Benzodiazepine use in the elderly: the EVA Study

BACKGROUND: The objectives of this study were to describe the use of benzodiazepines in the elderly and to identify socio-demographic and medical factors associated with this use. METHODS: Data on the use of sedative and sleeping drugs were collected from a self-reported questionnaire, in a sample of 1265 elderly subjects (aged 60 to 70 years) interviewed at the first follow-up examination of the EVA Study (Epidemiology of Vascular Aging Study). RESULTS: Use of sedative or sleeping drugs was reported by 28.7% of the participants and use of benzodiazepines by 23%. Most of the benzodiazepines used (71%) had anxiolytic indications, 48% were long-acting compounds (elimination half-life>=20 h.). Among benzodiazepine users, 71% reported using benzodiazepines daily and 77% reported they had been taking benzodiazepines for at least 2 years. Nearly two third of the benzodiazepine users reported taking their medications as prescribed. When they were not compliant, they took benzodiazepines less often and/or at slighter doses than prescribed. Use of benzodiazepines was associated with symptoms of depression or anxiety (women: odds-ratio=2.6 [1.7-4.1]; men: odds-ratio=4.4 [2.4-7.8]) and with regular use of at least three non-psychotropic drugs (women: odds-ratio=2.0 [1.4-2.9]; men: odds-ratio=1.8 [1.1-3.1]). Women with a high educational level or with moderate alcohol consumption were less likely to take benzodiazepines; these associations were not found in men. CONCLUSIONS: The present study shows that benzodiazepines are the sedative and sleeping drugs most widely used by the elderly. Nearly three quarters of benzodiazepine users were chronic users.     

The contribution of injecting drug users in Sydney,Melbourne and Brisbane to rising benzodiazepine use in Australia 2000 to 2006

Objective: To determine whether the increased utilisation of benzodiazepines in Australia from 2000 to 2006 could be accounted for by the increased use of benzodiazepines among those who inject heroin Method: Areas known to have high numbers of injecting drug users, (IDU) in Sydney, Melbourne and Brisbane, Australia were identified. Data were obtained from the Medicare and the Drug Utilization Sub‐Committee databases on all benzodiazepines dispensed to concession beneficiaries in the chosen areas and Australia as a whole. The utilisation of benzodiazepines was calculated in defined daily dose per 1000 (DDD/1000) beneficiaries and for IDU/day using the estimated numbers of IDU, from 2000‐2006. Results: The utilisation of benzodiazepines increased by 22% for all Australian concession beneficiaries but in areas with a high proportion of IDU, the utilisation of benzodiazepines decreased. Conclusions: In areas known to have a high proportion of IDU, the concession beneficiary use of benzodiazepines was estimated to be largely accounted for IDU usage. However, the overall increase in benzodiazepine utilisation by Australian concession beneficiaries from 2000 to 2006 was not primarily driven by use among IDU who only accounted for a small proportion of total benzodiazepines use. Implications: It appears that sub‐groups of the populations, other than IDU may be responsible for the increase in benzodiazepine use by concession beneficiaries.     

Long-term benzodiazepine users in family practice: differences from short-term users in mental health, coping behaviour and psychological characteristics

BACKGROUND: Contrary to short-term use, long-term benzodiazepine use is undesirable. Nevertheless, its prevalence is high. To prevent long-term use, it is important to know which short-term users are at risk of becoming long-term users. OBJECTIVES: The purpose of the present study was to identify patient-related factors of long-term versus short-term use of benzodiazepines. METHODS: A cross-sectional study was carried out in family practices among users of benzodiazepines with regard to DSM-IV diagnosis, coping and psychosocial characteristics,. In a multivariate logistic regression analysis, long-term use of benzodiazepines was the dependent variable. RESULTS: A total of 164 short-term and 158 long-term benzodiazepine users participated in the study. Having a DSM-IV disorder and psychiatric co-morbidity, being older, less educated, lonely and using more avoidance coping behaviour was associated with long-term use of benzodiazepines compared with short-term use. CONCLUSION: The associations found point to possibilities to reduce long-term benzodiazepine use, for example if patients with these characteristics are treated with the alternatives to benzodiazepines or are monitored closely for a short period after being prescribing benzodiazepines.     

Long-term benzodiazepine use by elderly people living in the community

Objective : To investigate the prevalence of long‐term benzodiazepine use in an elderly community sample, and factors associated with such use. Method : Data came from the Sydney Older Persons Study, a longitudinal study of people aged 75 or over. There were 337 subjects who were interviewed in 1991–93, and subsequently followed up after three and 4.5 years. At the first interview, subjects were assessed for socio‐demographic characteristics, physical and mental health, and use of health services. At the first and subsequent interviews, subjects were asked about use of medications, including benzodiazepines. Results : There were 16.6% who were using benzodiazepines at the time of all three interviews, while a further 19.6% were using them at one or two interviews. In a multivariate ordered logit regression model, long‐term benzodiazepine use was associated with treatment for nervous conditions, restless sleep, being female, being divorced and greater contact with medical services. Conclusions : The prevalence of benzodiazepine use in the elderly is high and much of this use is long term. The high prevalence of benzodiazepine use stands in contrast to the findings from national surveys that the elderly living in the community tend to have better mental health than younger age groups. Implications : Efforts are needed to reduce the number of elderly people becoming long‐term users. The use of benzodiazepines in this age group is of particular concern, because they may be a risk factor for falls and for cognitive impairment in the elderly.     

Concomitant prescribing of benzodiazepines during antidepressant therapy in the elderly

A follow-up study was performed in two ambulatory cohorts aged > or =65 to investigate whether the prevalence and incidence of anxiolytic/hypnotic benzodiazepine drug prescribing is comparable between users of serotonin reuptake inhibitors (SSRIs) and users of tricyclic antidepressants (TCAs). The prevalence and incidence of benzodiazepines during antidepressant therapy was estimated among users of TCAs and SSRIs. Coprescribing of benzodiazepines occurred in 53% of the TCA users and 57% of the SSRI users (prevalence RR 1.1; CI(95) 0.9-1.2). The average duration of benzodiazepine drug use was >65 days per 100 days of antidepressant use. During SSRI therapy, significantly more people started benzodiazepine drug therapy than during TCA therapy (incidence rate ratio (RR) 1.7; CI(95) 1.2-2.4). Analyses repeated 5 years later yielded similar results (overall incidence RR(MH) 1.6; CI(95) 1.3-2.0). These data indicate that SSRI use is associated with a significantly higher chance of starting benzodiazepines compared with TCA use.     

Views of general practitioners and benzodiazepine users on benzodiazepines: a qualitative analysis

Effectively assisting benzodiazepine users to cease use requires a greater understanding of general practitioners' (GPs) and benzodiazepine users' views on using and ceasing benzodiazepines. This paper reports the findings from a qualitative study that examined the views of 28 GPs and 23 benzodiazepine users (BUs) in Cairns, Australia. A semi-structured interview was conducted with all participants and the information gained was analysed using the Consensual Qualitative Research Approach, which allowed comparisons to be made between the views of the two groups of interviewees. There was commonality between GPs and BUs on reasons for commencing benzodiazepines, the role of dependence in continued use, and the importance of lifestyle change in its cessation. However, several differences emerged regarding commencement of use and processes of cessation. In particular, users felt there was greater need for GPs to routinely advise patients about non-pharmacological management of their problems and potential adverse consequences of long-term use before commencing benzodiazepines. Cessation could be discussed with all patients who use benzodiazepines for longer than 3 months, strategies offered to assist in management of withdrawal and anxiety, and referral to other health service providers for additional support. Lifestyle change could receive greater focus at all stages of treatment.     

The impact of attitudes and beliefs on length of benzodiazepine use: a study among inexperienced and experienced benzodiazepine users

Prolonged benzodiazepine use is a widespread phenomenon in medical practice. In the present article, we argue that psychological models may contribute to our understanding of benzodiazepine use. This study examined variables derived from the theory of planned behaviour and the health belief model in relation to the length of benzodiazepine use. Data were collected from a sample of all benzodiazepine users with a request for this medicine in the only pharmacy in a Dutch community (N=467). Determinants of the length of benzodiazepine use were analysed separately for inexperienced and experienced users using structural equation modelling (SEM) analyses. For both groups, results showed that the intention to use benzodiazepines was a predictor of length of use. Attitudes towards benzodiazepine use had an indirect influence on length of use, through intentions. Furthermore, a positive attitude toward using benzodiazepines was related to the perceived norm of the prescriber. Experienced users were more inclined to consume benzodiazepines when they had less control over drug taking. In this group, the belief that benzodiazepine use leads to dependence was associated with less control over drug taking and a high intention to use the drug. In addition, older experienced users reported a higher intention to use the drug. For inexperienced users, the perceived attitude of the prescriber towards use of the medicine was a strong determinant. Finally, results of SEM-analyses showed that the model accounted for far more variance in behaviour for experienced users (67%), than for inexperienced users (18%).     

Treatment methods for discontinuation of long-term benzodiazepine use

Treatment strategies for discontinuing long-term benzodiazepine usage can be divided into minimal interventions and gradual discontinuation programs. Minimal interventions invite patients to quit their long-term benzodiazepine usage on their own by making them aware of the adverse effects. This type of intervention is successful in about one fifth of patients. Gradual discontinuation programs are more extensive interventions in order to help those patients who are unable to discontinue benzodiazepine use on their own. These programs are successful in two-thirds of the patients and can be combined with additional pharmacological or psychological treatment. Once the withdrawal symptoms have diminished, most patients have an improved psychological functioning compared to when they were using benzodiazepines. Furthermore, no increase in medical consumption has been found.