Sedating Seniors

© Vera Kuttelvaserova Stuchelova |

© Vera Kuttelvaserova Stuchelova |

In September of 2014, the British Medical Journal published an article titled: “Benzodiazepine use and risk of Alzheimer’s disease.” It received a good bit of public attention because of its conclusion that there was an increased risk of up to 51% of Alzheimer’s disease with the use of benzodiazepines —for as short a period of time as three months. There was concern expressed by Psychiatric News, which quoted Davangeere Devanand, the director of the geriatric psychiatry program at Columbia, who said: “These findings emphasize the importance of restricting the use of benzodiazepines in the elderly population.”

Philip Hickey reviewed the article and noted where the study’s authors commented there findings were congruent with five previous studies. The authors also said their findings were of major importance for public health, particularly considering the widespread chronic use of benzodiazepines with older people. Guy Goodwin, a professor of psychiatry at Oxford, voiced a common assessment of the study, namely that it was more likely that the drugs were being given to people who were already ill. I’ve heard similar comments made by pharmaceutical researchers. This dismissal of the study’s results was despite the fact that the researchers specifically attempted to control for this factor. They said:

Our study was designed specifically to reduce the possibility of reverse causation bias and to provide additional arguments linking benzodiazepine use with Alzheimer’s disease, such as a dose-effect relation.

To a certain extent, this is a rehashing of old news, as I’ve previously addressed the BMJ study in “What a Drag It Is Getting Old.” But the concern over the use of benzos with older people hasn’t gone away. There was an article published in the February 2015 issue of JAMA Psychiatry that looked at “Benzodiazepine Use in the United States.” The article first appeared online in December of 2014. You can watch a short YouTube video by the lead author summarizing the study’s results here.

The study found that about 1 in 20 (5%) people between the ages of 18 and 80 received a benzodiazepine prescription in 2008. However, the percentage increased with age, rising to 8.7% among individuals 65 to 80. Women were twice as likely as men to receive prescriptions in all age groups. Most of the prescriptions—two thirds—were written by non-psychiatrists. For adults 65 to 80, this was 9 out of 10. Thomas Insel, the director of the National Institute of Mental Health (NIMH), voiced the following concerns with the NIMH-funded study’s results:

These new data reveal worrisome patterns in the prescribing of benzodiazepines for older adults, and women in particular. . . . This analysis suggests that prescriptions for benzodiazepines in older Americans exceed what research suggests is appropriate and safe.

In a Psychiatric News Alert, one of the study’s authors was quoted as saying that it was alarming to find the highest rates of benzodiazepine use among the groups with the highest risks. “Given that safer, effective options are available for anxiety and insomnia, it’s hard to make a clinical argument for these results.” In an editorial written about the study in JAMA Psychiatry, the authors commented that there seems to be a societal addiction to using benzodiazepines with the elderly. They said these drugs should only be used for very short periods of time. With individuals susceptible to cognitive impairment or to falls and fractures, benzodiazepines should be avoided altogether.

The editorial authors also suggested that prescribing benzodiazepines should be restricted to psychiatrists. Their recommendation was based upon the perception that psychiatrists seemed prescribe them properly in the JAMA Psychiatry study. They further recommended that benzodiazepines be reclassified as a Schedule II Controlled Substance with limited-duration prescriptions and no refills. “Such barriers could help the public and prescribers think more about these risks before prescribing or using benzodiazepines.”

I don’t think limiting the prescription of benzodiazepines to psychiatrists is either practical or realistic. Despite the dangers reviewed here, restricting benzodiazepines, while permitting antidepressants, neuroleptics and mood stabilizers to be prescribed by all medical doctors is nonsensical. All these additional classes of drugs have their own serous side effects. Some are arguably more problematic than benzodiazepines. If only psychiatrists were permitted to prescribe benzos, then pharmaceutical companies would adjust their marketing strategies to concentrate on psychiatrists.

Reclassifying benzodiazepines as Schedule II Controlled Substance has more merit, but will be hard to accomplish. The process to reclassify any prescription drugs is complicated and difficult.

I’m also not convinced that all psychiatrists would be better monitors of benzodiazepine use/abuse. I know of one person whose primary care physician was reluctant to continue a long-term benzodiazepine prescription, but a psychiatrist wasn’t. I know of another individual who has been prescribed daily benzodiazepine use for sleep by a psychiatrist for over two years. My thought is that the more entrenched any medical doctor is within a biological view of psychiatric disorders, the more willing they are to prescribe benzodiazepines long-term.

Sadly, all these concerns with the use of benzodiazepines with the elderly were voiced and know twenty-five years ago. The journal Drug Safety published “Problems and Pitfalls in the Use of Benzodiazepines in the Elderly” by Wolfgang Kruse in its September issue for 1990. Dr. Kruse noted benzodiazepines were frequently prescribed for elderly patients; and that their use was more common with women. Prolonged use was likely for treating not only insomnia and anxiety in the elderly, but also a wide range of nonspecific symptoms. “Long term users are likely to have multiple concomitant physical and psychological health problems.”

He noted that long-term studies on unwanted effects were scarce, but there was some evidence that benzodiazepines were implicated in drug-associated hospital admissions. “There is suggestive evidence that benzodiazepines, especially compounds with long half-lives, may contribute to the falls which are a major health problem in old age.” Prophetically, he stated:

Problems in the use of benzodiazepines will arise if the available knowledge on altered pharmacokinetics and pharmacodynamics and principal guidelines for drug prescribing in the elderly are neglected. Poor prescribing habits are related mainly to inadequate clinical assessment, excessive prescribing and inadequate supervision of treatment. Unlimited repeat prescribing, particularly for the treatment of sleep disturbances, is seldom justified.

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