What is the point of guidelines? Benzodiazepine and z-hypnotic use by an elderly population

doi:10.1016/j.sleep.2011.12.014

Sleep Medicine

Volume 13, Issue 7, August 2012, Pages 893-897

https://doi.org/10.1016/j.sleep.2011.12.014 Get rights and content

Abstract

Background

According to published guidelines regarding the use of benzodiazepines or z-hypnotics (BZD-Z), the elderly should avoid hypnotic BZD, and use anxiolytic BZD and z-hypnotics only at low doses and for a short time. Our objective is to quantify inappropriate BZD-Z use in the elderly.

Methods

The study population consisted of people aged 70–89 who filled at least two prescriptions in 2008 within one of three subgroups: anxiolytic BZD, hypnotics BZD, or z-hypnotics. Inappropriate use criteria used for this study were (1) any hypnotic BZD, (2) exceeding 300 DDD, or a dosage exceeding 9 DDD/week, or anxiolytic BZD and z-hypnotics use exceeding 30 weeks.

Results

118,526 persons, or 25% of elderly Norwegians, filled at least two prescriptions for one of these medication subgroups. Inappropriate use was found for 25% of anxiolytic BZD users, 100% of hypnotic BZD users, and 65% of z-hypnotic users. Altogether 57,276 elderly Norwegians, or 12.3% of the elderly source population, used BZD-Z inappropriately as defined in this study.

Conclusions

Clearly, inappropriate use of BZD-Z is widespread. An active response to such noncompliance with existing guidelines could consist of either (1) stricter enforcement of guidelines or (2) revamping guidelines through a fresh look at risks, benefits, and treatment practices. The implications of both options are discussed in some detail.

Section snippets

Background

Beers, with a panel of experts, developed a list of medications thought to be inappropriate for elderly people. This list is still widely used either as developed and updated or as a starting point for further guidelines or recommendations formulated to improve BZD-Z use by the elderly [1], [2], [3], [4], [5], [6]. Summarizing these and other recommendations, the guidelines to be used for this study will be that elderly people should use anxiolytic BZD-Z only at low doses [4], [6], [7], [8] and

Methods

All prescriptions filled in Norwegian pharmacies are registered in the Norwegian Prescription Database (NorPD). Information on each includes sex, age, personal identification (id), prescriber id, administrative codes indicating cancer or palliative care, and the WHO Anatomical Therapeutic Chemical (ATC) classification of each drug [26], [27], [28]. According to the ATC classification, which is based on assumed main indication, BZD-Z consisted of three subgroups: (a) anxiolytic benzodiazepines,

Results

Almost three quarter of a million prescriptions for BZD-Z were filled in 2008 by just under half a million Norwegians aged 70–89 (Table 1). Most commonly used were zopiclone, followed by oxazepam. The average DDD per prescription was especially high for hypnotic BZD, followed by z-hypnotics. Table 2 compared the use of any BZD-Z with the use of at least two prescriptions in any one subgroup. One third of the Norwegian population of this age group received any prescriptions for BZD-Z, while one

Discussion

In 2008 over 57,000 elderly Norwegians, i.e., 12% of this population, used BZD-Z inappropriately as defined in this study. Since the measures used were designed to err on the side of appropriate use, this astounding number is still an under-estimate. Clearly, many prescribers ignore guidelines and drug labels, and one can only ask: Why even have guidelines?

The data used for this study also has some limitations. For example, prescriptions for people residing in institutions are not registered in

Conflict of Interest

The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: doi:10.1016/j.sleep.2011.12.014.

. ICMJE Form for Disclosure of Potential Conflicts of Interest form.

Acknowledgement

Sponsor of research in this article: Norwegian Directorate of Health.

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Alrededor de un 40% de los ancianos que acuden a un servicio de urgencias por haber sufrido una caída se encontraban tomando BZD/Z. Hemos hallado algunas diferencias de género en la prescripción de BZD/Z, especialmente en la prescripción por encima de la dosis recomendada para ancianos y de fármacos de vida media larga.
Despite cautions by professional associations, benzodiazepines (BZD) and Z hypnotics (BZD/Z) are widely prescribed to older adults who are particularly susceptible to insomnia and anxiety, but who are also more sensitive to drugs adverse events. In this study, we assessed the prescription of BZD/Z drugs in a sample of older adults (≥ 65) who presented for emergency care after a fall.
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There is much concern about the widespread long-term use of benzodiazepines. Our manuscript addressed its use in the region of Southeastern Europe, which seems extensive, but insufficiently explored. At nine university psychiatric hospitals (Croatia, Macedonia and Serbia), we retrospectively analyzed discharge summary documents to find the prevalence of discharge benzodiazepine prescriptions and the prescribed benzodiazepine doses. This study included 1047 adult subjects and showed that 81.9% of them had benzodiazepines prescribed in the discharge summary document, with high mean daily dose of around 5 mg lorazepam equivalents. Factors associated with the prescriptions were exclusively clinical factors (diagnosis of schizophrenia spectrum disorders, more lifetime hospitalizations, psychiatric comorbidity, co-prescription of antidepressant or mood stabilizer, shorter duration of the hospitalization), while socio-demographic factors were not found to influence benzodiazepine discharge prescriptions. Similarly, factors which influenced the prescription of higher daily benzodiazepine dose were more lifetime psychiatric hospitalizations and co-prescription of antidepressant or mood stabilizer, as well as the diagnosis of mental/behavioral disorders due to substance use and co-prescribed antipsychotic. Our data are emphasizing an urgent need for guidelines and improved education of both health care professionals and patients, in order to prevent long term benzodiazepine (mis)use and related side-effects.
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According to the studies included in our systematic review, exposure to BZDs is associated with a higher risk for falls in older adults, which is consistent with the results reported in previous reviews and meta-analyses [10]. This review updates the results of previous studies and suggests that clinical practice guidelines and recommendations on reducing the use of BZDs in older patients [26] and on paying special attention to the occurrence of falls [27] have been so far ineffective. Thus, BZDs are still associated with the occurrence of falls among the elderly.
Falls in the elderly represent a major health problem. The etiology of falls is usually multifactorial. Special attention should be paid on benzodiazepines (BZDs) since they are widely used by older adults.
A literature search of the PUBMED and EMBASE databases from January 2007 to February 2017 was conducted using the MeSH terms “benzodiazepines”, “elderly” and “falls” or “accidental falls”. The systematic review was performed according to PRISMA criteria.
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Original ArticleWhat is the point of guidelines? Benzodiazepine and z-hypnotic use by an elderly population

Abstract

Background

Methods

Results

Conclusions

Section snippets

Background

Methods

Results

Discussion

Conflict of Interest

Acknowledgement

Soc Sci Med

Ann Epidemiol

J Clin Epidemiol

Clin Ther

Sleep Med

The Norwegian General Practice (NORGEP) criteria for assessing potentially inappropriate prescriptions to elderly patients. A modified Delphi study

Scand J Prim Health Care

Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts.

Arch Intern Med

STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation

Int J Clin Pharmacol Ther

Guidelines for the rational use of benzodiazepines. When and what to use

Drugs.

Explicit criteria for determining potentially inappropriate medication use by the elderly. An update

Arch Intern Med

The Compendium of Pharmaceuticals and Specialties (CPS)

Guidelines for the clinical use of benzodiazepines: pharmacokinetics, dependency, rebound and withdrawal. Canadian Society for Clinical Pharmacology

Can J Clin Pharmacol

Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits

BMJ

The use of benzodiazpines and related drugs amongst older people in Sweden: associated factors and concomitant use of other psychotropics

Int J Geriatr Psychiatry

Benzodiazepine prescribing to the Swiss adult population: results from a national survey of community pharmacies

Int Clin Psychopharmacol

The epidemiology of long-term benzodiazepine use

Int Rev Psychiatry

Characteristics of benzodiazepine long-term users: investigation of benzodiazepine consumers among pharmacy customers

Psychopharmacology (Berl)

Survival analytic approach to long-term prescription of benzodiazepine hypnotics

Psychiatry Clin Neurosci

Z-hypnotics – the dominating hypnotics in Norway

Norsk Farmaceutisk Tidsskrift

The diagnosis and management of insomnia in clinical practice. a practical evidence-based approach

CMAJ

Treatment considerations for anxiety in the elderly

CNS Spectr

Rebound insomnia and newer hypnotics

Psychopharmacology (Berl)

Long-term therapeutic use of benzodiazepines. I. Effects of abrupt discontinuation

Arch Gen Psychiatry

The benzodiazepine treadmill – does one prescription lead to more?

Pharmacoepidemiol Drug Saf

Original Article
What is the point of guidelines? Benzodiazepine and z-hypnotic use by an elderly population