HEALTH

Continued Questions on Benzodiazepine Use in Older Patients

Users of benzodiazepines, such as Valium, face increased risks of falls, auto accidents and reduced cognition. Newscom 
The New Old Age
By  PAULA SPAN
The word “benzodiazepines” and the phrase “widely prescribed for anxiety and insomnia” appear together so frequently that they may remind you of the apparently unbreakable connection between “powerful” and “House Ways and Means Committee.”
But now we have a better sense of just how widely prescribed these medications are. A studyin this month’s JAMA Psychiatry reports that among 65- to 80-year-old Americans, close to 9 percent use one of these sedative-hypnotics, drugs like Valium, Xanax, Ativan and Klonopin. Among older women, nearly 11 percent take them.
“That’s an extraordinarily high rate of use for any class of medications,” said Michael Schoenbaum, a senior adviser at the National Institutes of Mental Health and a co-author of the new report. “It seemed particularly striking given the identified clinical concerns associated with benzodiazepine use in anybody, but especially in older adults.”
He was referring to decades of warnings about the potentially unhappy consequences of benzodiazepines for older users. The drugs still are recommended for a handful of specific disorders, including acute alcohol withdrawal and, sometimes, seizures and panic attacks. But concerns about the overuse of benzodiazepines have been aired again and again: in the landmark nursing home reform law of 1987, in the American Geriatrics Society’s Choosing Wisely list of questionable practices in 2013, in last year’s study in the journal BMJ suggesting an association with Alzheimer’s disease.
Benzodiazepine users face increased risks of falls and fractures, of auto accidents, of reduced cognition. “Even after one or two doses, you have impaired cognitive performance on memory and other neuropsychological tests, compared to a placebo,” said Dr. D.P. Devanand, director of geriatric psychiatry at Columbia University Medical Center.
In 2012, the American Geriatrics Society updated its list of inappropriate medications for older patients and bluntly advised physicians to “avoid benzodiazepines (any type) for treatment of insomnia, agitation, or delirium.” The quality of evidence: “High.” The strength of the recommendation: “Strong.”
Not much ambiguity there. Yet when Dr. Schoenbaum and his colleagues dug into a 2008 database that tracked prescriptions at 60 percent of all retail pharmacies in the United States, including mail-order operations, they found benzodiazepine use rising sharply with age. “It just goes up and up,” he said.
Worse, they found that long-term use also increased with age. Patients of all ages are cautioned to use benzodiazepines for only a few weeks, but in the people aged 65 to 80, nearly a third had taken the drugs for more than 120 days.
“They could have been on that drug for 10 years,” said Dr. Mark Olfson, professor of psychiatry at Columbia University Medical Center, a co-author of the study. “Once people have started these drugs, it’s hard to get them off.”
An accompanying editorial was pointedly headlined “Why Are Benzodiazepines Not Yet Controlled Substances?” (Some states already impose limits: New York generally restricts prescriptions to a 30 day supply, without refills.) It is hard to think of another class of medications that, after 30 years of warnings, physicians still so frequently prescribe and older people so commonly take.
Why the stubborn attachment to benzodiazepines? Psychiatrists and researchers I consulted pointed out several factors:
■ They work, and fast. Older people develop more sleep problems. Take a benzodiazepine and “the first night, you’ll get a better night’s sleep,” Dr. Olfson said.
The medically recommended first-line treatments — improved sleep habits and hygiene for insomnia, antidepressants and brief cognitive behavioral therapy for anxiety — work too, research shows, but require far more time and effort. Therapy, often an unpopular option among the older patients, can prove hard to access.
“Older patients are socialized to think their prescribers have some magic, a pill for everything,” said Joan Cook, a psychologist at Yale University who has published research about benzodiazepine use.
Patients and doctors may notice the benefits – sleep! – but not recognize the downsides, Dr. Olfson pointed out, even when they occur. “If an older person falls out of bed and breaks a hip, benzos may not be seen as the culprit,” he said. “They increase the likelihood of events older people are prone to, anyway.”
(Note to insomniacs turning to the related “z-drugs” — Ambien (zolpidem), Lunesta and Sonata — thinking they are safer: The Centers for Disease Control and Prevention last year reported on psychiatric drug reactions that sent people to emergency rooms. “We were surprised by the number of adverse events that involved zolpidem,” said co-author Dr. Daniel Budnitz, director of the C.D.C.'s medications safety program. Among those over age 65, Ambien accounted for one E.R. visit in five.)
■ Benzos are addictive, though physicians prefer less-charged language like “habituating” or causing “dependence.” “If we want to help people taper off, we can’t seem to be judging or blaming them,” Dr. Cook cautioned.
Nonetheless, after several weeks’ use, people who discontinue them often suffer withdrawal symptoms, the same sleeplessness or sweaty nervousness that sent them to their doctors in the first place.
■ Though it is unclear if these drugs actually provide therapeutic benefit after the first few weeks, users often don’t want to consider discontinuing or trying alternate treatments. Dr. Cook’s interviews turned up a variety of justifications, fears and underestimations of side effects, among both patients and doctors.
Consider a pilot study that Dr. Gregory Simon, a psychiatrist and senior investigator at the Group Health Cooperative in Seattle, and his colleagues decided to undertake nearly 20 years ago.
They planned a program to help people discontinue chronic benzodiazepine use and sent letters announcing it to 50 older patients. “Half the people called and said, ‘Don’t contact me. I don’t want to talk about stopping,’” Dr. Simon recalled. Only five people agreed to discuss the pilot; two actually showed up. The study never took place.
■ The health care system hasn’t really encouraged older patients to wean themselves. Most prescribers are primary care doctors, struggling to address older people’s multiple health problems, and to supervise several medications, during brief visits.
They see tapering off as a major undertaking, Dr. Cook found, requiring weeks of visits and monitoring. “They said their patients would fight them tooth and nail,” she said. Refilling the prescription was easier.
This may be changing. At Group Health Cooperative, for example, the take-home documents given to patients taking sedative-hypnotics includes a forthright list of risks and warns that the physician may decide that “it is no longer safe or appropriate to continue prescribing chronic sedative therapy.”
There is also some evidence that weaning can be less daunting than patients and physicians believe. A Canadian study has shown that a simple brochure providing a schedule for tapering off the drug over several months can work for some motivated patients, even long-term users. Dr. Simon has recommended a website established by a British psychopharmacologist, C. Heather Ashton, that similarly guides users through gradual withdrawal.
Studies of benzodiazepine risks look at patterns in large groups of people but can’t predict risks in a given individual, of course, and many demonstrate associations but can’t prove that the drugs directly cause falls, accidents and cognitive problems. They may still be appropriate for certain conditions.
Still, Dr. Simon said, “I’m convinced that for a lot of the people, a lot of the time, the net effect of these medications is to make things worse.”