Thursday, October 31, 2013

Examining the Role of Benzodiazepines in Late-Life Anxiety

Maria K. Almoite

Anxiety disorders in late-life are known to significantly impair the quality of patients’ lives (Wetherell et al., 2004), decrease memory (Yochim, Mueller, & Segal, 2012), and high occurrence of comorbidity with depression (Bryant, Jackson, & Ames, 2008).  Since the ubiquity of anxiety in older adults is quite recent, the current diagnostic criteria and accessible treatments pose major drawbacks. Despite the criticism regarding benzodiazepine (BZD) use in older adults, it is irrefutable that BZDs play a pivotal role in treating anxiety in geriatric life. Therefore, instead of prohibiting the use of BZDs, an improved protocol for prescription and effective communication between patients and physicians are highly proposed. This analysis will examine the limitations of the diagnostic criteria for late-life anxiety, explore the literature supporting and against the continued use of BZDs, and conclude with recommended strategies to enhance the treatment guidelines.

        Diagnosing anxiety disorders in older adults can be challenging. First, the
guidelines are primarily based on the younger adult population which fails to account for atypical symptom presentations and influence of age-related psychosocial changes found in older adults (Palmer, Jeste, & Sheikh, 1997). Therefore, proper detection of late-life anxiety using the DSM index is extremely problematic. Lastly, anxiety often coexists with depression in older adults. The overlapping symptoms of these disorders tend to mimic those of cardiovascular disease (e.g., heart attacks) and endocrine disorders (Bryant et al., 2008). In fact, physicians often associate these symptoms as part of the normal health decline found in older adults, making it commonly misdiagnosed, undetected, or even untreated.

Another prevalent issue is the inherent danger of BZDs as the fundamental treatment for anxiety disorders. Although there are a few therapeutic interventions available such as psychotherapy, cognitive behavioral therapy, and anxiolytic medications (e.g., Azapirones, Benzodiazepines, and Antihistamines; Sheikh  & Cassidy, 2000). Many older adults are more defiant in receiving therapy, making anxiolytic drugs, such as BZDs, the utmost cure for anxiety (Lenze et al., 2003). The overuse of BZDs among older adults bewildered many due to its deleterious and unknown long-term side effects. For instance, BZD users are more prone to accidents demanding medical attention due to heightened risk of falls (Cumming et al., 1991) and hip fractures (Cumming & LeCouteur, 2003). The deteriorating health and limited mobility of a typical aging adult along with dire consequences of BZDs stirred controversy regarding its prolonged use.

In spite of the precaution on BZD use, physicians tend to favor and even
overprescribe BZDs. Others speculated that this may be due to a reflection of physicians’ psychological dependence on BZDs due to the rapid onset of its clinical effect and false sense of safety in line with a recent survey conducted in Philadelphia (Uchida et al., 2009). This study in Philadelphia is conducted by Cook, Marshall, Masci, and Coyne (2007) which analyzed the factors influencing chronic use of BZDs in older adults. Thirty-three physicians around Philadelphia were interviewed. All interviews were audiotaped and transcribed. It was evinced that physicians profoundly endorsed BZDs as the ultimate panacea for late-life anxiety, citing prompt action and strong patient satisfaction. Likewise, the consumption of BZDs in older adults was not seen as an issue because they did not exhibit drug-seeking behavior implying addiction. Additionally, physicians also attenuated other risks of BZDs. Further, they did not view monitoring or restricting renewal of prescriptions as an important clinical focus relative to higher-priority medical issues. These physicians’ approach on anxiolytic medications is worrisome; it can lead to misuse of BZDs.
A relevant study probed the factors related to older adults’ willingness to consider the termination of incessant BZD use. Forty-six habitual BZD users (aged 61-95 years) were evaluated over the phone using semi-qualitative interview and self-report questionnaires for anxiety (Beck Anxiety Inventory), sleep quality (Pittsburgh Sleep Quality Index), depression (Center for Epidemiological Studies Depression Scale), and psychological dependence on BZD (anxiety sensitivity index). The frequency of daily BZD intake and anxiety sensitivity greatly contributed to patients' willingness to halt the use of BZDs. This delineates that several chronic BZD users are skeptical about the discontinuation of BZD use (Cook, Biyanova, Thompson, & Coyne, 2007).  

In an attempt to regulate BZD prescriptions, researchers implemented tactics to reduce extraneous prescription of BZDs. For example, the effect of physicians’ behavior on prescribing BZDs was investigated. Data from 8,170 chronic users were collected. Out of 8,170 chronic users, 1, 256 chronic users received a letter advising them to reduce or stop the use of BZDs after general practitioners (GPs) had taken a course on proper BZD use. A notable reduction of BZD prescription was found compared to the control group (16% after 6 months and 14% after 12 months). They concluded that the diminution of BZD prescribing was due to the letter intervention and individual patient characteristics (Stewart et al., 2007).

Similarly, Simon and Ludman (2006) inspected the indications for BZD use, its baseline components, duration of use, and clinical outcomes of older adult patients prescribed with BZDs. Computerized records were used to identify outpatients (n =129) aged 60 years and older who attained new BZD prescriptions from GPs. This demonstrates that the most colloquial indications for BZD prescriptions were insomnia (42%) and anxiety (36%), and that the initial BZDs prescriptions were intended to treat insomnia and anxiety. Thereupon, a sizeable minority develops a pattern of long-term use which is concerning regarding dependence.
Finally, a longitudinal study by Tu, Mamdani, Hux, & Tu (2001) scrutinized the trends in BZD prescription dispersed in older adults from 1993 to 1998. The ratio of people with short versus long-acting BZD prescription was assessed annually. In addition, the rate of switching to other psychotropic agents and those who terminated BZD prescriptions were also examined yearly. Evidently, dispersion of BZDs substantially dropped over time (25.1% in 1991 and 22.5% in 1998) with a statistical significance of p<.001. This illustrates that the use of short-acting is dispersed more than long-acting BZDs while antidepressants replace BZDs without a noticeable increase in barbiturate consumption. Overall, GPs are making breakthrough in proper regulation of BZD prescription leading the right direction for future ramifications.

All the articles integrated in this paper investigated the role of BZDs in treating late-life anxiety. The first two studies (e.g., Cook, Marshall, et al., 2007; Cook, Biyanova, et al., 2007) perused the view of GPs’ and patients’ view on the potency of BZDs. Both studies indicated that patients and treatment providers are hesitant with the cessation of use. However, the major disparity between these studies is that one focused on GPs’ view on prescribing BZDs to patients (Cook, Marshall, et al., 2007). Whereas, the other focused on patients’ skepticism on the discontinuation of BZD use (Cook, Biyanova, et al., 2007). An impediment of these studies is that they were both conducted by an almost identical group of researchers. This creates little diversity and potential bias affecting both findings. Furthermore, both studies have a relatively small sample size acquired from a larger recruitment effort. Arguably, researchers were interested in obtaining qualitative data to shed light on more detailed information that a larger sample and quantitative data would otherwise not be able to provide.

The rest of these studies implemented techniques dedicated to improving GPs’ approach and views on BZDs and patients’ dependency on BZD use. The discrepancies between these studies were that one focused on restructuring the current index and patients’ pattern use of BZDs (Simon & Ludman, 2006; Stewart et al., 2007), while the other focused on improving BZD prescription by promoting milder, short-acting BZDs to treat anxiety (Tu et al., 2001).  The weaknesses of these studies must be taken into account prior to implementation. First, the initial prescription was not taken into consideration affecting the true effect size found in their data (Stewart et al., 2007). Next, the absence of data concerning patients’ and physicians’ decisions to continue or discontinue BZD use may have skewed the magnitude of the collected data (Simon & Ludman, 2006). Finally, the authors did not provide a detailed view differentiating the pros and cons of the short versus long-acting BZDs effects on one’s regimen. This lack of comprehensive data may have overestimated the reliability of the prominent reliance on short-acting BZDs (Tu et al., 2001).

This analysis delves into the shortcomings of the diagnostic criteria for anxiety disorders to rectify its classification. Since the surge of late-life anxiety is fairly new, it is inevitable to encounter a flaw in this diagnostic classification. Nonetheless, the contemporary implications of anxiety disorders in geriatric life call for immediate attention for a more effective therapeutic intervention. The role and efficacy of BZDs was also investigated by reviewing the literature. While the concerns pertaining to the debilitating side-effects of BZDs pose valid health concerns, prohibiting the continued use of BZDs is altogether unnecessary. BZDs remain a vital treatment for late-life anxiety; abolishing their use will not fix the problem but rather worsen the situation.  Therefore, the best approach to more balanced and safe BZD use is to ensure that GPs regularly attend a course on proper prescription of BZDs, utilize a combined treatment of medication and therapy, and prohibit long-term BZD use while slowly transitioning to a more structured long-term treatment tailored to the patients’ needs and desires. Ultimately, the purpose of this analysis is to come up with a better alternative solution than the complete cessation of BZD use. It is essential that physicians adequately detect anxiety in older adults and provide proper treatments to ensure balanced health in geriatric life—physically, mentally, and emotionally. Simply, the studies provided in this review support the suggested reconstruction of BZD guidelines.


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