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Greetings! This is Paul Zarkowski from the Psychopharmacology Institute. Despite the efficacy of benzodiazepines as hypnotic medication with a short duration of action, they increase the risk of falls, cognitive decline, and earlier nursing home placement in elderly patients. As many clinicians may attest, changing a long-standing prescription due to an altered risk–benefit equation can be challenging. An effective strategy to address this matter in patients taking benzodiazepines is required.
Interestingly, a recent study from Israel tests 2 basic interventions for initiating the process of discontinuing benzodiazepines. These interventions began in hospitalized patients—specifically in the internal and surgical divisions. The authors included patients who had taken either a benzodiazepine or nonbenzodiazepine agonist (Z-drug) for at least 3 months. The authors highlight guidelines that recommend only short-term use of benzodiazepines and Z-drugs after unsuccessful trials of cognitive–behavioral therapy for insomnia and other psychotherapeutic approaches.
Patients aged 60 and older were randomized into 2 intervention groups. The first was a minimal intervention group where subjects received information about the risks associated with long-term treatment. They also received recommendations to stop treatment and a letter to their family physician suggesting discontinuation of treatment with benzodiazepines and Z-drugs. In the second group—the tapering down intervention—subjects received additional tapering instructions along with other information and a letter to their family physician.
Inclusion criteria were Mini Mental Status Exam scores of 20 or better. Exclusion criteria included psychiatric disorders requiring benzodiazepines beyond insomnia alone, acute or unstable medical conditions, other narcotic use, or subjects needing more than 1 pill of hypnotic drug or unable to split pills for tapering purposes.
For comparison purposes, the authors included a retrospective cohort from chart reviews with the same criteria—except for the Mini-Mental Status Exam—to assess how many subjects discontinued benzodiazepines or Z-drugs 3 months posthospitalization without any known intervention. There was no significant age difference across the 3 groups; the average age was 75 years in each group.
Only 2 out of 114 subjects (1.8%) in the retrospective control group discontinued benzodiazepines or Z-drugs after 3 months. A significantly higher number of subjects ceased taking these medications after 3 months in both intervention groups: 15% (7 out of 46) in the minimal intervention group and 27% (15 out of 55) in the tapering-down group. The difference between interventions was not significant, possibly due to a low sample size.
The authors observed that the discontinuation rate was lower than in similar studies conducted on outpatients, where education and tapering instructions led to a discontinuation rate of 45%. This discrepancy is likely due to a stronger rapport between outpatient physicians and patients.
Interestingly, sleep quality, measured using the Pittsburgh Sleep Quality Index, did not change significantly among participants who did not stop treatment, shifting from an average score of 13 to 12.8 after 3 months. However, those who discontinued treatment experienced an improvement in their index scores, from 13.4 pre-intervention to 9.5 at 3 months later.
In evaluating the modest discontinuation rate of 27% in the tapering-down intervention, it is essential to consider its relatively low intensity: Specifically, an information sheet on long-term benzodiazepine or Z-drug use hazards with a table for tapering, almost an extension of an informed consent process.
One limitation of this study is that there was no measure of primary physician involvement—an important factor potentially influencing outcomes. Despite this limitation, this modest reduction contrasts favorably with other reports showing an increase in hypnotic drug use posthospitalization.
Abstract
Discontinuation of Benzodiazepines and Z-Drugs in Hospitalised Population at the Age of 60 and Above. An Open-Label Randomized Controlled Trial
Amit Kosto, Danielle Lev, Nadav Reiss, Tehilah Meged-Book, Yan Press
Background: Treating insomnia with hypnotic drugs in elderly patients has many adverse effects. This study aims to assess the effect of two discontinuation methods of hypnotic drugs during acute hospitalization.
Methods: We conducted an open-label randomized controlled trial that included participants aged 60 and above taking benzodiazepines or Z-Drugs for at least 3 months as a treatment for insomnia and were admitted to the hospital. In the prospective arm, patients were randomly assigned into two intervention groups. In the Minimal Intervention (MI) group, patients received an explanation of the dangers of long-term treatment and a recommendation to stop the treatment. In the Tapering Down Intervention (TDI) group, in addition to the explanation, patients received a tapering down table. In the retrospective arm (control group), we examined the use of hypnotic drugs among hospitalized patients 3 months after hospitalization, similar to the patients in the prospective arm.
Results: 46 patients were enrolled in the MI group, 55 patients in the TDI group, and 114 patients in the control group. The mean age in the three groups was 75.0 ± 8.2, 75.9 ± 9.0, and 75.0 ± 7.9 years respectively (p = 0.85). After 3 months, seven (15.2%) of the patients in the MI group, 15 (27.3%) in the TD group, and 2 (1.8%) in the control group (p = 0.00003) were weaned from the hypnotic drugs treatment, without a significant difference between the intervention groups (p = 0.221).
Conclusions: A short intervention during hospitalization results in a significant decrease in hypnotic drug use.
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Reference
Kosto, A., Lev, D., Reiss, N., Meged‐Book, T., & Press, Y. (2023). Discontinuation of benzodiazepines and Z‐drugs in hospitalised population at the age of 60 and above. An open‐label randomized controlled trial. International Journal of Geriatric Psychiatry, 38(10).
