Intermittent Use of Benzodiazepines
BARCELONA — Intermittent benzodiazepine use significantly reduces the risk for falls, fractures, and mortality in older adults compared with chronic use of these medications, results of a large-scale study show.
Investigators matched more than 57,000 chronic-benzodiazepine users with nearly 114,000 intermittent users and found that at 1-year, chronic users had an 8% increased risk for emergency department (ED) visits and/or hospitalizations for falls.
Chronic users also had a 25% increased risk for hip fracture, a 4% raised risk for ED visits and/or hospitalizations for any reason, and a 23% increased risk for death.
Study investigator Simon J.C. Davies, MD, PhD, MSc, Centre for Addiction & Mental Health in Toronto, Canada, said that the research shows that where possible, patients older than 65 years with anxiety or insomnia who are taking benzodiazepines should not stay on these medications continuously. However, he acknowledged that, "in practical terms, there will be some who can't change or do not want to change" their treatment.
Wide Range of Adverse Outcomes
The authors note that benzodiazepines are used to treat anxiety and insomnia but are associated with a range of adverse outcomes, including falls, fractures, cognitive impairment, and mortality as well as tolerance and dose escalation.
"These risks are especially relevant in older adults," they add, noting that some guidelines recommend avoiding the drugs in this population, whereas other suggest short-term benzodiazepine use for a maximum of 4 weeks.
Despite this, "benzodiazepines are widely prescribed in older adults. One study showed that almost 15% of adults aged 65 years or older received at least one benzodiazepine prescription.
Moreover, chronic use is more common in older vs younger patients.
Benzodiazepine use among older adults "used to be higher," Davies told Medscape Medical News, at around 20%, but the "numbers have come down," partly due to the introduction of benzodiazepine-like sleep medications but also due to educational efforts.
"There are certainly campaigns in Ontario to educate physicians," Davies said, "but I think more broadly people are aware of the activity of these drugs, and the tolerance and other issues."
To compare the risk associated with chronic vs intermittent use of benzodiazepines in older adults, the team performed a population-based cohort study using linked healthcare databases in Ontario.
They focused on adults aged 65 years or older with a first benzodiazepine prescription after at least 1 year without taking the drugs. Chronic benzodiazepine use was defined as 120 days of prescriptions over the first 180 days after the index prescription. Patients who met these criteria were matched with intermittent users in a 2:1 ratio by age and sex. Patients were then propensity matched using 24 variables including health system use in the year prior to the index prescription, clinical diagnoses, prior psychiatric health system use, falls, and income level.
The team identified 57,072 chronic-benzodiazepine users and 312,468 intermittent users, of whom, 57,041 and 113,839, respectively, were propensity matched. As expected, chronic users were prescribed benzodiazepines for more days than were the intermittent users over both the 180-exposure period, at 141 days vs 33 days, and again during a further 180-day follow-up period, at 181 days vs 19 days.
Over the follow-up period, the daily lorazepam dose-equivalents of chronic users four times that of intermittent users. Hospitalizations and/or ED visits for falls were higher among patients in the chronic-benzodiazepine group, at 4.6% vs 3.2% in those who took the drugs intermittently. After adjusting for benzodiazepine dose, the team found that chronic benzodiazepine use was associated with a significant increase in the risk for falls leading to hospital presentation over the 360-day study period compared with intermittent use. (hazard ratio [HR], 1.08; P = .0124).
Sex Differences
In addition, chronic use was linked to a significantly increased risk for hip fracture (HR, 1.25; P = .0095), and long-term care admission (HR, 1.32; P < .0001).
There was also a significant increase in ED visits and/or hospitalizations for any reason with chronic benzodiazepine use vs intermittent use (HR, 1.04; P = .0007), and an increase in the risk for death (HR, 1.23; P < .0001). A nonsignificant increased risk for wrist fracture was also associated with chronic use of benzodiazepines (HR, 1.02; P = .8683).
Further analysis revealed some sex differences. For instance, men had a marked increase in the risk for hip fracture with chronic use (HR, 1.50; P = .0154), whereas the risk was not significant in women (HR, 1.16; P = .1332). In addition, mortality risk associated with chronic use was higher in men than in women (HR, 1.39; P < .0001 vs HR, 1.10; P = .2245).
The decision to discontinue chronic benzodiazepine use can be challenging, said Davies. "If you're advising people to stop, what happens to the treatment of their anxiety?" He said that there are many other treatment options for anxiety that don't come with tolerance or risk for addiction. "My position would be that intermittent use is perfectly acceptable while you bide your time to explore other treatments. They may be pharmacological; they may, of course, be lifestyle changes, psychotherapies, and so on," said Davies. If, however, patients feel that chronic benzodiazepine use is their only option, this research informs that decision by quantifying the risks. "We've always known that there was a problem, but there haven't been high-quality epidemiological studies like this that allowed us to say what the numbers are," said Davies.
Confirmatory Research
Commenting on the research for Medscape Medical News, Christoph U. Correll, MD, Professor of Psychiatry at the Zucker School of Medicine at Hofstra/Northwell, New York, NY, noted that the risk associated with benzodiazepine use, especially in older people, has been demonstrated repeatedly.
"In that context, it is not surprising that less continuous exposure to an established risk factor attenuates the risk for these adverse outcomes," he said. Correll, who was not involved in the study pointed out there is nevertheless a "risk of residual confounding by indication." In other words, "people with intermittent benzodiazepine use may have less severe underlying illness and better healthy lifestyle behaviors than those requiring chronic benzodiazepine administration."
Also commenting on the research, Christian Vinkers, MD, PhD, psychiatrist and professor of stress and resilience, Amsterdam University Medical Centre, Amsterdam, the Netherlands, said that it confirms "once again that long-term benzodiazepine use should not be encouraged."
"The risk of falls, as well as cognitive side effects and impaired driving skills, with the risk of road accidents, make chronic overuse of benzodiazepines a public health issue. Of course, there is a small group of patients who should have access to long-term use, but it is reasonable to assume that this group is currently too large," he added.
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