Psychiatry and Primary CareOutcome of new benzodiazepine prescriptions to older adults in primary care☆
Introduction
The prescription of benzodiazepines to elderly patients is one area in which common practice appears to diverge from expert opinion.
Expert guidelines and reviews typically urge caution when prescribing benzodiazepines to older adults [1], [2], with greatest concerns regarding long-term use. Epidemiological studies have found that benzodiazepine use is associated with increased risk of falls and injuries [3], [4], [5], cognitive decline [6], [7] and functional decline, leading to institutionalization [8]. Concerns have also been raised regarding the overprescription of benzodiazepines to older adults with depressive disorders [9], [10].
Despite these concerns, epidemiological data [11], [12], [13] indicate that benzodiazepines are among the drugs most commonly prescribed to older adults. Among community-dwelling older adults, 10–30% reported using benzodiazepine at any given time, with approximately half of those being long-term users.
This divergence between expert opinion and everyday practice raises questions regarding indications for benzodiazepine use, the clinical characteristics of users and the factors associated with progression to long-term use. Data regarding these questions are limited, as previous research has often relied on computerized pharmacy records or cross-sectional surveys.
Here we use data from a cohort of older primary care patients who received a new prescription for benzodiazepine to examine perceived indications for the initial prescription, the clinical characteristics of patients at the time of prescription and the predictors of continued use 2 months later.
Section snippets
Methods
The study was conducted between 2001 and 2002 at staff model clinics of Group Health Cooperative, a prepaid health plan serving approximately 450,000 members in western Washington State. Most members are covered through employer-purchased plans, but enrollment at the time of this study included approximately 45,000 Medicare members and 35,000 members covered by Medicaid or by Washington's Basic Health Plan (a state program for low-income residents). Group Health Cooperative members are similar
Results
Invitation letters were mailed to 200 potential participants. Seventeen could not be reached by telephone, and 10 were found to be ineligible (disenrolled from Group Health Cooperative; index prescription was not a new prescription). Forty-four declined to participate, leaving a baseline sample of 129 (68% of those eligible).
Participants had a mean age of 73 years (S.D.=7.3), with a range of 61–95 years. Sixty-four percent of the participants were female, and 93% were Caucasian. Approximately
Discussion
These findings provide some reassurance regarding the initial prescription of benzodiazepines to older adults in primary care. First, the most common indications were insomnia and anxiety (where benzodiazepine is potentially appropriate and efficacious) rather than depression. Second, the proportion of patients with alcohol use disorder or untreated depressive disorder (where benzodiazepine prescription might be inappropriate or contraindicated) was small.
Limited data regarding the probability
Acknowledgments
This work was supported by the National Institute of Mental Health grant R01 MH51338.
References (21)
- et al.
Comparing clinical practice with guideline recommendations for the treatment of depression in geriatric patients: findings from the APA practice research network
Am J Geriatr Psychiatry
(2003) - et al.
Benzodiazepine use in older adults enrolled in a health maintenance organization
Am J Geriatr Psychiatry
(2003) - et al.
Predictors of chronic benzodiazepine use in a health maintenance organization sample
J Clin Epidemiol
(1996) - et al.
Test–retest reliability and validity of the Pittsburgh Sleep Quality Index in primary insomnia
J Psychosom Res
(2002) - et al.
Treatment of primary insomnia
J Am Board Fam Pract
(2004) Diagnosis and management of insomnia in older people
J Am Geriatr Soc
(2005)- et al.
A 5-year prospective assessment of the risk associated with individual benzodiazepines and doses in new elderly users
J Am Geriatr Soc
(2005) - et al.
Psychotropic medication and risk for falls among community-dwelling frail older people: an observational study
J Gerontol A Biol Sci Med Sci
(2005) - et al.
Hazardous benzodiazepine regimens in the elderly: effects of half-life, dosage, and duration on risk of hip fracture
Am J Psychiatry
(2001) - et al.
Benzodiazepine use and physical performance in community-dwelling older women
J Am Geriatr Soc
(2003)
Cited by (44)
The long-term but not short-term use of benzodiazepine impairs motoric function and upregulates amyloid β in part through the suppression of translocator protein
2020, Pharmacology Biochemistry and BehaviorCitation Excerpt :Patients with BZD therapy encounter frequent falls, fall-related injuries (Landi et al., 2005), and poor motoric tasks (Dawson et al., 2008). In particular, elderly women are the predominant BZD users (Blazer et al., 2000; Simon and Ludman, 2006) and outnumber elderly men for frequent prescriptions of BZD. A clinical study reported that 243 prescriptions of BZD were written to old women compared to 100 to old men (Martinez-Cengotitabengoa et al., 2018).
Chronic benzodiazepine suppresses translocator protein and elevates amyloid β in mice
2018, Pharmacology Biochemistry and BehaviorCitation Excerpt :BZD use is associated with fall injuries (Landi et al., 2005), slow motor reaction, and the inaccuracy of motor tasks (Cumming and Le Couteur, 2003; Dawson et al., 2008), all of which are more severe in the elderly than in young individuals (Greenblatt et al., 1991; Fernandez-Guasti and Martinez-Mota, 2003). The adverse effect of BZD is particularly problematic for elderly women because they are the predominant BZD users, even when several factors are normalized (Blazer et al., 2000; Verhaeghe et al., 1996; Simon and Ludman, 2006). Elderly women are twice as likely to use BZD as elderly men (Nurmi-Luthje et al., 2006).
Elucidating the associations between sleep disturbance and depression, fatigue, and pain in older adults with cancer
2018, Journal of Geriatric OncologyCitation Excerpt :However, it was still difficult to ascertain from the medical record the reasons behind prescribing these drugs. Studies suggested that sleep disturbance is the most common indication for prescription of benzodiazepines, trazodone, and melatonin [34]. We also did not formally assess anxiety, which can commonly co-occur with sleep disturbance, in our study since this measure was not included in our geriatric assessment [6].
Review: Adjunctive pharmacologic approaches for benzodiazepine tapers
2018, Drug and Alcohol DependenceCitation Excerpt :Benzodiazepine cessation was actually greater in the placebo group (47.7%) when compared to those who received melatonin (38.1%). Anxiety is one of the most common indications for prescribing benzodiazepines (Simon and Ludman, 2006). During benzodiazepine tapering, individuals with anxiety disorders often have difficulty discontinuing benzodiazepines due to the similarity of withdrawal and anxiety disorder symptoms.
Sedative hypnotic use among veterans with a newly reported mental health disorder
2016, International PsychogeriatricsManagement of insomnia and long-term use of sedative-hypnotic drugs in older patients
2013, CMAJ. Canadian Medical Association Journal
- ☆
The National Institute of Mental Health had no role in the study design, execution, analysis and interpretation of results, or preparation of this manuscript.