Sleep of poor quality, long-term prescription and white race are key factors that predict the conversion to long-term use of benzodiazepine in the elderly, a practice that is strongly linked to poor results, including death.
The results emphasize the need to "start with the end in mind" when prescribing a benzodiazepine, author Lauren B. Gerlach, DO, a geriatric psychiatrist and assistant professor in the department of psychiatry and the program for positive aging, University from Michigan, Ann Arbor, told Medscape Medical news.
This means "starting with a short-term prescription and involved patients when discussing when their symptoms need to be re-evaluated and start tapping the patient," she said.
Gerlach said that more work is needed to improve access to effective non-pharmacological treatments, such as cognitive behavioral therapy, and to provide access to education about such treatments.
The study was published online on September 10th JAMA Psychiatry.
A common practice
Treatment guidelines recommend that benzodiazepines should be used in the short term if used at all. However, research shows that up to one third of the long-term useful life is used and that use is the most common in older adults.
The researchers point out that the factors that predict that long-term benzodiazepine is used are poorly understood.
To identify these risk factors, the researchers used data from the supportive treatment and intervention seniors program (SUSTAIN), which complements a Pennsylvania medication program for older adults with low incomes.
Programs include detailed interviews to screen for psychological problems such as anxiety, depression and sleep problems, as well as pain and analysis of prescription records and other clinical data.
The researchers investigated how many elderly people who received a new prescription of benzodiazepine from a non-psychiatric care provider used long-term use of the drug. They also evaluated the patient and clinical characteristics that predicted long-term use.
Prolonged use was defined as a medication utilization ratio (MPR) of more than 30% in the year following the original prescription. Gerlach explained that the MPR was calculated by dividing the number of days of medication divided by 365 days.
The study included 576 older adults (mean age, 78.4 years).
The analysis showed that 1 year after the index prescription, 26.4% of the patients met the criteria for long-term use. They were prescribed benzodiazepines for an average of 232.7 days.
Although treatment guidelines recommend only short-term prescribing, "these long-term patients were prescribed almost 8 months of medication after their first prescription," Gerlach said.
In custom analyzes, white race (odds ratio [OR]4.19; 95% confidence interval [CI] 1.51 – 11.59; P = .006), days delivered on the index recipe (OR, 1.94, 95% CI, 1.52 – 2.47; P <.001) and poor sleep quality (OR for very, very bad versus very good, 4.05; 95% CI, 1.44 – 11.43; P = .008) were factors that were associated with increased long-term use of benzodiazepine.
"Cause for concern"
It is a cause for concern that non-clinical factors are associated with the prescription of benzodiazepines, Gerlach said.
"The decision to prescribe and then continue a benzodiazepine – or any other medical treatment – must be directed by a clinical need," she said.
Gerlach said it was "particularly striking" that for every 10 extra days of prescribed medication, "the risk of long-term use of a patient almost doubled in the next year."
This finding suggests that providers should pause and think more carefully when providing a new prescription for benzodiazepines, such as a delivery of 14 days instead of a 30-day drug, "Gerlach said.
Also with regard to the average age of participants in the study when they first received a benzodiazepine prescription (78 years), because national guidelines say that these drugs "should rarely be given to adults over 65," she said.
Of the clinical measures that the researchers evaluated, including depression, anxiety, sleep and pain, only bad sleep was associated with the likelihood of continued use of benzodiazepine.
"This is despite the fact that benzodiazepines are not recommended for long-term use as sleeping pills, and may worsen sleep outcomes as they are used longer," Gerlach said.
Because non-psychiatric doctors increasingly prescribe psychotropic drugs to older adults, the authors state that it is "crucial" to improve access to and education about non-pharmacological treatments.
The authors note that the study did not take into account the required medication use, which may have had an effect on the calculation of long-term use. Also, the analysis was limited to older adults with a low income from Pennsylvania, which can limit the generalizability.
The authors also point out that the definitions of long-term use of benzodiazepine vary and that it is possible that a different definition of long-term use may have produced different results. However, the researchers used three alternative definitions, without significant differences in the findings.
Respond to the article before Medscape Medical news, Peter Yellowlees, MD, professor of psychiatry and vice-chairman for faculty development, Department of Psychiatry, University of California, Davis, said he was somewhat surprised that no more patients converted to long-term benzodiazepine prescriptions and that whites and non-minority groups were more likely to long-term medications are prescribed.
He said the "main message" from the study is that patients should know from the outset that their prescription for benzodiazepine will be short-term.
In his own practice Yellowlees said that he "very rarely" prescribes benzodiazepines and "it is much more likely" to slim patients off these drugs.
He strives to ensure that patients take these addictive medicines only three or four times a week – not every day – to prevent them from becoming addicted & # 39; and patients & # 40; extremely slow & # 39; to slim down – more than 3 to 6 months.
"Most people try to subtract patients in a matter of maybe 2 or 3 weeks, they go from, say, from 10 mg a week, to 5 mg the next, to whatever, and frankly, that is just too difficult for many people, patients, "he said.
The problem is that such a slow, tapered approach can be time-consuming, and that GPs can only consult 15 minutes per patient.
Benzodiazepines have been associated with falls and cognitive impairment, Yellowlees said.
"The effects can mimic early dementia, people get confused and that leads to falls and being unable to live at home, with patients having to go to a nursing home," he said.
There are also risks of taking these drugs and then driving, Yellowlees said.
Instead of benzodiazepines, he often uses cognitive behavioral therapy for patients who have problems with sleep or anxiety.
The study was funded by the Pharmaceutical Assistance Contract for the elderly of the Commonwealth of Pennsylvania. Dr. Gerlach and Dr. Yellowless have not disclosed relevant financial relationships.
JAMA Psychiatry. Published onlineSeptember 10, 2018. Summary
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