Elsevier

General Hospital Psychiatry

Volume 28, Issue 5, September–October 2006, Pages 374-378
General Hospital Psychiatry

Psychiatry and Primary Care
Outcome of new benzodiazepine prescriptions to older adults in primary care

https://doi.org/10.1016/j.genhosppsych.2006.05.008Get rights and content

Abstract

Objective

The objective of this study was to examine the indications for benzodiazepine use, and the baseline characteristics, duration of use and clinical outcomes of older primary care patients prescribed benzodiazepines.

Methods

Computerized records were used to identify outpatients (n=129) aged ≥60 years who received new benzodiazepine prescriptions from primary care physicians of a group model managed care organization. A baseline telephone survey assessed indications for prescription, sleep quality (Pittsburgh Sleep Quality Index), depression (Symptom Checklist depression scale and Structured Clinical Interview for DSM-IV), alcohol use (CAGE) and functional status (SF-36). A 2-month follow-up survey assessed benzodiazepine use, sleep quality and depression.

Results

The most common indications for prescription were insomnia (42%) and anxiety (36%). At baseline, participants reported moderate sleep disturbance (mean Pittsburgh Sleep Quality Index=9.3, S.D.=4.0), only 15% met criteria for current depressive episode and only 3% reported at-risk alcohol use. After 2 months, 30% of participants used benzodiazepines at least daily. Both those continuing daily use and those not continuing daily use reported significant improvements in sleep quality and depression, with no difference between groups in rates of improvement.

Conclusions

Initial benzodiazepine prescriptions to older adults are typically intended for the treatment of anxiety or insomnia, with little evidence for occult depression or alcohol abuse. A significant minority develops a pattern of long-term use, raising concerns about tolerance and dependence.

Introduction

The prescription of benzodiazepines to elderly patients is one area in which common practice appears to diverge from expert opinion.

Expert guidelines and reviews typically urge caution when prescribing benzodiazepines to older adults [1], [2], with greatest concerns regarding long-term use. Epidemiological studies have found that benzodiazepine use is associated with increased risk of falls and injuries [3], [4], [5], cognitive decline [6], [7] and functional decline, leading to institutionalization [8]. Concerns have also been raised regarding the overprescription of benzodiazepines to older adults with depressive disorders [9], [10].

Despite these concerns, epidemiological data [11], [12], [13] indicate that benzodiazepines are among the drugs most commonly prescribed to older adults. Among community-dwelling older adults, 10–30% reported using benzodiazepine at any given time, with approximately half of those being long-term users.

This divergence between expert opinion and everyday practice raises questions regarding indications for benzodiazepine use, the clinical characteristics of users and the factors associated with progression to long-term use. Data regarding these questions are limited, as previous research has often relied on computerized pharmacy records or cross-sectional surveys.

Here we use data from a cohort of older primary care patients who received a new prescription for benzodiazepine to examine perceived indications for the initial prescription, the clinical characteristics of patients at the time of prescription and the predictors of continued use 2 months later.

Section snippets

Methods

The study was conducted between 2001 and 2002 at staff model clinics of Group Health Cooperative, a prepaid health plan serving approximately 450,000 members in western Washington State. Most members are covered through employer-purchased plans, but enrollment at the time of this study included approximately 45,000 Medicare members and 35,000 members covered by Medicaid or by Washington's Basic Health Plan (a state program for low-income residents). Group Health Cooperative members are similar

Results

Invitation letters were mailed to 200 potential participants. Seventeen could not be reached by telephone, and 10 were found to be ineligible (disenrolled from Group Health Cooperative; index prescription was not a new prescription). Forty-four declined to participate, leaving a baseline sample of 129 (68% of those eligible).

Participants had a mean age of 73 years (S.D.=7.3), with a range of 61–95 years. Sixty-four percent of the participants were female, and 93% were Caucasian. Approximately

Discussion

These findings provide some reassurance regarding the initial prescription of benzodiazepines to older adults in primary care. First, the most common indications were insomnia and anxiety (where benzodiazepine is potentially appropriate and efficacious) rather than depression. Second, the proportion of patients with alcohol use disorder or untreated depressive disorder (where benzodiazepine prescription might be inappropriate or contraindicated) was small.

Limited data regarding the probability

Acknowledgments

This work was supported by the National Institute of Mental Health grant R01 MH51338.

References (21)

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The National Institute of Mental Health had no role in the study design, execution, analysis and interpretation of results, or preparation of this manuscript.

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