Current issues of ACP Journal Club are published in Annals of Internal Medicine


Etiology

Age and medical conditions were the strongest predictors of functional status in older people

ACP J Club. 1998 Jul-Aug;129:22. doi:10.7326/ACPJC-1998-129-1-022


Source Citation

Ried LD, Johnson RE, Gettman DA. Benzodiazepine exposure and functional status in older people. J Am Geriatr Soc. 1998 Jan;46:71-6. [PubMed ID: 9434668]


Abstract

Question

In people ≥ 65 years of age, is exposure to benzodiazepines still associated with functional status once medical conditions are controlled for?

Design

Cohort analytic study.

Setting

Oregon, United States.

Participants

4192 adults who were ≥ 65 years of age and were members of Kaiser Permanente, Northwest Division (a health maintenance organization), for ≥ 1 year. Participants were also enrolled in the Social Health Maintenance Organization Project, for which a mailed questionnaire, the Health Status Form, was completed by participants at enrollment and annually thereafter.

Assessment of risk factors

An automated outpatient pharmacy system was used to obtain data on sex, age, and benzodiazepines that were dispensed in the previous year. The Health Status Form recorded whether participants had particular medical conditions, whether they lived alone, their educational level, and their household income.

Main outcome measure

Participants who needed help with activities of daily living or instrumental activities of daily living (scores ranged from 0 [lowest level of functioning] to 10 [highest level of functioning] on selected items of the Health Status Form).

Main results

Lower functional status was associated with increasing age, being male, and not living alone (P < 0.001 for all associations). Stepwise regression analyses showed that after controlling for sociodemographic characteristics, which accounted for 18% of the variance, lower functional status was associated with the following medical conditions: severe memory loss; stroke; Parkinson disease; circulation, lung, urinary tract, stomach, or bowel problems; hip fractures; arthritis; heart trouble; and diabetes (P < 0.001 for all associations). After controlling for sociodemographic characteristics and medical conditions, which together accounted for 41% of the variance, lower functional status was associated with exposure to benzodiazepines (P < 0.001). The addition of benzodiazepine use to the regression model accounted for an additional 0.4% of the variance (P < 0.001), a percentage similar to that seen with several chronic medical conditions. In the final model, age was the largest single predictor of functional status.

Conclusions

After sociodemographic characteristics and medical conditions were controlled for, exposure to benzodiazepines was associated with lower functional status in older persons to the same extent as several chronic medical conditions. Age and medical conditions were the strongest predictors of functional status.

Sources of funding: In part, National Institute on Aging.

For correspondence: Dr. L.D. Ried, Pharmacy Health Care Administration, P.O. Box 100496, JHMHSC, University of Florida, Gainesville, FL 32610-0496, USA. FAX 352-392-7782.


Commentary

Ried and colleagues' findings support an association described many times previously: that benzodiazepine use is associated with disabilities. As the authors point out, the study's methods cannot address causality. Interpreting the results of this study is complicated by the many uses of benzodiazepines. They are used as anxiolytics and sleeping pills and to modulate behavioral symptoms of dementia. Anxiety and depression are both associated with many disabling conditions, and insomnia is a frequent symptom of depression. Therefore, it is difficult to determine whether the benzodiazepines cause excess disability or whether persons with excess disability are more likely to need benzodiazepines.

As a practical issue, enough well-documented problems with benzodiazepine use in elderly patients exist—increased falls (1), sleep architecture alteration, impaired cognition, and withdrawal effects—to make it apparent that safer alternative therapies are preferable. A few randomized controlled trials compare benzodiazepines with alternative therapies for chronic anxiety (2) or sleep disorders (3). Despite the widespread use of benzodiazepines, no clinical trials have compared these drugs with alternative therapies for behavioral symptoms of dementia.

This study adds to the mountain of evidence supporting the approach of minimizing benzodiazepine use in elderly patients if a less problematic alternative therapy is available and of using the lowest efficacious dose for the shortest possible time if benzodiazepines are necessary. Benzodiazepine use, however, added a statistically significant but clinically minuscule 0.4% of the variance among levels of disability when added to the model after the effects of the chronic medical conditions. This should reassure the physician that benzodiazepines could be used judiciously when they are indicated in elderly patients who are chronically ill.

Jay S. Luxenberg, MD
Jewish Home for the AgedSan Francisco, California, USA

Jay S. Luxenberg, MD
Jewish Home for the Aged
San Francisco, California, USA


References

1. Cumming RG. Long-term risk of recurrent stroke after a first-ever stroke. The Oxfordshire Community Stroke Project. Drugs Aging. 1998;12:43-53. [PubMed ID: 9467686]

2. Delle Chiaie R, Pancheri P, Cassacchia M, et al. Assessment of the efficacy of buspirone in patients affected by generalized anxiety disorder, shifting to buspirone from prior treatment with lorazepam: a placebo-controlled, double-blind study.J Clin Psychopharmacol. 1995;15:12-9. [PubMed ID: 771422]

3. Nowell PD, Mazumdar S, Buysse DJ, et al. Benzodiazepines and zolpidem for chronic insomnia: a meta-analysis of treatment efficacy. JAMA. 1997;278:2170-7. [PubMed ID: 9417012]