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Benzodiazepine use in Belgian nursing homes: a closer look into indications and dosages

  • Pharmacoepidemiology and Prescription
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Abstract

Aim

(1) To describe the prevalence of benzodiazepine use in Belgian nursing homes, with specific attention to indications and dosages. (2) To compare actual and recommended dosages of benzodiazepines for anxiety and insomnia. (3) To explore the risk profile for chronic benzodiazepine use in institutionalised older adults.

Methods

Medication charts of 1,730 residents from 76 nursing homes in Belgium were collected and analysed, using the ATC classification. Drug name, indication and daily dosage were recorded. From authoritative international sources, we extracted for each drug and each indication a daily dosage recommended not to be exceeded in older adults for comparison with observed actual dosages.

Results

Among the chronic benzodiazepine or z-drug (BZD/Z) users (50% of the residents), the leading indication was ‘insomnia’ (59% of the users) followed by ‘anxiety’ (17%) and ‘unrest’ (10%). In the chronic prescriptions of BZD/Zs indicated for insomnia, the actual daily dose exceeded the geriatric upper limit in 95% of lormetazepam prescriptions, 82% of zolpidem, 78% of zopiclone and 35% of lorazepam prescriptions. For anxiety, daily doses also exceeded the limit but not to the same extent. Multivariate analysis showed BZD/Z use was positively associated with pain (OR 1.58, 95% CI 1.27–1.97), constipation (OR 1.43, 95% CI 1.16–1.76) and depression (OR 1.68, 95% CI 1.35–2.08). Residents with dementia were less likely to receive a BZD/Z (OR 0.60, 95% CI 0.48–0.74).

Conclusion

Efforts to reduce the use of BZD/Zs in nursing homes should concentrate on insomnia, with interventions aimed at reducing too high prevalence of chronic use and too high daily dosages in this indication.

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References

  1. Azermai M, Elseviers M, Petrovic M, Van Bortel L, Stichele RV (2011) Geriatric drug utilisation of psychotropics in Belgian nursing homes. Hum Psychopharmacol. doi:10.1002/hup.1160

  2. 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 Psychiatr 20(8):712–721. doi:10.1002/gps.1349

    Article  Google Scholar 

  3. 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

    Article  PubMed  Google Scholar 

  4. Petek Ster M, Cedilnik Gorup E (2011) Psychotropic medication use among elderly nursing home residents in Slovenia: cross-sectional study. Croat Med J 52(1):16–24

    Article  PubMed  Google Scholar 

  5. Ashton H (1994) Guidelines for the rational use of benzodiazepines—when and what to use. Drugs 48(1):25–40

    Article  PubMed  CAS  Google Scholar 

  6. Neutel CI (2005) The epidemiology of long-term benzodiazepine use. Int Rev Psychiatry 17(3):189–197. doi:10.1080/09540260500071863

    Article  PubMed  Google Scholar 

  7. Canadian Agency for Drugs and Technologies in Health (CADTH) (2010) Benzodiazepines in older adults: a review of clinical effectiveness, cost-effectiveness, and guidelines. http://www.cadth.ca/media/pdf:M0022_Benzodiazepines_Elderly.pdf. Accessed 10 Aug 2011

  8. National Institute for Health an Clinical Excellence (NICE) (2011) Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults. http//www.nice.org.uk/nicemedia/live/13314/52599/52599.pdf. Accessed 10 Aug 2011

  9. Martin JL, Sainz-Pardo M, Furukawa TA, Martin-Sanchez E, Seoane T, Galan C (2007) Benzodiazepines in generalized anxiety disorder: heterogeneity of outcomes based on a systematic review and meta-analysis of clinical trials. J Psychopharmacol 21(7):774–782. doi:10.1177/0269881107077355

    Article  PubMed  CAS  Google Scholar 

  10. Beland SG, Preville M, Dubois MF, Lorrain D, Voyer P, Bosse C, Grenier S, Moride Y (2011) The association between length of benzodiazepine use and sleep quality in older population. Int J Geriatr Psychiatr 26(9):908–915. doi:10.1002/gps.2623

    Google Scholar 

  11. Lader M, Tylee A, Donoghue J (2009) Withdrawing benzodiazepines in primary care. CNS Drugs 23(1):19–34. doi:10.2165/0023210-200923010-00002

    Article  PubMed  CAS  Google Scholar 

  12. Voyer P, Preville M, Cohen D, Berbiche D, Beland SG (2010) The prevalence of benzodiazepine dependence among community-dwelling older adult users in Quebec according to typical and atypical criteria. Can J Aging 29(2):205–213. doi:10.1017/S0714980810000115

    Article  PubMed  Google Scholar 

  13. Verdoux H, Lagnaoui R, Begaud B (2005) Is benzodiazepine use a risk factor for cognitive decline and dementia? A literature review of epidemiological studies. Psychol Med 35(3):307–315. doi:10.1017/s0033291704003897

    Article  PubMed  Google Scholar 

  14. Wu CS, Wang SC, Chang IS, Lin KM (2009) The association between dementia and long-term use of benzodiazepine in the elderly: nested case–control study using claims data. Am J Geriatr Psychiatry 17(7):614–620

    Article  PubMed  Google Scholar 

  15. Barker MJ, Greenwood KM, Jackson M, Crowe SF (2004) Cognitive effects of long-term benzodiazepine use—a meta-analysis. Cns Drugs 18(1):37–48

    Article  PubMed  CAS  Google Scholar 

  16. Klotz U (1998) Effect of age on pharmacokinetics and pharmacodynamics in man. Int J Clin Pharmacol Therapeut 36(11):581–585

    CAS  Google Scholar 

  17. Petrovic M, Mariman A, Warie H, Afschrift M, Pevernagie D (2003) Is there a rationale for prescription of benzodiazepines in the elderly? Review of the literature. Acta Clin Belg 58(1):27–36

    PubMed  CAS  Google Scholar 

  18. Madhusoodanan SBOJ (2004) Safety of benzodiazepines in the geriatric population. Expert Opin Drug Saf 3(5):485–493

    Article  PubMed  CAS  Google Scholar 

  19. Cook PJ, Huggett A, Graham-Pole R, Savage IT, James IM (1983) Hypnotic accumulation and hangover in elderly inpatients: a controlled double-blind study of temazepam and nitrazepam. Br Med J (Clin Res Ed) 286(6359):100–102

    Article  CAS  Google Scholar 

  20. Mustard CA, Mayer T (1997) Case-control study of exposure to medication and the risk of injurious falls requiring hospitalization among nursing home residents. Am J Epidemiol 145(8):738–745

    Article  PubMed  CAS  Google Scholar 

  21. The British National Formularium (BNF). British Medical Association and the Royal Pharmaceutical Society. http://bnf.org:bnf:index.htm. Accessed 10 Aug 2011

  22. KNMP (Royal Dutch Society of Pharmacy) (2009) Informatorium Medicametorum. Koninklijke Nederlandse Maatschappij ter bevordering van de Farmacie. www.knmp.nl. Accessed 8 June 2011

  23. Sweetman SC (ed) Martindale: the complete drug reference, 36th ed. Pharmaceutical Press, London

  24. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH (2003) Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med 163(22):2716–2724. doi:10.1001/archinte.163.22.2716163/22/2716

    Article  PubMed  Google Scholar 

  25. Rancourt CMJ, Baillargeon L, Verreault R, Laurin D, Grégoire JP (2004) Potentially inappropriate prescriptions for older patients in long-term care. BMC Geriatr 4:9

    Google Scholar 

  26. Laroche ML, Charmes JP, Merle L (2007) Potentially inappropriate medications in the elderly: a French consensus panel list. Eur J Clin Pharmacol 63(8):725–731. doi:10.1007/s00228-007-0324-2

    Article  PubMed  Google Scholar 

  27. Stevenson DG, Decker SL, Dwyer LL, Huskamp HA, Grabowski DC, Metzger ED, Mitchell SL (2010) Antipsychotic and benzodiazepine use among nursing home residents: findings from the 2004 National Nursing Home Survey. Am J Geriatr Psychiatry 18(12):1078–1092. doi:10.1097/JGP.0b013e3181d6c0c6

    Article  PubMed  Google Scholar 

  28. Holmquist IB, Svensson B, Hoglund P (2003) Psychotropic drugs in nursing- and old-age homes: relationships between needs of care and mental health status. Eur J Clin Pharmacol 59(8–9):669–676. doi:10.1007/s00228-003-0679-y

    Article  PubMed  Google Scholar 

  29. Elseviers MVSR, Soenen K, Gobert M, Van Bortel L, Van De Voorde C (2010) Drug utilisation in Belgian nursing homes: impact of residents' and institutional characteristics. Pharmacoepidemiol Drug Safety 19:1041–1048

    Article  Google Scholar 

  30. Katz S, Akpom CA (1976) 12. Index of ADL. Med Care 14(5 Suppl):116–118

    Article  PubMed  CAS  Google Scholar 

  31. WHO Collaborating Centre for Drug Statistics Methodology (2009) ATC/DDD system. http://www.whocc.no. Accessed 20 June 2011

  32. Westbury J, Jackson S, Gee P, Peterson G (2010) An effective approach to decrease antipsychotic and benzodiazepine use in nursing homes: the RedUse project. Int Psychogeriatr 22(1):26–36. doi:10.1017/s1041610209991128

    Article  PubMed  Google Scholar 

  33. Bartlett G, Abrahamowicz M, Tamblyn R, Grad R, Capek R, du Berger R (2004) Longitudinal patterns of new benzodiazepine use in the elderly. Pharmacoepidemiol Drug Saf 13(10):669–682. doi:10.1002/pds.908

    Article  PubMed  Google Scholar 

  34. Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D (2008) STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Therapeut 46(2):72–83

    CAS  Google Scholar 

  35. BCFI (Belgian Centre for Pharmacotherapeutic Information) (2010) Home page. http://www.bcfi.be/. Accessed 8 June 2011

  36. B Terluin FBVH, K Van der Meer, GJH Neomagus, J Hekman, L P J Aulbers, J S Starreveld and M H Grol (2009) NHG-Standaarden Angststoornissen In: NHG-Standaarden voor huisartsened. Nederlandse huisartsen genootschap

  37. Morin AK (2006) Strategies for treating chronic insomnia. Am J Manag Care 12(8 Suppl):S230–S245

    PubMed  Google Scholar 

  38. van Vliet P, van der Mast RC, van den Brock M, Westendorp RGJ, de Craen AJM (2009) Use of benzodiazepines, depressive symptoms and cognitive function in old age. Int J Geriatr Psychiatr 24(5):500–508. doi:10.1002/gps.2143

    Article  Google Scholar 

  39. Kripke DF (2007) Greater incidence of depression with hypnotic use than with placebo. BMC Psychiatry 7:42. doi:10.1186/1471-244X-7-42

    Article  PubMed  Google Scholar 

  40. Bliwise DL (2004) Sleep disorders in Alzheimer's disease and other dementias. Clin Cornerstone 6(Suppl 1A):S16–S28

    Article  PubMed  Google Scholar 

  41. 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

    Article  PubMed  Google Scholar 

  42. Manji HK, Drevets WC, Charney DS (2001) The cellular neurobiology of depression. Nat Med 7(5):541–547. doi:10.1038/8786587865

    Article  PubMed  CAS  Google Scholar 

  43. Cloos JM, Ferreira V (2009) Current use of benzodiazepines in anxiety disorders. Curr Opin Psychiatry 22(1):90–95. doi:10.1097/YCO.0b013e32831a473d

    Article  PubMed  Google Scholar 

  44. Ruths S, Straand J, Nygaard HA (2003) Multidisciplinary medication review in nursing home residents: what are the most significant drug-related problems? The Bergen District Nursing Home (BEDNURS) study. Qual Saf Health Care 12(3):176–180

    Article  PubMed  CAS  Google Scholar 

  45. Berdot S, Bertrand M, Dartigues JF, Fourrier A, Tavernier B, Ritchie K, Alperovitch A (2009) Inappropriate medication use and risk of falls—a prospective study in a large community-dwelling elderly cohort. BMC Geriatr 9:30. doi:10.1186/1471-2318-9-30

    Article  PubMed  Google Scholar 

  46. Ensrud KE, Blackwell TL, Mangione CM, Bowman PJ, Whooley MA, Bauer DC, Schwartz AV, Hanlon JT, Nevitt MC (2002) Central nervous system-active medications and risk for falls in older women. J Am Geriatr Soc 50(10):1629–1637

    Article  PubMed  Google Scholar 

  47. Boyle N, Naganathan V, Cumming RG (2010) Medication and falls: risk and optimization. Clin Geriatr Med 26(4):583–605. doi:10.1016/j.cger.2010.06.007

    Article  PubMed  Google Scholar 

  48. Svarstad BL, Mount JK (2001) Chronic benzodiazepine use in nursing homes: effects of federal guidelines, resident mix, and nurse staffing. J Am Geriatr Soc 49(12):1673–1678

    Article  PubMed  CAS  Google Scholar 

  49. Anthierens S, Pasteels I, Habraken H, Steinberg P, Declercq T, Christiaens T (2010) Barriers to nonpharmacologic treatments for stress, anxiety, and insomnia. Family physicians' attitudes toward benzodiazepine prescribing. Can Fam Phys 56(11):E398–E406

    Google Scholar 

  50. 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

    Article  PubMed  CAS  Google Scholar 

  51. Cormack MA, Owens RG, Dewey ME (1989) The effect of minimal interventions by general practitioners on long-term benzodiazepine use. J R Coll Gen Pract 39(327):408–411

    PubMed  CAS  Google Scholar 

  52. Gorgels WJ, Oude Voshaar RC, Mol AJ, van de Lisdonk EH, van Balkom AJ, van den Hoogen HJ, Mulder J, Breteler MH, Zitman FG (2005) Discontinuation of long-term benzodiazepine use by sending a letter to users in family practice: a prospective controlled intervention study. Drug and Alcohol Depend 78(1):49–56. doi:10.1016/j.drugalcdep.2004.09.001

    Article  Google Scholar 

  53. Denis C, Fatseas M, Lavie E, Auriacombe M (2006) Pharmacological interventions for benzodiazepine mono-dependence management in outpatient settings. Cochrane Database Syst Rev 3: CD005194 doi:10.1002/14651858.CD005194.pub2

  54. Morin CM, Bootzin RR, Buysse DJ, Edinger JD, Espie CA, Lichstein KL (2006) Psychological and behavioral treatment of insomnia: update of the recent evidence (1998–2004). Sleep 29(11):1398–1414

    PubMed  Google Scholar 

  55. Mendelson WB (1995) Long-term follow-up of chronic insomnia. Sleep 18(8):698–701

    PubMed  CAS  Google Scholar 

  56. Bain KT (2006) Management of chronic insomnia in elderly persons. Am J Geriatr Pharmacother 4(2):168–192. doi:10.1016/j.amjopharm.2006.06.006

    Article  PubMed  CAS  Google Scholar 

  57. Alessi CA, Schnelle JF (2000) Approach to sleep disorders in the nursing home setting. Review article. Sleep Med Rev 4(1):45–56. doi:10.1053/smrv.1999.0066

    Article  PubMed  Google Scholar 

  58. Lyne J, Quinlivan L, Byrne CA, Malone K, Walsh C (2011) Sleep hygiene use in a psychiatry outpatient setting. Ir Med J 104(2):49–50

    PubMed  CAS  Google Scholar 

  59. Charlson F, Degenhardt L, McLaren J, Hall W, Lynskey M (2009) A systematic review of research examining benzodiazepine-related mortality. Pharmacoepidemiol Drug Saf 18(2):93–103. doi:10.1002/pds.1694

    Article  PubMed  Google Scholar 

  60. Anthierens S, Grypdonck M, De Pauw L, Christiaens T (2009) Perceptions of nurses in nursing homes on the usage of benzodiazepines. J Clin Nurs 18(22):3098–3106. doi:10.1111/j.1365-2702.2008.02758.x

    Article  PubMed  Google Scholar 

  61. Verrue CL, Petrovic M, Mehuys E, Remon JP, Vander Stichele R (2009) Pharmacists' interventions for optimization of medication use in nursing homes: a systematic review. Drugs Aging 26(1):37–49. doi:10.2165/0002512-200926010-000032613

    Article  PubMed  Google Scholar 

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Acknowledgements

We thank Prof. Dr. Thierry Christiaens from the Department of Family Medicine and Primary Care and Dr. Hans Debruyne, psychiatrist at the Dr. Guislain Centre for Psychiatry, for their contribution.

Competing interest

There are no competing interests to declare.

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Authors and Affiliations

  1. Heymans Institute of Pharmacology, Ghent University, De Pintelaan 185 (1 blok B), 9000, Ghent, Belgium

    Jolyce Bourgeois, Monique M. Elseviers, Majda Azermai, Luc Van Bortel, Mirko Petrovic & Robert R. Vander Stichele

  2. Department of Nursing Science, University of Antwerp, Antwerp, Belgium

    Monique M. Elseviers

  3. Service of Geriatrics, Ghent University Hospital, Ghent, Belgium

    Mirko Petrovic

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  1. Jolyce Bourgeois
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  2. Monique M. Elseviers
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Correspondence to Jolyce Bourgeois.

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Bourgeois, J., Elseviers, M.M., Azermai, M. et al. Benzodiazepine use in Belgian nursing homes: a closer look into indications and dosages. Eur J Clin Pharmacol 68, 833–844 (2012). https://doi.org/10.1007/s00228-011-1188-z

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