The Overuse of Anxiolytics in Long-Term Care
Prescription of anxiolytics persists in long-term care facilities. But what does the evidence say about their effectiveness?
The CMS F605 guidelines require adequate indication for use before psychotropic drugs can be prescribed for nursing home patients. This standard exists to help prevent unnecessary use of these drugs and to keep patients from being chemically restrained by them. However, there are other categories of drugs that have been similarly over-prescribed, leading to negative outcomes similar to the ones F605 was put in place to address.
Over-prescription of anxiolytics is a growing problem
Anxiolytic drugs, specifically benzodiazepines, are vulnerable to the same reflexive prescription patterns that led CMS to rule on psychotropics. As noted elsewhere on the GuideStar Eldercare blog, anxiety and depression in dementia are clinical problems well worth addressing. However, recent studies point to a disconnect between the prescription of anxiolytic medications for nursing home patients and observable positive clinical outcomes for those patients.
What are the risks of benzodiazepines?
The European Journal of Pharmacology reports that “the sedative effects of [benzodiazepines] represent a significant limitation to their daytime use.” The journal goes on to list other side effects, including “ataxia and impaired cognition, in addition to seizures, tremors, and increased anxiety.” (L Ren et al)
Insights published in BMC Psychiatry reveal a similar issue with emotional regulation. “Healthy volunteer studies suggest,” the journal writes, “that diazepam [a common benzodiazepine] reduces emotional processing ability.” (Haime Z et al)
The negative effects of benzodiazepine are so widely observed that the journal PLoS One has called for the term BIND (Benzodiazepine-Induced Neurological Dysfunction) as a catch-all term for the “symptoms and associated adverse life consequences that may emerge during benzodiazepine use, tapering, and continue after benzodiazepine discontinuation.” (Ritvo AD et al)
Benzodiazepine use is especially risky for older adults
The Journal of the American Geriatrics Society observes that “older adults are commonly prescribed long-term benzodiazepines for anxiety and insomnia despite evidence of risks and limited evidence of long-term benefits.” (Chae S et al) These risks are further outlined in the journal Sleep, where researchers note that “chronic use disrupts sleep regulation and cognition.” (Barbaux L et al)
Continued use of benzodiazepines, even when effective to treat symptoms, can lead to further issues long term, including “development of dependence, tolerance, and cognitive decline, especially among older adults,” as also noted in PloS One. (Barboza Zanetti MO et al)
The specter of increased tolerance is also raised in Panminerva Medica, where researchers note that benzodiazepines “often show progressive tolerance, necessitating an increase in dosage, and therefore their use should be discouraged.” (R Melcarne et al)
Long-term care patients using benzodiazepines are at greater risk when they discontinue those medications as well. Older adults who stop taking benzodiazepines often experience serious withdrawal symptoms, including seizures, central nervous system depression, and impaired performance. Consequently, the National Committee for Quality Assurance has noted that “many chronic users are rarely encouraged to discontinue the medication” even though their use can increase dementia and impair physical, cognitive and emotional function. (NCQA)
The overall risk to nursing home patients is such that Panminerva Medica eventually concludes that “deprescription of [benzodiazepines] is advisable with the availability of other therapies and interventions, especially in elderly subjects.” (R Melcarne et al).
Negative interactions between anxiolytics and other conditions
Patients in long-term care often receive a number of different medications at once. Particular care must be taken to avoid harmful interactions between these medications. Here, adding anxiolytics like benzodiazepine to the mix can often lead to negative outcomes. As noted in Croatian medical journal, “simultaneous use of benzodiazepines with opioids and benzodiazepine-related medications in individuals aged 65 and above correlated with increased outpatient and overall mortality.” (Kozole Smid AK et al)
Benzodiazepine use can also blunt the effects of cancer treatment in some circumstances. The journal Oncoimmunology has revealed that “treatment with benzodiazepines was associated with poor clinical responses to chemoimmunotherapy in patients with non-small cell lung cancer as compared to individuals not receiving any psychotropic drugs.” These studies have led researchers to conclude that “benzodiazepines may confer systemic immunosuppression.” (Montégut L et al)
The Annals of clinical and translational neurology suggest that benzodiazepines can also lead to an increased risk of Parkinson’s disease. Their study notes that “the use of antidepressants, anxiolytics or multiple psychotropic medication types and transitions in psychotropic medication use was associated with increased risk amongst older women.” (Beydoun HA et al)
Awareness is not enough
While the risks associated with benzodiazepines in long-term care have been studied and published widely, more work remains to be done to induce facilities and clinicians to respond. Too often, patients exhibiting cognitive or neurological symptoms are summarily medicated. The Journal of the American Geriatric Society reports that “a positive delirium screen at skilled-nursing facility admission can trigger a simultaneous diagnosis of Alzheimer's Disease or related dementia and lead to psychoactive medication treatment despite a lack of evidence supporting use.” (Briesacher BA et al)
Researchers publishing in the Annals of medicine speak directly to the urgency of the problem. “Our research underscores the persistent challenge of inappropriate medication use and drug-related harms among older nursing home residents, despite existing evidence and professional campaigns,” they write. (Kummer I et al)
The study also points at a potential need for governmental and organizational intervention. “Effective regulatory and policy interventions, including the implementation of geriatrician and clinical pharmacy services, are essential to address this critical issue and ensure optimal medication management for vulnerable populations.” (Kummer I et al)
It is in this clinical landscape that anxiolytics should be subject to greater scrutiny. An article in JAMA network open highlights a national case-control study of nursing home residents with Alzheimer’s disease or related dementia. The study concludes that for “residents with ADRD receiving hospice care, initiation of benzodiazepine or antipsychotic use was associated with increased 180-day mortality.” (Gerlach LB et al)
The threat level is such that PloS One also invokes the need for intervention. “Authorities and health care providers must take steps to encourage gradual cessation of prolonged benzodiazepine prescriptions.” (Barboza Zanetti MO et al)
GuideStar Eldercare can help your clinical outcomes and regulatory compliance
At GuideStar Eldercare, we make it our mission to promote better quality of life for LTC patients. In addition to our Antipsychotic Stewardship services, our clinicians and staff take a neurology-forward approach to emerging challenges such as anxiolytic medications and dementia care. We believe that by treating the whole patient and understanding the underlying neurology of their condition, we can help your facilities achieve a standard of care that meets or exceeds CMS mandates, while also preparing you for the new challenges presented by a growing geriatric population. Contact us to learn more about how we can help.