological distress (OR 2.61, 95% CI 2.06 to 3.30). In Moscow, psychoactive medicinal drug use was also associated with psychological distress (OR 1.68, 95% CI 1.18 to 2.39), and was less common among patients aged 41 to 60 years (OR 0.62, 95% CI 0.43 to 0.88) than among patients aged 18 to 40 years.

CONCLUSION

A significant proportion of admitted patients used one or more psychoactive medicinal drugs, in particular benzodiazepines (Oslo and Moscow) and opiates (Oslo). We suggest formalised screening for inappropriate prescription drug use and increased adherence to clinical prescription guidelines.

Dependence, withdrawal and rebound of CNS drugs: an update and regulatory considerations for new drugs development

The purpose of this article is to describe dependence and withdrawal phenomena related to CNS drugs discontinuation and to clarify issues related to the evaluation of clinical drug withdrawal and rebound as they relate to safety in new drug development. The article presents current understanding and definitions of drug dependence and withdrawal which are also relevant and important features of addiction, though not the same. Addiction, called substance use disorder in DSM-5, affects an individual’s brain and behaviour, represents uncontrollable drug abuse and inability to stop taking a drug regardless of the harm it causes. Characteristic withdrawal syndromes following abrupt discontinuation of CNS-active drugs from numerous drug classes are described. These include drugs both scheduled and non-scheduled in the Controlled Substances Act, which categorizes drugs in five schedules based on their relative abuse potentials and dependence liabilities and for regulatory purposes. Schedules 1 and 2 contain drugs identified as those with the highest abuse potential and strictest regulations. Less recognized aspects of drug withdrawal, such as rebound and protracted withdrawal syndromes for several drug classes are also addressed. Part I presents relevant definitions and describes clinical withdrawal and dependence phenomena. Part II reviews known withdrawal syndromes for the different drug classes, Part III describes rebound and Part IV describes protracted withdrawal syndromes. To our knowledge, this is the first compilation of withdrawal syndromes for CNS drugs. Part V provides details of evaluation of dependence and withdrawal in the clinical trials for CNS drugs, which includes general design recommendations, and several tools, such as withdrawal questionnaires and multiple scales that are helpful in the systematic evaluation of withdrawal. The limitations of different aspects of this method of dependence and withdrawal evaluation are also discussed.

Medication management issues identified during home medication reviews for ambulatory community pharmacy patients

Background

The health risks associated with poor medication practices in the home suggest that patients would benefit from home-based medication reviews that could detect and resolve these issues. However, remuneration for home visits often excludes ambulatory, nonhomebound patients. A subset of these patients have issues that cannot be adequately identified and resolved during the course of a typical pharmacy-based medication review.

Purpose

This study aims to characterize the prevalence and nature of "hidden in the home" medication management issues in nonhomebound patients.

Methods

Pharmacists facilitated subject enrollment among patients at 6 community pharmacies in Toronto over a 15-month period, from January 2016 to March 2017. Patients taking 5 or more chronic medications who were ambulatory (able to visit the pharmacy) and scored 3 points or higher on a prescreening questionnaire were invited to participate. Visits included a standard medication review, the identification of drug therapy problems and an assessment of the patient's medication and organization/storage practices, followed by a medication cabinet cleanup.

Results

One hundred patients were recruited, with a mean age of 76.9 years and taking on average 10 chronic medications. Pharmacists identified a total of 275 drug therapy problems (2.75 per patient). The most common issues reported additional therapy required (23.6%), nonadherence (23.3%) and adverse drug reactions (17.8%). For those patients 65 years or older (87%), 32% were found to be using at least 1 medication on the Beers Criteria list, while 6% were using 3 or more. Sulfonylureas, non-steroidal anti-inflammatory drugs and short-acting benzodiazepines were the most commonly implicated drugs. Medications were removed from the homes of 67% of the patients, with expiry of medication being the most common reason for removal (54.2%). The mean duration of a home visit was 49.5 minutes.

Conclusion

Pharmacist-directed home medication reviews offer an effective mechanism to address the pharmacotherapy issues of patients taking multiple medications. These findings highlight the frequency of medication management issues in this group and suggest that home medication reviews could serve to minimize inappropriate use of medication and maximize health care cost savings in this unique patient population. Can Pharm J (Ott) 2019;152:xx-xx.

Concurrent benzodiazepine use in older adults treated with antidepressants in Asia

ABSTRACTBackground:Little is known about the combined use of benzodiazepines and antidepressants in older psychiatric patients. This study examined the prescription pattern of concurrent benzodiazepines in older adults treated with antidepressants in Asia, and explored its demographic and clinical correlates.

METHODS

The data of 955 older adults with any type of psychiatric disorders were extracted from the database of the Research on Asian Psychotropic Prescription Patterns for Antidepressants (REAP-AD) project. Demographic and clinical characteristics were recorded using a standardized protocol and data collection procedure. Both univariate and multiple logistic regression analyses were performed.

RESULTS

The proportion of benzodiazepine and antidepressant combination in this cohort was 44.3%. Multiple logistic regression analysis revealed that higher doses of antidepressants, younger age (<65 years), inpatients, public hospital, major comorbid medical conditions, antidepressant types, and country/territory were significantly associated with more frequent co-prescription of benzodiazepines and antidepressants.

CONCLUSIONS

Nearly, half of the older adults treated with antidepressants in Asia are prescribed concurrent benzodiazepines. Given the potentially adverse effects of benzodiazepines, the rationale of benzodiazepines and antidepressants co-prescription needs to be revisited.

Pharmacokinetic and pharmacodynamic considerations in the treatment of the elderly patient with hypertension

INTRODUCTION

Hypertension is an important risk factor for developing cardiovascular diseases. It is more prevalent in the elderly population. Recently updated American and European guidelines recommend treating every elderly patient with hypertension independent of age, starting with a low dose of antihypertensive drugs. However, little information is available on the optimal dosages of antihypertensive drugs to treat the elderly safely. Areas covered: Comorbidities, co-medication and frailty status can alter the clinical outcome of drug treatment and can cause adverse events in the elderly. Also, due to pharmacokinetic and pharmacodynamic changes the interpatient variability when using antihypertensive drugs is considerable. In this review, an overview is given on the extent to which the previously mentioned parameters are changed in elderly patients and what this means for the exposure to antihypertensive medication. Also, recommendations on the starting dose of the most frequently used antihypertensive drugs are given based on literature data. Expert opinion: We believe that recommendations on starting dosages followed by a stepwise increase of dosages will lead to improved blood pressure control and less adverse drug reactions in the elderly patient. This may improve adherence to antihypertensive therapy.

Initiation and long-term use of benzodiazepines and Z-drugs in bipolar disorder

OBJECTIVES

Increasing evidence points to the harmful effects of long-term benzodiazepine treatment. Our objective was to study the incidence of, and predictors for, long-term use of benzodiazepines and Z-drugs in bipolar disorder.

METHODS

We conducted a population-based cohort study, using data from Swedish national registers. Swedish residents aged 18-75 years with a recorded diagnosis of bipolar disorder or mania between July 2006 and December 2012, and no history of benzodiazepine/Z-drug use in the past year, were included. Patients were followed for 1 year with regard to prescription fills of benzodiazepines/Z-drugs. Initiators were followed for another year during which continuous use for >6 months was defined as "long-term". Patient and prescription characteristics were investigated as potential predictors for long-term use in multivariate logistic regression models.

RESULTS

Out of the 21 883 patients included, 29% started benzodiazepine/Z-drug treatment, of whom one in five became long-term users. Patients who were prescribed clonazepam or alprazolam had high odds for subsequent long-term use (adjusted odds ratios [aORs] 3.78 [95% confidence interval (CI) 2.24-6.38] and 2.03 [95% CI 1.30-3.18], respectively), compared to those prescribed diazepam. Polytherapy with benzodiazepines/Z-drugs also predicted long-term use (aOR 2.46, 95% CI 1.79-3.38), as did age ≥60 years (aOR 1.93, 95% CI 1.46-2.53, compared to age <30 years), and concomitant treatment with psychostimulants (aOR 1.78, 95% CI 1.33-2.39).

CONCLUSIONS

The incidence of subsequent long-term use among bipolar benzodiazepine initiators is high. Patients on clonazepam, alprazolam or benzodiazepine/Z-drug polytherapy have the highest risk of becoming long-term users, suggesting that these treatments should be used restrictively.

Approach to the Agitated Emergency Department Patient

BACKGROUND

Acute agitation is a common occurrence in the emergency department (ED) that requires rapid assessment and management.

OBJECTIVE

This review provides an evidence-based summary of the current ED evaluation and management of acute agitation.

DISCUSSION

Acute agitation is an increasingly common presentation to the ED and has a broad differential diagnosis including metabolic, neurologic, infectious, toxicologic, and psychiatric etiologies. Missed diagnosis of a dangerous etiology of the patient's agitation may result in severe morbidity and mortality. Assessment and management of the agitated patient should occur concurrently. Focused history and physical examination are recommended, though control of the patient's agitation may be required. All patients should receive a point-of-care glucose test, with additional testing depending upon the specific patient presentation. Initial management should involve verbal de-escalation techniques, followed by pharmacologic interventions, with physical restraints reserved as a last resort. Pharmacologic options include first-generation antipsychotics, second-generation antipsychotics, benzodiazepines, and ketamine. Finally, the management of pediatric, pregnant, and elderly patients warrants special consideration.

CONCLUSION

Acute agitation is an important presentation that requires prompt recognition and treatment. A focused and thorough examination coupled with appropriate management strategies can assist emergency clinicians to safely and effectively manage these patients.

Off-label prescription of psychiatric drugs by non-psychiatrist physicians in three general hospitals in Germany

BACKGROUND

Off-label prescribing of psychoactive drugs is a common practice in psychiatry. Here, we sought to investigate the frequency of off-label prescribing in a population of hospitalized patients with a somatic illness who were also suffering from a psychiatric pathology.

METHODS

Using a prospective, observational design, we collected data from 982 hospitalized patients with a somatic illness for whom a psychiatric consultation was requested because of the presence of additional psychiatric symptoms. Data were collected at three hospitals in Germany. Demographic and clinical data, including the previous psychoactive medications and an assessment of the suitability of the previous medications, were recorded and analyzed.

RESULTS

Data on the previous psychiatric medications were available for 972 patients. In 16.6% of patients, at least one psychoactive drug had been prescribed off-label, 20.2% had received on-label medication, and 63.2% had not received any psychiatric medication. Among all patients receiving psychiatric medication, 45.1% had received off-label medication. The logistic regression analysis showed a significant influence of age on the likelihood of receiving off-label medication (p = 0.018). Benzodiazepines were the most frequent off-label prescription (25.8% of off-label prescriptions), followed by atypical antipsychotics (18.2%) and low-potency antipsychotics (17.2%). Notably, 57.1% of off-label prescriptions were judged to be 'not indicated' by experienced psychiatrists.

CONCLUSIONS

Our data show a high frequency of the off-label prescription of psychoactive drugs by physicians treating patients with somatic illnesses in general hospitals. Because more than half of these cases were judged to be "not indicated", these prescriptions indicate a potential risk to patients. Furthermore, the classes of drugs that were most frequently prescribed off-label, benzodiazepines and antipsychotics, both show a substantial risk profile, particularly for elderly patients.

Long-term use of benzodiazepines: Definitions, prevalence and usage patterns – a systematic review of register-based studies

Background

Numerous treatment guidelines recommend that long-term use of benzodiazepines (BZD) should be avoided primarily due to development of tolerance and a risk for BZD dependence. Despite this, long-term BZD use remains a controversial subject in clinical patient care with “for and against” debates. However, there is no explicit understanding of what is meant by long-term BZD use in real world. The aim of this study was to assess different definitions, usage patterns, prevalence and other characteristics of long-term BZD use based on published register-based studies. Synthesis of these characteristics is essential to derive a meaningful definition of long-term BZD.

Methods

Systematic review of register-based studies on long-term BZD use published in 1994–2014.

Results

Fourty-one studies met our predetermined inclusion criteria. The length of BZD use defined as “long-term” varied in these studies ranging from one month to several years. The most common definition was six months or longer during a year. The prevalence of long-term BZD use in the general population was estimated to be about 3%. The relative proportion of long-term BZD users (all definitions) in adult BZD users ranged from 6% to 76% (mean 24%; 95% CL 13–36%). The estimates were higher in studies only on the elderly (47%; 95% CL 31–64%). Long-term use involved typically steady treatment with low BZD doses. However, in elderly patients long-term BZD use and exceeding recommended doses was relatively common. Several characteristics associated with long-term use were found.

Conclusions

Long-term BZD use is common and a clinical reality. Uniform definitions for “long-term”, which is in line with population-based evidence, is needed to have more comparable results between studies. Our systematic review suggests that duration of BZD treatment over six months, the most common definition for long-term BZD use in the included studies. As also recommended previously, it is a useful starting point for further analyses on disadvantages but also potential advantages associated with long-term BZD use.

Potential drug-drug interactions in Alzheimer patients with behavioral symptoms

The use of multi drug regimens among the elderly population has increased tremendously over the last decade although the benefits of medications are always accompanied by potential harm, even when prescribed at recommended doses. The elderly populations are particularly at an increased risk of adverse drug reactions considering comorbidity, poly-therapy, physiological changes affecting the pharmacokinetics and pharmacodynamics of many drugs and, in some cases, poor compliance due to cognitive impairment and/or depression. In this setting, drug–drug interaction may represent a serious and even life-threatening clinical condition. Moreover, the inability to distinguish drug-induced symptoms from a definitive medical diagnosis often results in addition of yet another drug to treat the symptoms, which in turn increases drug–drug interactions. Cognitive enhancers, including acetylcholinesterase inhibitors and memantine, are the most widely prescribed agents for Alzheimer’s disease (AD) patients. Behavioral and psychological symptoms of dementia, including psychotic symptoms and behavioral disorders, represent noncognitive disturbances frequently observed in AD patients. Antipsychotic drugs are at high risk of adverse events, even at modest doses, and may interfere with the progression of cognitive impairment and interact with several drugs including anti-arrhythmics and acetylcholinesterase inhibitors. Other medications often used in AD patients are represented by anxiolytic, like benzodiazepine, or antidepressant agents. These agents also might interfere with other concomitant drugs through both pharmacokinetic and pharmacodynamic mechanisms. In this review we focus on the most frequent drug–drug interactions, potentially harmful, in AD patients with behavioral symptoms considering both physiological and pathological changes in AD patients, and potential pharmacodynamic/pharmacokinetic drug interaction mechanisms.

Adverse performance effects of acute lorazepam administration in elderly long-term users: pharmacokinetic and clinical predictors

BACKGROUND

The benzodiazepine lorazepam is widely utilized in the treatment of elderly individuals with anxiety disorders and related conditions. Negative effects of acute lorazepam administration on cognitive performance, especially memory, have been reported in both previously untreated elderly and in individuals who have received short term (up to three weeks) treatment with therapeutic doses. However, it remains unclear if these adverse cognitive effects also persist after long-term use, which is frequently found in clinical practice.

METHODS

Cognitively intact elderly individuals (n=37) on long-term (at least three months) daily treatment with lorazepam were studied using a double-blind placebo-controlled cross-over study design. Subjects were administered their highest daily unit dose of lorazepam (0.25-3.00 mg) or placebo on different days, approximately 1 week apart in a random order, and were assessed on memory, psychomotor speed, and subjective mood states.

RESULTS

Subjects had significantly poorer recall and slowed psychomotor performance following acute lorazepam administration. There were no significant effects on self-ratings of mood, sedation, or anxiety in the whole group, but secondary analyses suggested a differential response in subjects with Generalized Anxiety Disorder.

CONCLUSIONS

The reduced recall and psychomotor slowing that we observed, along with an absence of significant therapeutic benefits, following acute lorazepam administration in elderly long-term users reinforces the importance of cognitive toxicity as a clinical factor in benzodiazepine use, especially in this population.

Liver physiology and liver diseases in the elderly

The liver experiences various changes with aging that could affect clinical characteristics and outcomes in patients with liver diseases. Both liver volume and blood flow decrease significantly with age. These changes and decreased cytochrome P450 activity can affect drug metabolism, increasing susceptibility to drug-induced liver injury. Immune responses against pathogens or neoplastic cells are lower in the elderly, although these individuals may be predisposed to autoimmunity through impairment of dendritic cell maturation and reduction of regulatory T cells. These changes in immune functions could alter the pathogenesis of viral hepatitis and autoimmune liver diseases, as well as the development of hepatocellular carcinoma. Moreover, elderly patients have significantly decreased reserve functions of various organs, reducing their tolerability to treatments for liver diseases. Collectively, aged patients show various changes of the liver and other organs that could affect the clinical characteristics and management of liver diseases in these patients.

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.

Association between risk factors for injurious falls and new benzodiazepine prescribing in elderly persons

Background

Benzodiazepines are frequently prescribed to elderly patients' despite concerns about adverse effects leading to injurious falls. Previous studies have not investigated the extent to which patients with pre-existing risk factors for falls are prescribed benzodiazepines. The objective of this study is to assess if some of the risk factors for falls are associated with new benzodiazepine prescriptions in elderly persons.

Methods

Using provincial administrative databases, elderly Quebec residents were screened in 1989 for benzodiazepine use and non-users were followed for up to 5 years. Logistic regression models were used to evaluate potential predictors of new benzodiazepine use among patient baseline characteristics.

Results

In the 252,811 elderly patients who had no benzodiazepine prescription during the baseline year (1989), 174,444 (69%) never filled a benzodiazepine prescription and 78,367 (31%) filled at least one benzodiazepine prescription. In the adjusted analysis, several risk factors for falls were associated with statistically significant increases in the risk of receiving a new benzodiazepine prescription including the number of prescribing physicians seen at baseline (OR: 1.12; 95% CI 1.11–1.13), being female (OR: 1.20; 95% CI 1.18–1.22) or a diagnosis of arthritis (OR: 1.11; 95% CI 1.09–1.14), depression (OR: 1.42; 95% CI 1.35–1.49) or alcohol abuse (OR: 1.24; 95% CI 1.05–1.46). The strongest predictor for starting a benzodiazepine was the use of other medications, particularly anti-depressants (OR: 1.85; 95% CI 1.75–1.95).

Conclusion

Patients with pre-existing conditions that increase the risk of injurious falls are significantly more likely to receive a new prescription for a benzodiazepine. The strength of the association between previous medication use and new benzodiazepine prescriptions highlights an important medication safety issue.

Chronic liver disease in an ageing population

The prevalence of chronic liver disease is increasing in the elderly population. With a mostly asymptomatic or non-specific presentation, these diseases may easily go undiagnosed. Abnormal liver function tests of unknown cause are a common reason for referral to secondary care. Investigating the older person with abnormal liver function is important; even with mild abnormalities, the same vigilance should be applied to an older person as in a young person. Liver biopsy is safe but often overlooked in this age group and may provide useful information to diagnose, direct therapy and prognosticate. Treatment options are similar for all age groups, with a few subtle differences, although further evidence is frequently required for the older population. Morbidity and age-adjusted mortality are often more severe in older people, and therefore early diagnosis and intervention is important. Presented here are the most common chronic liver diseases that geriatricians are likely to encounter in clinical practise. Their epidemiology, clinical features, investigation, treatment and mortality are described with a particular focus on the elderly population.

The homeopathic preparation Nervoheel N can offer an alternative to lorazepam therapy for mild nervous disorders

In an open-label, prospective non-randomized cohort study, we compared the effectiveness and tolerability profiles of the homeopathic remedy Nervoheel N with those of the benzodiazepine, lorazepam, in 248 patients with insomnia, distress, anxieties, restlessness or burnout and similar nervous conditions ('mild nervous disorders'). Patients were treated with Nervoheel N or lorazepam at the recommended doses for a maximum of 4 weeks. Dose variations were allowed if in the patient's best interest. Treatment effects were evaluated by the practitioner in a dialogue with the patient at the start of treatment, after 2 weeks and after maximally 4 weeks of treatment. Tolerability data were recorded as adverse events. At baseline, lorazepam patients were on average slightly older and there was a somewhat greater percentage of men in this group than in the Nervoheel group. Both treatment groups reported significant symptomatic improvements of similar magnitude during the course of the study. The sum of symptom scores improved by 4.4 points with Nervoheel N and by 4.2 points with lorazepam. The differences between the treatment groups were not significant. All differences between treatments were within 10% of the maximum score ranges, demonstrating non-inferiority of Nervoheel N. Both treatments were well tolerated, with few adverse events and very good self-assessed tolerability ratings by the patients. Thus, in patients who opt for a homeopathic treatment regimen for the short-term relief of mild nervous disorders, the effects of Nervoheel N are non-inferior to those of lorazepam.

Psychoactive drug abuse in older adults

BACKGROUND

Misuse and abuse of legal and illegal drugs constitute a growing problem among older adults.

OBJECTIVE

This article reviews the prevalence, risks and protective factors, and screening and diagnosis of drug abuse in older adults. Treatment concerns and the consequences of drug problems are examined briefly.

METHODS

MEDLINE and PsychInfo were searched using the terms substance-related disorders, drug-use disorders, abuse, dependency, opioid-related disorders, stimulant-related disorders, cocaine-related disorders, marijuana-related disorders, and withdrawal syndrome. The review included articles published in English between January 1, 1990, and May 31, 2006.

RESULTS

Despite a wealth of information on the epidemiology and treatment of alcohol abuse in older adults, few comparable data are available on drug abuse in this population. The evidence suggests that although illegal drug use is relatively rare among older adults compared with younger adults and adolescents, there is a growing problem of the misuse and abuse of prescription drugs with abuse potential. It is estimated that up to 11% of older women misuse prescription drugs and that nonmedical use of prescription drugs among all adults aged > or =50 years will increase to 2.7 million by the year 2020. Factors associated with drug abuse in older adults include female sex, social isolation, history of a substance-use or mental health disorder, and medical exposure to prescription drugs with abuse potential. No validated screening or assessment instruments are available for identifying or diagnosing drug abuse in the older population. Special approaches may be necessary when treating substance-use disorders in older adults with multiple comorbidities and/or functional impairment, and the least intensive approaches should be considered first.

CONCLUSIONS

Psychoactive medications with abuse potential are used by at least 1 in 4 older adults, and such use is likely to grow as the population ages. The treatment of disorders of prescription drug use in older adults may involve family and caretakers, and should take into account the unique physical, emotional, and cognitive factors of aging. Further research is needed on the epidemiologic, health services, and treatment aspects of drug abuse in older adults, as well as the development of appropriate screening and diagnostic tools.

Modeling cumulative dose and exposure duration provided insights regarding the associations between benzodiazepines and injuries

BACKGROUND AND OBJECTIVES

Accurate assessment of medication impact requires modeling cumulative effects of exposure duration and dose; however, postmarketing studies usually represent medication exposure by baseline or current use only. We propose new methods for modeling various aspects of medication use history and employment of them to assess the adverse effects of selected benzodiazepines.

STUDY DESIGN AND SETTING

Time-dependent measures of cumulative dose or duration of use, with weighting of past exposures by recency, were proposed. These measures were then included in alternative versions of the multivariable Cox model to analyze the risk of fall related injuries among the elderly new users of three benzodiazepines (nitrazepam, temazepam, and flurazepam) in Quebec. Akaike's information criterion (AIC) was used to select the most predictive model for a given benzodiazepine.

RESULTS

The best-fitting model included a combination of cumulative duration and current dose for temazepam, and cumulative dose for flurazepam and nitrazepam, with different weighting functions. The window of clinically relevant exposure was shorter for flurazepam than for the two other products.

CONCLUSION

Careful modeling of the medication exposure history may enhance our understanding of the mechanisms underlying their adverse effects.

Incidence and Characteristics of Benzodiazepine Use in an Elderly Cohort: The EVA Study

OBJECTIVE

The aim of this study was to estimate the incidence of benzodiazepine use in an elderly population and to identify associated factors.

METHODS

Data were collected in four self-report questionnaires on the use of sedatives and sleeping drugs. These questionnaires were sent every 6 months, over a 2-year period, to the 1272 elderly subjects interviewed at the first follow-up examination of the EVA (Epidemiology of Vascular Aging) Study.

RESULTS

The incidence rate of benzodiazepine use was 4.7 per 1000 person-months (95% confidence interval [CI] 3.6, 5.8). In multivariable analyses (logistic regression model), incident use of benzodiazepines was significantly associated with depressive or anxious symptoms (odds ratio [OR] = 3.3; 95% CI 1.7, 6.4), high use of non-psychotropic drugs (> or = 3; OR = 1.8; 95% CI 1.1, 3.1) and female gender (OR = 1.9; 95% CI 1.1, 3.3).

CONCLUSION

Simultaneous use of benzodiazepines and other medications should be carefully assessed in elderly patients, considering the risk of adverse drug reactions and drug-drug interactions.

From psychophysiological insomnia to organic sleep disturbances: a continuum in late onset insomnia - with special concerns relating to its treatment

The population suffering from insomnia in old age onset (LOI) is quite large. LOI might include a larger scale of syndromes ranging from typical psychophysiological insomnia to night delirium. The correlation between the biological, biochemical changes and the quantitative as well as the qualitative alterations of the sleep process through aging has not been fully explored. One can suppose that any cerebral lesion leading to a dysfunction in mental performance can also act on the sleep. The majority of LOI brain metabolic disturbances might therefore have some etiological role. The authors suggest the application of this concept in the clinical evaluation of LOI. The authors constructed a heuristic model for the pathophysiology and treatment of LOI. It is a bipolar axis containing the most typical symptoms of LOI. On the opposite margins psychophysiological insomnia and organic/metabolic insomnia (up to delirious states) are settled. The position on the axis (i.e., its distance from the "edge syndromes") gives information on the probability of its organic nature. Based on their clinical experiences and considering the data of the very few studies, they suppose that with the help of a detailed analysis of the symptoms of LOI and using some additional (electrophysiological and neuroimaging) laboratory methods most patients with LOI can get a strict diagnostic position on the LOI axis. Using the LOI axis not only a detailed evaluation of the symptomatology but also more sophisticated therapeutic interventions become possible. Symptoms on the "metabolic side" can be cured by a single evening application of any drugs improving the function of the brain (like nootropics, neuroprotective agents or even slight stimulants, e.g., caffeine) might show a "paradoxical hypnotic" effect, or in combination with sleeping pills they can cause an additive effect in LOI patients. The efficacy of this treatment can also have a diagnostic value: i.e., it helps to differentiate between the primary (organic) and psychophysiological (exogenous or emotional/psychic) forms of LOI.

An assessment of quality of sleep and the use of drugs with sedating properties in hospitalized adult patients

Background

Hospitalization can significantly disrupt sleeping patterns. In consideration of the previous reports of insomnia and apparent widespread use of benzodiazepines and other hypnotics in hospitalized patients, we conducted a study to assess quality of sleep and hypnotic drug use in our acute care adult patient population. The primary objectives of this study were to assess sleep disturbance and its determinants including the use of drugs with sedating properties.

Methods

This single-centre prospective study involved an assessment of sleep quality for consenting patients admitted to the general medicine and family practice units of an acute care Canadian hospital. A validated Verran and Snyder-Halpern (VSH) Sleep Scale measuring sleep disturbance, sleep effectiveness, and sleep supplementation was completed daily by patients and scores were compared to population statistics. Patients were also asked to identify factors influencing sleep while in hospital, and sedating drug use prior to and during hospitalization was also assessed.

Results

During the 70-day study period, 100 patients completed at least one sleep questionnaire. There was a relatively even distribution of males versus females, most patients were in their 8th decade of life, retired, and suffered from multiple chronic diseases. The median self-reported pre-admission sleep duration for participants was 8 hours and our review of PharmaNet^R profiles revealed that 35 (35%) patients had received a dispensed prescription for a hypnotic or antidepressant drug in the 3-month period prior to admission. Benzodiazepines were the most common sedating drugs prescribed. Over 300 sleep disturbance, effective and supplementation scores were completed. Sleep disturbance scores across all study days ranged 16–681, sleep effectiveness scores ranged 54–402, while sleep supplementation scores ranged between 0–358. Patients tended to have worse sleep scores as compared to healthy non-hospitalized US adults in all three scales. When compared to US non-hospitalized adults with insomnia, our patients demonstrated sleep disturbance and supplementation scores that were similar on Day 1, but lower (i.e. improved) on Day 3, while sleep effectiveness were higher (i.e. better) on both days. There was an association between sleep disturbance scores and the number of chronic diseases, the presence of pain, the use of bedtime tricyclic antidepressants, and the number of chronic diseases without pain. There was also an association between sleep effectiveness scores and the length of hospitalization, the in hospital use of bedtime sedatives and the presence of pain. Finally, an association was identified between sleep supplementation scores and the in hospital use of bedtime sedatives (tricyclic antidepressants and loxapine), and age. Twenty-nine (29%) patients received a prescription for a hypnotic drug while in hospital, with no evidence of pre-admission hypnotic use. The majority of these patients were prescribed zopiclone, lorazepam or another benzodiazepine.

Conclusions

The results of this study reveal that quality of sleep is a problem that affects hospitalized adult medical service patients and a relatively high percentage of these patients are being prescribed a hypnotic prior to and during hospitalization.

Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications

Advancing age is characterized by impairment in the function of the many regulatory processes that provide functional integration between cells and organs. Therefore, there may be a failure to maintain homeostasis under conditions of physiological stress. The reduced homeostatic ability affects different regulatory systems in different subjects, thus explaining at least partly the increased interindividual variability occurring as people get older. Important pharmacokinetic and pharmacodynamic changes occur with advancing age. Pharmacokinetic changes include a reduction in renal and hepatic clearance and an increase in volume of distribution of lipid soluble drugs (hence prolongation of elimination half-life) whereas pharmacodynamic changes involve altered (usually increased) sensitivity to several classes of drugs such as anticoagulants, cardiovascular and psychotropic drugs. This review focuses on the main age-related physiological changes affecting different organ systems and their implications for pharmacokinetics and pharmacodynamics of drugs.

Prevalence and risk factors for falls in an older community-dwelling population

BACKGROUND

Falls are responsible for considerable morbidity, immobility, and mortality among elderly people. The aim of this study was to determine the prevalence of falls and related intrinsic and extrinsic risk factors in a community-dwelling older population.

METHODS

An observational study was performed on all patients (N = 5570) admitted from 1997 to 2001 to home care programs in 19 home health agencies that participated in the National Silver Network project in Italy. Patient evaluation was performed through the Minimum Data Set-Home Care (MDS-HC) instrument.

RESULTS

A 35.9% falls prevalence was found within 90 days of the patient assessment through the MDS-HC instrument. After adjusting for all potential confounding factors, the logistic regression showed a high increase in risk of falling for those patients who wandered (odds ratio [OR] 2.38; 95% confidence interval [CI] 1.81-3.12) or suffered with gait problems (OR 2.13; 95% CI 1.81-2.51). Patients affected by depression were more likely to fall (OR 1.53; 95% CI 1.36-1.73). Those who lived in an unsafe place with environmental hazards had an increase in the risk of falling (OR 1.51; 95% CI 1.34-1.69). The associations of main risk factors for falls were also evaluated.

CONCLUSIONS

Rate of falls among frail elderly people living in the community is very high and frequently correlates with potentially reversible factors. To identify those with higher falling risk, home care staff and general practitioners could use the MDS-HC assessment tool.

Assessment and treatment of alcoholism and substance-related disorders in the elderly

Substance-related disorders in the elderly remain overlooked and undertreated. Up to 16% of the elderly have alcohol use disorders. With Americans age 65 and older constituting the fastest growing segment of our population, this issue becomes increasingly important. The author reviews the prevalence of geriatric alcoholism, the two typical drinking patterns seen in the elderly, the acute and chronic consequences of alcohol consumption with particular relevance to older persons, barriers to proper assessment of alcoholism in this age group, usefulness of available screening tools, treatment of alcohol withdrawal in the elderly, treatment of alcohol dependence in the elderly with focus on brief intervention, and aspects of nonalcohol drug abuse in the elderly.

Treating epilepsy in the elderly: safety considerations

The incidence of epilepsy increases with advancing age. Epilepsy in the elderly has different aetiologies from that in younger populations, cerebrovascular disease being the most common condition associated with seizures. Partial seizures are the predominant seizure type in older patients. A diagnosis of epilepsy in the elderly is based mainly on the history and is frequently delayed. In addition, seizure imitators are especially frequent. In many cases ancillary tests for diagnosis may show normal age-related variants, sometimes making results difficult to interpret. Treating epilepsy in the elderly is problematic due to a number of issues that relate to age and comorbidity. The physical changes associated with increasing age frequently lead to changes in the pharmacokinetics of many anticonvulsants. The treatment of epilepsy in the elderly is also complicated by the existence of other diseases that might affect the metabolism or excretion of anticonvulsants and the presence of concomitant medications that might interact with them. Moreover, specific trials of anticonvulsants in the aged population are scarce. General guidelines for treatment include starting at lower doses, slowing the titration schedule, individualising the choice of anticonvulsant to the characteristics of the patient, avoiding anticonvulsants with important cognitive or sedative adverse effects, and where possible, treating with monotherapy.

Improving benzodiazepine prescribing for elderly hospital inpatients using audit and multidisciplinary feedback

BACKGROUND

Benzodiazepines are commonly prescribed for older people. Inappropriate benzodiazepine prescribing may result in serious adverse effects, including confusion and falls.

AIMS

To determine the prevalence and appropriateness of benzodiazepine prescribing for elderly inpatients at nine public hospitals in Victoria, Australia, and to assess the impact of multidisciplinary feedback on quality of benzodiazepine prescribing.

METHODS

Clearance for the study was obtained from ethics committees of participating hospitals. Medication charts for 1301 patients aged 65 years and over were reviewed to identify patients prescribed a benzodiazepine. Using an evidence-based indicator of prescribing appropriateness, cross-sectional notes-based audits were conducted at three time points (baseline, 4-8 weeks and 6 months). Feedback of baseline audit results was provided to medical, pharmacy and nursing staff at multidisciplinary meetings. Changes in benzodiazepine prescribing over the following 6 months were assessed.

RESULTS

At baseline, benzodiazepines were prescribed for 36% of patients, and 20% of prescriptions were appropriate. Four to six weeks after feedback, the proportion of patients prescribed a benzodiazepine had not changed significantly (31%, P = 0.125); however, more prescriptions were appropriate (44%, P < 0.0001). For patients who were using a benzodiazepine prior to admission and had a contraindication, there were more attempts to withdraw or reduce the dose (47% vs 21%, P = 0.002) and more prescriptions were for acceptable indications (7.4% vs 2.6%, P = 0.024). Six months after feedback, appropriateness of prescribing remained improved compared with baseline (50%, P = 0.002).

CONCLUSIONS

Benzodiazepines were prescribed for approximately one in three elderly hospital inpatients and a large proportion was inappropriate. A multidisciplinary intervention based on audit and feedback improved prescribing and the impact of the intervention was still evident after 6 months.

Multiple-dose tolerability, pharmacodynamics, and pharmacokinetics of the quinolizinone hypnotic Ro 41-3696 in elderly subjects

The objectives of this double-blind, placebo-controlled study were to assess the multiple-dose tolerability, pharmacodynamics, and pharmacokinetics of the hypnotic agent Ro 41-3696 in elderly men and women (55-75 y of age). On day 1 and days 3-8, doses of 1, 3, 5, and 10 mg were administered sequentially to 4 groups of 10 subjects, 2 of whom received placebo. Psychomotor performance tests (tracking and attention) were conducted just before and at 1.5, 4, and 8 hours after drug intake on days 1, 4, 6, and 8. Memory was assessed at 24 hours after drug intake on days 1 and 8 by recall of a list of 10 words, which had been learned at 2 hours after intake. Ro 41-3696 was well tolerated at all dose levels. One subject dropped out of the study because of a hypersensitive skin reaction during treatment with 10 mg. Performance in both a tracking test and a memory search test was significantly affected by a dose of 10 mg and moderately affected by doses of 3 and 5 mg. The results of the 1-mg dose were indistinguishable from those of placebo. Long-term memory, as assessed by a word learning and recall test, showed the same pattern. Partial tolerance to the impairing effects in the psychometric tests developed over the course of treatment. Pharmacokinetics of both Ro 41-3696 and its O-desethyl metabolite Ro 41-3290 were dose proportional and time independent. Ro 41-3696 was absorbed and eliminated rapidly (time of maximum plasma concentration, approximately 1 hour; elimination half-life, approximately 2 hours). Plasma levels of Ro 41-3290 were higher than those of the parent drug, and it was more slowly eliminated (values for time of maximum plasma concentration and elimination half-life, approximately 2 and approximately 7 hours, respectively).

Zaleplon shortens subjective sleep latency and improves subjective sleep quality in elderly patients with insomnia. The Zaleplon Clinical Investigator Study Group

Insomnia is a frequent complaint in the elderly population. Hypnotic agents, including benzodiazepines, with longer pharmacological half-lives have been associated with side effects, including residual sedation, memory impairment, and discontinuation effects. Zaleplon is a short-acting (elimination half-life of 1 hour), non-benzodiazepine hypnotic that acts on the benzodiazepine type 1 site of the gamma-aminobutyric acid type A (GABA(A)) receptor complex. The pharmacology and pharmacokinetics of Zaleplon suggest a safety profile that is improved over other hypnotics. The objective of this placebo-controlled study was to evaluate the efficacy and safety of Zaleplon (5 and 10 mg) in elderly (> or =65 years) outpatients with primary insomnia. This was a multicenter, double-blind, randomised, placebo-controlled 2-week outpatient study. Postsleep questionnaires were used to record subjective sleep variables: sleep latency, sleep duration, number of awakenings, and sleep quality. Zaleplon significantly reduced subjective sleep latency during both weeks of the study with both 5- and 10-mg doses. Subjective sleep quality was improved for significantly more patients treated with zaleplon 10 mg than those treated with placebo during both weeks of treatment. There was a weak indication of rebound insomnia after discontinuation of treatment with the 10-mg dose, but no significant difference in common treatment-emergent adverse events across treatment groups. Zaleplon is an effective and safe hypnotic for the treatment of insomnia in the elderly.

Zaleplon, A Novel Nonbenzodiazepine Hypnotic, Effectively Treats Insomnia in Elderly Patients Without Causing Rebound Effects

BACKGROUND: Insomnia is a very common symptom, particularly in the elderly. Thus, all hypnotic medications should be carefully evaluated in the elderly population. Zaleplon, a new nonbenzodiazepine hypnotic with a short elimination half-life (approximately 1 hour), was evaluated in the current study. METHOD: This multicenter, randomized, placebo-controlled outpatient study evaluated the efficacy and safety of zaleplon, 5 and 10 mg, in elderly patients with insomnia (as defined by DSM-IV); zolpidem, 5 mg, was the active comparator. Sleep was assessed in 549 elderly patients (>/= 65 years old) by using morning questionnaires completed after each of 7 baseline nights during which placebo was given, 14 nights of double-blind treatment, and 7 nights of placebo after discontinuation of active treatment. RESULTS: Zaleplon, 10 mg, and zolpidem, 5 mg, significantly reduced sleep latency during both weeks of the study. Zaleplon, 5 mg, reduced sleep latency only during week 2. Sleep duration was increased with zolpidem, 5 mg, during weeks 1 and 2 and with zaleplon, 10 mg, during week 1. No clinically significant rebound insomnia was observed after discontinuation of treatment with zaleplon, whereas evidence of rebound effects was seen with zolpidem. There was no significant difference between either zaleplon dose and placebo in the frequency of any central nervous system adverse events. CONCLUSION: Zaleplon is effective in reducing latency to sleep without evidence of undesired effects in elderly patients with insomnia.

A procedure for withdrawal of sleep medication in elderly women who have been long-term users

A program for withdrawal of sedative/hypnotic medication was investigated in elderly women, ages 64 to 91. The sleep cycles of 10 drug withdrawal (DW) and 10 non-drug withdrawal (N-DW) subjects were monitored for a 24-hour period for 5 successive weeks, using a nonintrusive recording procedure. The first 2 baseline weeks were followed by 1 week of half-dose, then 2 weeks of full withdrawal for the DW group. The results indicated no demonstrable effect on sleep, sleep complaints, levels of depression, or daytime sleepiness on the DW group. The conclusion is that the procedure of withdrawal from sleep medication over a 2-week period, combined with the use of a substitute pill to maintain the ritual of nightly pill-taking, is appropriate and effective for long-term elderly users.

Correlates and prevalence of benzodiazepine use in community-dwelling elderly

OBJECTIVE

To describe the prevalence of benzodiazepine use, sociodemographic and physical health factors associated with use, dosages taken, and directions for use among individuals aged 65 years and older.

DESIGN

Cross-sectional analysis of baseline data from the community-based, prospective observational Cardiovascular Health Study.

PATIENTS/PARTICIPANTS

Medicare eligibility lists from four U.S. communities were used to recruit a representative sample of 5,201 community-dwelling elderly, of which 5,181 participants met all study criteria.

MEASUREMENTS AND MAIN RESULTS

Among participants, 511 (9.9%) were taking at least one benzodiazepine, primarily anxiolytics (73%). Benzodiazepines were often prescribed to be taken pro re nata (PRN "as needed"), and 36.5% of prescriptions with instructions to be taken regularly were taken at a dose lower than prescribed. Reported over-the-counter (OTC) sleep aid medication use was 39.2% in benzodiazepine users and 3.3% in nonusers. In a multivariate logistic model, the significant independent correlates of benzodiazepine use were being white (odds ratio [OR] 1.9; 95% confidence interval [CI] 1.0, 3.4), female (OR 1.7; CI 1.4, 2.2), and living in Forsyth County, North Carolina, or Washington County, Maryland, compared with living in Sacramento County, California, or Allegheny County, Pennsylvania (OR 2.3; CI 1.4, 2.2); having coronary heart disease (OR 1.6; CI 1.2, 2.1), health status reported as poor or fair (OR 1.8; CI 1.4, 2.3), self-reported diagnosis of nervous or emotional disorder (OR 6.7; CI 5.1, 8.7), and reporting use of an OTC sleep aid medication (OR 18.7; CI 14.1, 24.7).

CONCLUSIONS

One in 10 participants reported taking a benzodiazepine, most frequently an anxiolytic, often at a lower dose than prescribed and usually PRN. The high prevalence of OTC sleep aid medication and benzodiazepine use may place the patient at increased risk of psychomotor impairment. Physicians should assess OTC sleep aid medication use when prescribing benzodiazepines.

Pharmacokinetic changes in the elderly. Do they contribute to drug abuse and dependence?

The elderly frequently use psychoactive drugs including alcohol (ethanol), benzodiazepines and opioid analgesics, which have a propensity to cause abuse and dependence. Theoretically, the changes in pharmacokinetics of these agents in the elderly may modify their abuse and dependence potential. In the elderly, blood alcohol concentrations following an oral dose are higher, alcohol withdrawal syndrome follows a more severe and protracted clinical course and requires treatment with higher doses of chlordiazepoxide than needed for younger adults. However, there is no direct evidence that supports an increased direct abuse and dependence potential of alcohol because of its altered kinetics in the elderly. In the case of oxidatively metabolised benzodiazepine, both age-related pharmacokinetics and pharmacodynamic changes may increase their clinical effects in the elderly. The hypothesis that benzodiazepines have an increased abuse and dependence potential in the elderly has not been tested. Many of the benzodiazepines (e.g. alprazolam, triazolam and midazolam) are metabolised by the cytochrome P450 (CYP)3A subfamily. The pharmacokinetics of these agents may be modified by inhibition of CYP3A due to concurrently administered medications such as selective serotonin reuptake inhibitors. Unfortunately, data on the direct measures of abuse and dependence potential of benzodiazepines are not available in the elderly. Thus, a conclusive statement on the contribution of age-related pharmacokinetic changes to benzodiazepine abuse and dependence cannot be made at the present time. The clinical effects of codeine do not appear to change with age. Codeine is O-demethylated to its active metabolite morphine by the genetically polymorphic CYP2D6 isozyme. The activity of this isozyme is unaltered by age, gender or smoking habits; however, it is subject to potent inhibition by some of the frequently used medications in the elderly, such as the antidepressants paroxetine and fluoxetine. This may result in an impairment in O-demethylation of codeine to morphine and may lead to a decrease in the abuse and dependence potential of codeine. Conversely, those with a very rapid CYP2D6 catalytic activity may have an increased potential for codeine abuse and dependence. The clinical significance of age-related pharmacokinetic changes should be evaluated within the context of clinical practice. Most physicians are inclined to prescribe lower doses to the elderly, which may offset the potential impact of altered pharmacokinetics on the abuse and dependence potential of psychoactive agents. In summary, the available data are not sufficient for a definitive conclusion on whether the pharmacokinetic changes in the elderly translate to an increase in the abuse and dependence potential of alcohol, benzodiazepines or opioids. In particular, the data on age-associated changes in direct measures of abuse potential of these agents are missing. Future comparative systemic pharmacokinetic-pharmacodynamic studies assessing pertinent outcome measures on abuse and dependence potential of commonly used psychoactive drugs are required to resolve the ongoing controversy on risk factors for drug abuse and dependence in the elderly.