`Patient Empowerment` Helps Seniors Taper Off Benzodiazepines

By Anne Harding

NEW YORK - Giving older patients educational materials on the risks of benzodiazepine use is an effective way to encourage them to taper off the risky drugs, according to a new cluster randomized trial published Monday in JAMA Internal Medicine.

"The message from this study is that older adults can be engaged in helping to make those decisions," Dr. Cara Tannenbaum of the University of Montreal, an author of the new study, told Reuters Health in a telephone interview. "Patients were not scared to say to their doctor, 'let's re-discuss this for the first time in 15 years."

"I think what was a little disappointing in this study was the number of physicians who said to patients, 'don't worry about it,'" Dr. Tannenbaum added.

While benzodiazepines have long been understood to carry a risk of serious side effects for older patients, including a higher risk for falls and worsening cognitive impairment, up to half of doctors continue to prescribe them to patients over 65, "citing patient dependence and benefit as justification for their actions," Dr. Tannenbaum and her colleagues note in their report.

The American Geriatrics Society (AGS) advises physicians not to use benzodiazepines as first-line treatment for insomnia in older patients, as part of the American Board of Internal Medicine Foundation's Choosing Wisely Campaign, an effort launched in 2012 to reduce the use of potentially harmful medical resources. Benzodiazepines account for up to 25% of inappropriate medication use among older people, Dr. Tannenbaum and her team note, with estimates of their use ranging from 5% to 32% of community-dwelling older people.

In their EMPOWER (Eliminating Medications Through Patient Ownership of End Results) trial, Dr. Tannenbaum and her colleagues investigated whether patient empowerment -- a process that aims to "help people gain control, which includes people taking the initiative, solving problems, and making decisions" -- would be an effective strategy for reducing inappropriate benzodiazepine use among older people.

The investigators enrolled 303 patients who had been filling benzodiazepine prescriptions at one of 30 different community pharmacies for at least three months and who were receiving at least five active prescriptions. Patients at 15 of the pharmacies received an eight-page booklet detailing the risks of benzodiazepine use, alternative strategies for treating insomnia and anxiety, and a 21-week tapering protocol. Patients who used the 15 other pharmacies served as a "wait list" control group.

Patients in the study had been using benzodiazepines for a mean of 10 years, and the average daily dose was the equivalent of 1.3 mg of lorazepam.

At the six-month follow-up, 261 participants were still enrolled. Among patients in the intervention group, 62% had spoken to their physician or pharmacist about discontinuing benzodiazepines, and 27% had stopped using the drugs. In the control group, 5% had stopped filling their benzodiazepine prescriptions.

Another 11% of patients in the intervention group had reduced their dosage.

"Discouragement by their physician or pharmacist" was the most common reason cited for not choosing to taper off the medication, mentioned by one-third of the 52 patients who stayed on the medication. Other reasons included fear of withdrawal symptoms, lack of concern about the risks of the drugs, and "difficult life circumstances."

Multivariate analysis found no interaction between age over 80, gender, duration of benzodiazepine use, indication for benzodiazepine use, dosage, number of previous tapering attempts, and polypharmacy (taking 10 drugs or more daily), and discontinuation of benzodiazepine therapy.

"Even patients who have been taking sleeping pills for 30 years, many of them in their 80s and 90s, were able to get off the sleeping pills once they realized that these pills could cause falls, memory problems, and car accidents," Dr. Tannenbaum told Reuters Health.

"The added value of directly educating the patient, in the absence of initial physician involvement, likely promotes patient buy-in for discontinuation at an early stage and allows the patient to act as a catalyst for initiating discussions about medication management, which is a more effective approach than the traditional paternalistic approach to patient care," she and her colleagues write.

Several physicians in the study discouraged patients from tapering off benzodiazepines, the researchers note, while some patients were put on "equally harmful sedative medication" as a substitute. "Continuing medical education to physicians about the harms of all sedative hypnotic medication may eventually overcome this obstacle," they write.

The editors of JAMA Internal Medicine have made the brochure (and the entire study) available for free online for one month. The brochure, published as a pdf supplement, is at archinte.jamanetwork.com/data/Journals/INTEMED/0/IOI140026supp1_prod.pdf.

"It would be great if physicians printed it out and gave it to all their patients who are taking their sleeping pills," Dr. Tannenbaum said.

"I think there's a certain professional responsibility to get people off medications that increase the risk of harm with aging," she added. "If we have a way of reducing the risk of falls and hip fractures I think it's something we need to do from a preventive public health perspective."

Dr. Ariel Green, a fellow in geriatric medicine at Johns Hopkins Medicine in Baltimore, reviewed the study for Reuters Health. She was a member of the AGS workgroup that developed the recommendation against using benzodiazepines as first-line treatment for insomnia in older adults.

Dr. Green noted that older patients who take benzodiazepines are twice as likely to have unwanted side effects as they are to have improved sleep. "They really have meager benefit and it's far outweighed by substantial risks," she added. "People will be willing and able to stop these medications. It is up to us as health care providers to share the information about the substantial risks with patients."

SOURCE: bit.ly/1gI6hJZ

JAMA Intern Med 2014.

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