Abstract
Purpose
Guidelines discourage chronic benzodiazepines and related Z drugs (BZD/Zs) for sleep problems. However, prevalence among nursing home residents remains high. Discontinuing these drugs is widely recommended but seems difficult to implement. The aim of our study was to evaluate the overall feasibility in the nursing home, in terms of willingness towards discontinuation and success rate at 8 months, together with the impact on withdrawal symptoms, change in sleep quality, quality of life and medication use.
Methods
In a convenience sample of five nursing homes (823 residents), we included cognitively competent residents with chronic BZD/Z use for insomnia. We investigated sleep quality [with Pittsburgh Sleep Quality Index (PSQI)], quality of life (EQ-5D) and withdrawal symptoms [Benzodiazepine Withdrawal Symptom Questionnaire (BWSQ)]. Success rate was analysed with survival analysis.
Results
Of the 135 eligible residents, both general physician (GP) and resident were willing to initiate discontinuation in 38 residents. Reasons for refusing to initiate discontinuation among GPs was the unmotivated patient and among residents the reluctance towards change. At 8 months, 66.0 % were successful discontinuers, with the subjective PSQI component evolving favourably (p = 0.013) and a decreasing number of midnight awakenings (p = 0.041). In the relapse group (n = 13), the quality of life decreased (p = 0.012), with mainly an increase of problems with activities and pain/discomfort. In both groups, the withdrawal symptoms, functionality and medication use did not change.
Conclusion
Discontinuation of chronic BZD/Z use is feasible in the nursing home setting without noticeable withdrawal symptoms, without a switch in medication use, without detrimental effect on quality of life and with a positive effect on the self-perceived sleep quality.
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References
Glass J, Lanctot KL, Herrmann N, Sproule BA, Busto UE (2005) Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ 331(7526):1169. doi:10.1136/bmj.38623.768588.47
2 McIntosh B, Clark M, Spry C. (2011) Benzodiazepines in older adults: a review of clinical effectiveness, cost-effectiveness, and guidelines. Rapid response report: peer-reviewed summary with critical appraisal. Canadian Agency for Drugs and Technologies in Health, Ottawa
Ashton H (1994) Guidelines for the rational use of benzodiazepines—when and what to use. Drugs 48(1):25–40
Bloom HG, Ahmed I, Alessi CA, Ancoli-Israel S, Buysse DJ, Kryger MH, Phillips BA, Thorpy MJ, Vitiello MV, Zee PC (2009) Evidence-based recommendations for the assessment and management of sleep disorders in older persons. J Am Geriatr Soc 57(5):761–789
Committee on Safety of Medicines (1988) UK Government Bulletin to Prescribing Doctors: benzodiazepines, dependence and withdrawal symptoms
Turnham H. (2001) Federal Nursing Home Reform Act from the Omnibus Budget Reconciliation Act of 1987. National Long Term Care Ombudsman Resource Center
(2011) The impact of psychotropics on health with special attention to the elderly. Belgium Superior Health Council
Bourgeois J, Elseviers MM, Van Bortel L, Petrovic M, Vander Stichele RH (2013) Sleep quality of benzodiazepine users in nursing homes: a comparative study with nonusers. Sleep Med 14(7):614–621. doi:10.1016/j.sleep.2013.03.012
Hosia-Randell H, Pitkala K (2005) Use of psychotropic drugs in elderly nursing home residents with and without dementia in Helsinki, Finland. Drugs Aging 22(9):793–800
Gobert M, D’Hoore W (2005) Prevalence of psychotropic drug use in nursing homes for the aged in Quebec and in the French-speaking area of Switzerland. Int J Geriatr Psychiatry 20(8):712–721. doi:10.1002/gps.1349
de Souto Barreto P, Lapeyre-Mestre M, Mathieu C, Piau C, Bouget C, Cayla F, Vellas B, Rolland Y (2013) Indicators of benzodiazepine use in nursing home residents in France: a cross-sectional study. J Am Med Dir Assoc 14(1):29–33. doi:10.1016/j.jamda.2012.09.002
Lader M, Tylee A, Donoghue J (2009) Withdrawing benzodiazepines in primary care. CNS Drugs 23(1):19–34. doi:10.2165/0023210-200923010-000022312
Ostini R, Jackson C, Hegney D, Tett SE (2011) How is medication prescribing ceased? A systematic review. Med Care 49(1):24–36. doi:10.1097/MLR.0b013e3181ef9a7e
Voshaar RC, Couvee JE, van Balkom AJ, Mulder PG, Zitman FG (2006) Strategies for discontinuing long-term benzodiazepine use: meta-analysis. Br J Psychiatry 189:213–220. doi:10.1192/bjp.189.3.213
Rickels K, Schweizer E, Case WG, Greenblatt DJ (1990) Long-term therapeutic use of benzodiazepines. I Effects of abrupt discontinuation. Arch Gen Psychiatry 47(10):899–907
Petrovic M, Pevernagie D, Van Den Noortgate N, Mariman A, Michielsen W, Afschrift M (1999) A programme for short-term withdrawal from benzodiazepines in geriatric hospital inpatients: success rate and effect on subjective sleep quality. Int J Geriatr Psychiatry 14(9):754–760. doi:10.1002/(SICI)1099-1166(199909)14:9<754::AID-GPS15>3.0.CO;2-E
Ashton H (1987) Benzodiazepine withdrawal: outcome in 50 patients. Br J Addict 82(6):665–671
Gould RL, Coulson MC, Patel N, Highton-Williamson E, Howard RJ (2014) Interventions for reducing benzodiazepine use in older people: meta-analysis of randomised controlled trials. Br J Psychiatry 204(2):98–107. doi:10.1192/bjp.bp.113.126003
Salonoja M, Salminen M, Aarnio P, Vahlberg T, Kivela SL (2010) One-time counselling decreases the use of benzodiazepines and related drugs among community-dwelling older persons. Age Ageing 39(3):313–319. doi:10.1093/ageing/afp255
Petrovic M, Pevernagie D, Mariman A, Van Maele G, Afschrift M (2002) Fast withdrawal from benzodiazepines in geriatric inpatients: a randomised double-blind, placebo-controlled trial. Eur J Clin Pharmacol 57(11):759–764
Tham TC, Brown H, Taggart HM (1989) Temazepam withdrawal in elderly hospitalized patients: a double blind randomised trial comparing abrupt versus gradual withdrawal. Ir J Med Sci 158(12):294–299
Avorn J, Soumerai SB, Everitt DE, Ross-Degnan D, Beers MH, Sherman D, Salem-Schatz SR, Fields D (1992) A randomized trial of a program to reduce the use of psychoactive drugs in nursing homes. N Engl J Med 327(3):168–173. doi:10.1056/NEJM199207163270306
Habraken H, Soenen K, Blondeel L, VanElsen J, Bourda J, Coppens E, Willeput M (1997) Gradual withdrawal from benzodiazepines in residents of homes for the elderly: experience and suggestions for future research. Eur J Clin Pharmacol 51(5):355–358
Bell JS, Lavikainen P, Korhonen M, Hartikainen S (2011) Benzodiazepine discontinuation among community-dwelling older people: a population-based cohort study. Eur J Clin Pharmacol 67(1):105–106. doi:10.1007/s00228-010-0897-z
Tsunoda K, Uchida H, Suzuki T, Watanabe K, Yamashima T, Kashima H (2010) Effects of discontinuing benzodiazepine-derivative hypnotics on postural sway and cognitive functions in the elderly. Int J Geriatr Psychiatry 25(12):1259–1265. doi:10.1002/gps.2465
Gilbert A, Owen N, Innes JM, Sansom L (1993) Trial of an intervention to reduce chronic benzodiazepine use among residents of aged-care accommodation. Aust N Z J Med 23(4):343–347
Salzman C, Fisher J, Nobel K, Glassman R, Wolfson A, Kelley M (1992) Cognitive improvement following benzodiazepine discontinuation in elderly nursing-home residents. Int J Geriatr Psychiatry 7(2):89–93
Elseviers MM, Vander Stichele RR, Van Bortel L (2010) Drug utilization in Belgian nursing homes: impact of residents’ and institutional characteristics. Pharmacoepidemiol Drug Saf 19(10):1041–1048. doi:10.1002/pds.1983
Katz S, Akpom CA (1976) 12. Index of ADL. Med Care 14(5 Suppl):116–118
WHO (2009) ATC/DDD system. WHO Collaborating Centre for Drug Statistics Methodology
Ashton CH (2007) Benzodiazepine equivalence table
Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, Leirer VO (1982) Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 17(1):37–49
Smalbrugge M, Jongenelis L, Pot AM, Beekman AT, Eefsting JA (2008) Screening for depression and assessing change in severity of depression. Is the Geriatric Depression Scale (30-, 15- and 8-item versions) useful for both purposes in nursing home patients? Aging & Mental Health 12(2):244–248. doi:10.1080/13607860801987238
Jongenelis K, Gerritsen DL, Pot AM, Beekman ATF, Eisses AMH, Kluiter H, Ribbe MW (2007) Construction and validation of a patient- and user-friendly nursing home version of the Geriatric Depression Scale. Int J Geriatr Psychiatry 22(9):837–842. doi:10.1002/Gps.1748
Tyrer P, Murphy S, Riley P (1990) The Benzodiazepine Withdrawal Symptom Questionnaire. J Affect Disord 19(1):53–61
Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ (1989) The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res 28(2):193–213
Verster JC, David B, Morgan K, Olivier B (2008) Validation of the Dutch Occupational Impact of Sleep Questionnaire (OISQ). Ind Health 46(6):601–606
Rabin R, de Charro F (2001) EQ-5D: a measure of health status from the EuroQol Group. Ann Med 33(5):337–343
Al Aqqad SM, Chen LL, Shafie AA, Hassali MA, Tangiisuran B (2014) The use of potentially inappropriate medications and changes in quality of life among older nursing home residents. Clin Interv Aging 9:201–207. doi:10.2147/CIA.S52356
Dolan P, Gudex C, Kind P, Williams A (1996) The time trade-off method: results from a general population study. Health Econ 5(2):141–154. doi:10.1002/(SICI)1099-1050(199603)5:2<141::AID-HEC189>3.0.CO;2-N
Holmes HM, Luo R, Kuo YF, Baillargeon J, Goodwin JS (2013) Association of potentially inappropriate medication use with patient and prescriber characteristics in Medicare Part D. Pharmacoepidemiol Drug Saf 22(7):728–734. doi:10.1002/pds.3431
Gorgels W, Oude Voshaar R, Mol A, van de Lisdonk E, van den Hoogen H, van Balkom A, Breteler M, Zitman F (2008) General practitioners’ opinions of a stepped-care benzodiazepine discontinuation programme. Eur J Gen Pract 14(1):37–39. doi:10.1080/13814780701855666
Cook JM, Marshall R, Masci C, Coyne JC (2007) Physicians’ perspectives on prescribing benzodiazepines for older adults: a qualitative study. J Gen Intern Med 22(3):303–307. doi:10.1007/s11606-006-0021-3
Siriwardena AN, Qureshi Z, Gibson S, Collier S, Latham M (2006) GPs’ attitudes to benzodiazepine and ‘Z-drug’ prescribing: a barrier to implementation of evidence and guidance on hypnotics. Br J Gen Pract 56(533):964–967
Iliffe S, Curran HV, Collins R, Kee SCY, Fletcher S, Woods B (2004) Attitudes to long-term use of benzodiazepine hypnotics by older people in general practice: findings from interviews with service users and providers. Aging & Mental Health 8(3):242–248. doi:10.1080/13607860410001669778
van Hulten R, Bakker AB, Lodder AC, Teeuw KB, Bakker A, Leufkens HG (2003) The impact of attitudes and beliefs on length of benzodiazepine use: a study among inexperienced and experienced benzodiazepine users. Soc Sci Med 56(6):1345–1354
Anthierens S, Habraken H, Petrovic M, Deveugele M, De Maeseneer J, Christiaens T (2007) First benzodiazepine prescriptions: qualitative study of patients’ perspectives. Can Fam Physician 53(7):1200–1201
Tsunoda K, Tanabe A, Uchida H, Suzuki T, Tomita M, Yamashima T, Watanabe K, Kashima H (2008) Effects of discontinuing benzodiazepine-derivative hypnotics on cognitive and motor functions in the elderly: A pilot study. Int J Neuropsychopharmacol 11:301–301
Vicens C, Socias I, Mateu C, Leiva A, Bejarano F, Sempere E, Basora J, Palop V, Mengual M, Beltran JL, Aragones E, Lera G, Folch S, Pinol JL, Esteva M, Roca M, Arenas A, Del Mar SM, Campoamor F, Fiol F (2011) Comparative efficacy of two primary care interventions to assist withdrawal from long term benzodiazepine use: a protocol for a clustered, randomized clinical trial. BMC Fam Pract 12:23. doi:10.1186/1471-2296-12-23
Parsons C, Hughes CM, Passmore AP, Lapane KL (2010) Withholding, discontinuing and withdrawing medications in dementia patients at the end of life: a neglected problem in the disadvantaged dying? Drugs Aging 27(6):435–449. doi:10.2165/11536760-000000000-00000
Bourgeois JEM, Azermai M, Van Bortel L, Petrovic M, Vander SR (2014) Barriers to discontinuation of chronic benzodiazepine use in nursing home residents: perceptions of general practitioners and nurses. Eur Geriatr Med 5(3):181–187
Baldwin D, Woods R, Lawson R, Taylor D (2011) Efficacy of drug treatments for generalised anxiety disorder: systematic review and meta-analysis. BMJ 342:d1199. doi:10.1136/bmj.d1199
Curran HV, Collins R, Fletcher S, Chin YKS, Woods RT, Iliffe S (2003) Withdrawal of older adults from benzodiazepine hypnotics in general practice: effects on cognitive function, sleep, mood and quality of life. J Psychopharmacol 17(3):A26–A26
Linden M, Bar T, Geiselmann B (1998) Patient treatment insistence and medication craving in long-term low-dosage benzodiazepine prescriptions. Psychol Med 28(3):721–729
Parr JM, Kavanagh DJ, Young RM, McCafferty K (2006) Views of general practitioners and benzodiazepine users on benzodiazepines: a qualitative analysis. Soc Sci Med 62(5):1237–1249. doi:10.1016/j.socscimed.2005.07.016
Dyas JV, Apekey TA, Tilling M, Orner R, Middleton H, Siriwardena AN (2010) Patients’ and clinicians’ experiences of consultations in primary care for sleep problems and insomnia: a focus group study. Br J Gen Pract 60(574):e180–200. doi:10.3399/bjgp10X484183
Parr JM, Kavanagh DJ, Cahill L, Mitchell G, Mc DYR (2009) Effectiveness of current treatment approaches for benzodiazepine discontinuation: a meta-analysis. Addiction 104(1):13–24. doi:10.1111/j.1360-0443.2008.02364.x
Soldatos CR, Dikeos DG, Whitehead A (1999) Tolerance and rebound insomnia with rapidly eliminated hypnotics: a meta-analysis of sleep laboratory studies. Int Clin Psychopharmacol 14(5):287–303
Wolkove N, Elkholy O, Baltzan M, Palayew M (2007) Sleep and aging: 2. Management of sleep disorders in older people. Cmaj 176(10):1449–1454. doi:10.1503/cmaj.070335
Ong MK, Xu H, Zhang L, Azocar F, Ettner SL (2012) Effect of medicare part D benzodiazepine exclusion on psychotropic use in benzodiazepine users. J Am Geriatr Soc 60(7):1292–1297. doi:10.1111/j.1532-5415.2012.04031.x
Weintraub M, Singh S, Byrne L, Maharaj K, Guttmacher L (1991) Consequences of the 1989 New York State triplicate benzodiazepine prescription regulations. JAMA 266(17):2392–2397
Zullich SG, Grasela TH Jr, Fiedler-Kelly JB, Gengo FM (1992) Impact of triplicate prescription program on psychotropic prescribing patterns in long-term care facilities. Ann Pharmacother 26(4):539–546
Acknowledgments
We thank all participating nursing homes, the general physicians and, especially, the head nurses for their collaboration.
Contribution of authors
J. Bourgeois formulated the research question, did the date collection, performed analyses and wrote the paper.
M. Elseviers formulated the research question, did the supervision of the statistical analyses and assisted with writing the paper.
M. Petrovic assisted with writing the paper and gave input from a clinical geriatric point of view.
L. Van Bortel assisted with writing the paper.
R. Vander Stichele formulated the research question, assisted with writing the paper and helped interpret the results.
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Bourgeois, J., Elseviers, M.M., Van Bortel, L. et al. Feasibility of discontinuing chronic benzodiazepine use in nursing home residents: a pilot study. Eur J Clin Pharmacol 70, 1251–1260 (2014). https://doi.org/10.1007/s00228-014-1725-7
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DOI: https://doi.org/10.1007/s00228-014-1725-7