Warnings About Benzodiazepine Use in the Elderly Go Unheeded

Despite years of warnings about the hazards of prescribing benzodiazepines for the elderly, these drugs continue to be used at a higher rate than what is considered appropriate in older Americans — particularly older women, new data show.

A recent report released by Athena Health shows that individuals older than 65 years are prescribed benzodiazepines — including alprazolam (multiple brands), lorazepam (multiple brands), diazepam (multiple brands), and clonazepam (Klonapin, Roche) — more than other age groups are.

In 2017, 8.4% of individuals aged 65 and older were prescribed one of the drugs, a drop from 8.7% the previous year. Just over 8% of 50- to 64-year-olds were prescribed a benzodiazepine in 2017, compared to 7.5% of those aged 40 to 49 and 6.6% of those aged 30 to 39.

Ten percent of women older than 65 were prescribed a benzodiazepine, compared to just under 6% of men.

The data come from a sample of 3 million patients treated by primary care providers who are part of the Athena Health data network.

The data “are consistent with earlier research that suggests significant benzodiazepine overuse, especially among older adults,” Mark Olfson, MD, MPH, professor of psychiatry and epidemiology, Columbia University, New York City, told Medscape Medical News.

Since 2012, the American Geriatrics Society (AGS) has urged clinicians to avoid use of benzodiazepines in older adults. That recommendation is being reiterated in the AGS 2018 prescribing guidelines (called the Beers Criteria), which are under final review.

Physicians Not Getting the Message

The AGS notes that benzodiazepines increase the risk for cognitive impairment, delirium, falls, fractures, and motor vehicle crashes. The drugs can be appropriate for seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, and periprocedural anesthesia, the AGS says.

Since benzodiazepines were first introduced in the 1960s, prescribing authorities and public health agencies have periodically issued warnings about the potential for addiction and other side effects.

In May, the deprescribing guidelines for the elderly project, based at the Bruyère Research Institute in Ottawa, Ontario, Canada, launched an effort to help clinicians wean long-term users off benzodiazepines and the benzodiazepine receptor agonists zolpidem (multiple brands), zopiclone (Zunesta, Suovion), and zaleplon (Sonata, Pfizer).

“We need to be a little bit more judicious with these,” Nicole Brandt, PharmD, MBA, BCGP, BCPP, FASCP, executive director of the Peter Lamy Center on Drug Therapy and Aging, University of Maryland, Baltimore, told Medscape Medical News. Brandt said she continues to be concerned about the persistence of benzodiazepine use in the face of so many warnings and guidelines.

Robert Roca, MD, chair of the American Psychiatric Association’s Council on Geriatric Psychiatry, said he was surprised — but not entirely — at the Athena data indicating that women received benzodiazepines at twice the rate of men.

“Women are more willing to express distress, and they’re more likely to receive psychotropics of all kinds,” Roca, vice president and chief medical officer, Sheppard Pratt Health System, Baltimore, told Medscape Medical News.

Women also have a higher risk for dementia, and, given the pressure to reduce the use of antipsychotics in patients with dementia, it’s possible that benzodiazepines are being substituted, said Roca. But, he added, benzodiazepines “are not a particularly good alternative.”

Olfson said that women “have higher rates of insomnia, anxiety disorders, and mood disorders, all of which are related to benzodiazepine use.” He also noted, however, that “because women assume more caregiver roles than men, they are under greater stress, which contributes to anxiety and sleep problems.”

Dementia Risk

Brandt agrees that caregiving is a major stressor for women. He noted that “it’s easier to get a medication paid for than to get counseling paid for or respite care paid for.” Benzodiazepines are prescribed for many medical problems, but “there are also lots of psychosocial issues where they may be the go-to agent,” she said.

She added that she’s seen benzodiazepines prescribed to help older people cope with losses, including the loss of mobility and the loss of friends or family members.

“I think benzodiazepines are a surrogate for a much bigger issue,” she said.

Many factors account for the continuing popularity and persistent use of benzodiazepines. Olfson said there is limited access to alternative evidence-based treatments for insomnia and noted that there’s “an unwillingness of some older people to consider reducing or discontinuing” the drugs.

In addition, said Olfson, “for some primary care physicians who have competing clinical demands on their time, given common comorbid medical problems in older adults, pharmacological options for managing insomnia and anxiety may be attractive.”

Roca noted that they are generally safe and effective in reducing anxiety and generally are not abused, although “there is no question they are potentially addictive.”

Benzodiazepines can also be a bridge therapy for patients who need an antidepressant, which can take weeks to start working, said Roca. He favors short-acting benzodiazepines, which, unlike long-acting ones like diazepam, are not taken up by adipose tissue.

But that type of analysis may not be familiar to physicians who more often prescribe the medications to younger people. “They are not so tuned in to the risks of prescribing to older people,” said Roca.

Besides the risks outlined by the AGS, some data now suggest that long-term exposure may increase the risk for dementia, he said. “There are all kinds of reasons to be careful,” said Roca.

Medicare has kept an eye on benzodiazepine use among older people who participate in the federal health plan. The Affordable Care Act initially banned coverage of benzodiazepines through Medicare Part D drug plans. That prohibition was lifted in January 2014; the drug class is now covered under Part D for any medically accepted indication.

A Hidden Epidemic?

The agency has taken an even closer look since it became clear that the drugs were often being prescribed in tandem with opioids. In 2015, the Centers for Medicare & Medicaid Services reported that 17% of Medicare beneficiaries were using benzodiazepines and that about a quarter were using them in conjunction with opioids.

A study published in JAMA Psychiatry in June found that rates of new opioid prescriptions written for adults using a benzodiazepine skyrocketed from 189 to 351 per 1000 persons from 2005 to 2010.

Although it decreased to 172 per 1,000 by 2015, “the likelihood of receiving a new opioid prescription during an ambulatory visit remained higher for patients concurrently using benzodiazepines compared with the general population after adjusting for demographic characteristics, comorbidities, and diagnoses associated with pain,” the authors note.

The dual use — and continued high use of benzodiazepines — has alarmed many clinicians and public health officials.

“Despite the many parallels to the opioid epidemic, there has been little discussion in the media or among clinicians, policymakers, and educators about the problem of overprescribing and overuse of benzodiazepines and z-drugs, or about the harm attributable to these drugs and their illicit analogues,” Anna Lembke, MD, Jennifer Papac, MD, and Keith Humphreys, PhD, wrote in an editorial published in the New England Journal of Medicine in February.

Overdose deaths related to benzodiazepine use continue to rise. Lembke noted that data from the National Institute on Drug Abuse (NIDA) show that overdose deaths involving benzodiazepines increased from 1135 in 1999 to 8791 in 2015. In 2016, NIDA reported 10,684 overdoses in which benzodiazepines were involved. Most of the deaths occurred in people who were also taking opioids, said NIDA.

Brandt said the opioid crisis provides lessons for how benzodiazepines should be monitored and prescribed. Benzodiazepines are not villains, however, she said. Like opioids, they are “a tool to address a problem,” said Brandt. She noted that she would not want to see them blacklisted.

Both Roca and Olfson said they supported adding benzodiazepines to state prescription drug monitoring programs. Including them would help flag those people who are using benzodiazepines and opioids, said Olfson. He also said that because a lot of the risk with the drug class is associated with long-term use, “policies should be considered and evaluated that restrict the days’ supply of benzodiazepines in a single prescription.”

Roca expressed concern about overly restrictive policies. “If you put a target on the back of these medications, you may make it difficult for patients who need them,” he said.

Are the Elderly Really Taking Too Many Vitamins?

Story at-a-glance

  • According to The New York Times, studies have linked high-dose vitamin E with a higher risk of prostate cancer. In reality, a single study found a very small increase in prostate cancer among those using synthetic vitamin E
  • Studies looking at natural vitamin E show tocotrienols — specifically gamma tocotrienol — prevent prostate cancer and even kill prostate cancer stem cells. Gamma-tocotrienol may also be effective against existing prostate tumors
  • Your body’s ability to absorb B12 diminishes significantly with age, and Alzheimer’s symptoms are extremely similar to the symptoms of B12 deficiency
  • The New York Times also claims beta-carotene causes cancer. This myth is based on research showing smokers given a low dose of synthetic beta-carotene had a slightly increased risk of cancer. However, the treatment group had been smoking a year longer than the controls
  • When properly prescribed, and taken as directed, the death toll from drugs is between 85,000 to 135,000 Americans per year. There’s no evidence of dietary supplements having caused a single death in over 30 years

By Dr. Mercola

The conventional view of dietary supplements is, for the most part, predictably negative. The New York Times recently offered a perfect demonstration of this view in its April 3 article, “Older Americans Are ‘Hooked’ on Vitamins.”1 In this interview, Dr. Andrew Saul, editor-in-chief of the Orthomolecular Medicine News Service and author of “Doctor Yourself: Natural Healing That Works” and “Fire Your Doctor: How To Be Independently Healthy,” breaks down the myths and inaccuracies presented in that article.

While drug overdoses are currently killing 63,000 Americans each year — with opioids being responsible for nearly 50,000 of them and being a leading cause of death for Americans under 50 — the media is still pretending that people getting “hooked” on vitamins is a dangerous trend.

“The funny thing is that for those who are hooked on opioids, high doses of vitamin C had been shown — in two really good studies — to enable people to get off opioids without withdrawal symptoms, or greatly reduced withdrawal symptoms. Being hooked on vitamin C would actually help you get unhooked from heroin,” Saul notes.

Vitamin C — A Powerful Healer

Vitamin C is actually a very important and powerful detoxifier. In addition to helping you detox from drugs, this is also something to remember when you’re seeing a dentist. If you’re taking large doses of vitamin C, you may need a larger dose of anesthetic, as your body will break the drug down faster. On the other hand, loading up on vitamin C prior to a dental appointment will also quicken healing, sealing the gums faster, and reduce both bleeding and pain.

“If you have a tooth extraction or a root canal or anything that’s really invasive, vitamin C is the dentist’s best friend, because nothing makes gums stronger and quicker than vitamin C. Not only oral vitamin C; you can even take nonacidic vitamin C, such as calcium ascorbate, magnesium ascorbate or sodium ascorbate and put that right on the gums.

You can even put it right on the socket. People who have dry sockets or extended bleeding, when they use vitamin C topically — not ascorbic acid, mind you, but nonacidic C topically — they get immediate relief. It was Dr. Hugh Riordan at the now-famous Riordan Clinic who brought some of this forward decades ago. It’s good advice,” Saul says.

Do Seniors Need Vitamin Supplements?

Getting back to that New York Times article, “The Times has laid-off or fired a very large number of copyeditors … They wanted to save money, so they eliminated the copydesk. They got rid of about 100 copyeditors … In my opinion, this article is a good example of a piece that should have been properly copyedited and fact-checked, and wasn’t,” Saul says.

For example, it mentions that studies have linked high-dose vitamin E with a higher risk of prostate cancer. In reality, a single study found a very small, and possibly questionable, increase in prostate cancer among people in that particular study. Importantly, the study in question used synthetic vitamin E, not the natural E. They also used fairly low dosages.

The salient point here is that there are studies looking at natural vitamin E, using all four tocopherols and four tocotrienols. These studies were not quoted, even though two such studies show tocotrienols — specifically gamma tocotrienol — actually prevent prostate cancer2 and even kill prostate cancer stem cells.3

These are the cells from which prostate cancer actually develops. They are, or quickly become, chemotherapy-resistant. Yet, natural vitamin E complex is able to kill these stem cells. Mice given oral gamma-tocotrienol had an astonishing 75 percent decrease in tumor formation.

A third study4 found gamma-tocotrienol was also effective against existing prostate tumors by modulating cell growth and the apoptosis (cell death) response. “Now, that has got to be newsworthy. The New York Times decided that’s news not fit to print,” Saul says.

Are Seniors Really Getting All the Nutrients They Need From Their Diet?

The New York Times article also states that older Americans get plenty of essential nutrients in their diet, and that the Western diet is not short on vitamins. “This is demonstrably nonsense,” Saul says, adding “The elderly tend to have poor diets in general, especially those who live alone or are institutionalized.” There are a number of reasons for this, including:

  • The elderly tend to have poor appetite due to higher rates of depression
  • As people get older, their sense of smell and, therefore, their sense of taste, diminishes
  • The elderly rarely drink enough water, as the sense of thirst diminishes with age

As noted by Saul, “If they’re not eating proper meals because they’re sad, depressed or lonely, or they’re just getting mediocre care, then they can’t possibly get enough nutrients — because even the paltry amount of nutrients in an American diet is not there if you don’t even eat the American diet.”

Most Seniors Are Deficient in B12, Magnesium and Vitamin D

Your body’s ability to absorb B12 also diminishes significantly with age, and Alzheimer’s symptoms are in fact extremely similar to the symptoms of severe B12 deficiency. Many clinicians would likely have a hard time distinguishing between the two.

“If B12 absorption is poor, and if the elderly are not eating proper meals, the amount of B12 in an older person is going to be low. For the article to say that it’s an abundant nutrient for the elderly is absolutely not true,” Saul says. There’s also ample evidence showing most soils are depleted of nutrients, which has led to lower nutrient values in whole foods. So, while Americans are not deficient in calories, many are indeed deficient in crucial nutrients.

“Dr. Abram Hoffer asked me years ago to write a paper on, ‘Can supplements take the place of a good diet?’ My comment was, ‘Well, they’re going to have to.’ Because people eat such lousy diets. If they’re going to eat lousy diets, it’s better to have a lousy diet and take supplements than to have a lousy diet without supplements. The solution, really, is to have a really good diet.

But I don’t have to tell you what a hospital diet looks like, or what a nursing home diet looks like. You don’t have to tell me what a school lunch diet looks like. These are really poor meals. You have exactly the wrong nutrients in abundance — the calorie nutrients. And then you have a dearth of the micronutrients.

One more thing:  the article talks about how there’s an abundance of nutrients and everybody gets enough. With the mineral magnesium, if you look over decades of studies, National Health and Nutrition Examination Survey studies and all kinds of very large-scale studies of what people eat, magnesium deficiency is probably the most common mineral deficiency in the United States. Almost no Americans get the U.S. recommended dietary allowance (RDA) of magnesium …

The other one is vitamin D. Vitamin D deficiency is so prevalent in the elderly that half of the people hospitalized for hip fractures are demonstrably and measurably vitamin D-deficient. What’s really interesting is that the article says taking extra calcium did not help fractures. That’s not the point. It’s extra vitamin D and vitamin K that help put the calcium where it needs to be. They didn’t mention that.”

The Importance of Magnesium

Saul cites a Blue Cross Blue Shield study showing that seniors who took vitamin D supplements not only had fewer fractures, but they didn’t fall as often. “Vitamin D actually helps prevent the fracture by preventing falling,” Saul says. Magnesium deficiency is also problematic as it plays an important role in heart health and muscle function.

Magnesium may also help protect your body against the ravages of electrical pollution. Electromagnetic fields (EMFs), which are pervasive everywhere these days, cause oxidative damage similar to that of smoking. Magnesium acts as a calcium-channel blocker, which appears to be one of the primary mechanisms through which EMFs cause oxidative stress. Hence, having enough magnesium in your body may be protective.

Types of Magnesium and Advice on Dosage

When it comes to oral magnesium supplementation, there’s the issue of it having a laxative effect, which can upset your microbiome. One simple solution to this is to take regular Epsom salts baths. It’s a good way to relax sore muscles, and your body will absorb the magnesium transdermally, meaning through your skin, bypassing your gastrointestinal tract altogether.

The worst form of magnesium, in terms of absorbability, is magnesium oxide, which incidentally is also the most common form available to consumers. Better alternatives include magnesium gluconate, magnesium citrate or magnesium chloride, the latter of which has the greatest absorbability of the three.

Two of my personal favorites are magnesium malate (malic acid) and magnesium threonate. Magnesium malate is a Krebs cycle intermediate and may help increase adenosine triphosphate (ATP) production, while magnesium threonate has been shown to effectively penetrate the blood-brain barrier. So, for brain benefits, threonate appears to be preferable.

“If you take magnesium in small divided doses, you’re less likely to disturb your belly,” Saul says. “Some people don’t need to take a lot of extra magnesium; others do. It’s really a matter of [doing] a therapeutic trial. I would start small. Take your magnesium between meals and see when you feel better. It’s simply a matter of trial and error …

It was Dr. Richard Passwater who first brought that idea to me in the late ‘70s, in his wonderful book ‘Super-Nutrition: Megavitamin Revolution.’ He said, ‘To determine your dose of nutrients as you want to supplement with, start taking them and see if you feel better. If you do, take a little more. If you’re feeling still better, then use the higher dose. If you don’t feel any better, go to the lower dose that gets the most results.

I just love that. It’s so simple. We can all do this, and should. That doesn’t mean you’re hooked on vitamins, folks. It means that you’re an intelligent human being. How intelligent? Well, at least half of all Americans are taking vitamins every day. With the elderly, it may be as high as two-thirds. I have heard, unofficially, that among physicians, 3 out of 4 doctors take supplements regularly. They just don’t talk about it.”

When I was still practicing, intravenous magnesium was one of the minerals I regularly used for acute migraines, infections and asthma attacks. In high doses, magnesium has a very potent vasodilatory effect. In fact, if administered too quickly, it’s almost like a niacin flush. But it was profoundly effective for aborting migraines and asthma attacks, and rapidly resolved coughs and colds. Magnesium will also help prevent and/or ease menstrual cramps.

Does Beta-Carotene Cause Cancer?

The New York Times also revisited the age-old myth that beta-carotene causes cancer. This fallacy is based on research from the 1990s that found a certain population of men in Finland, when given 20 milligrams of beta-carotene a day — the equivalent found in two or three carrots — had a very small but widely touted increase in cancer.

What is regularly not mentioned is the fact that they were heavy smokers, and the treatment group had been smoking a year longer than the controls. The patients also were not prescreened to see if they had any precancerous conditions.

“People say to me, ‘Beta-carotene can cause cancer.’ No. Smoking causes cancer. ‘Beta-carotene can be harmful.’ No. Cigarettes are harmful. SMOKING is what’s harmful to smokers. The problem, folks, is not the carrots,” Saul says. Another significant variable that may have played a role is the fact that they used synthetic beta-carotene.

“The study is a bad study. Therefore, The New York Times should know better than to quote it. They not only quote it, they kind of misquote it because they don’t use the word ‘smoker,’” Saul says. “If you’re hooked on cigarettes, you’re going to have problems. If you’re hooked on vitamins, you’re not.

This brings us to the fundamental question of what kills and what wastes money. Consumer Reports estimates that $200 billion a year is spent on incorrect harmful medication. The entire food supplement industry worldwide is one-fifth of that, at most. We are wasting huge amounts on giving drugs that are harmful and complaining about the people who are doing good preventive care and taking their vitamins.”

Supplements Versus Drugs — What’s More Dangerous?

Saul also notes that Harvard School of Public Health has assessed the role of drugs in deaths at great depth. When properly prescribed and taken as directed, the lowest estimated death toll from pharmaceutical drugs is still around 85,000 people a year. The high estimate is around 135,000 people annually, while the generally accepted estimate is about 106,000 people a year.

That’s 106,000 dead Americans every year from properly prescribed drugs, not medical errors; drugs taken as directed, not overdose. That means that each decade, “normal” side effects of drugs are killing about 1 million people in the U.S.

According to the American Association of Poison Control Centers (AAPCC), which has been tracking this information for over three decades, there have been 13 alleged deaths from vitamins in 31 years. However, Saul notes, “My team looked into this and we could not find substantiation, documentation, proof or convincing evidence of one single death … from vitamins in the last 31 years.” In most cases, the individual was taking both drugs and vitamins.

This year, the AAPCC actually removed the vitamin category, because it’s always been zero. “Personally, I think they got tired of the Orthomolecular Medicine News Service saying, ‘No deaths from vitamins. No deaths from minerals. No deaths from amino acids. No deaths from herbals. No deaths from homeopathic substances,’” Saul says.5,6

“These alternative treatments are effective. They’re safe, and they’re cheap. I want to emphasize they are safe. People are dying in our land and in our world because we’re giving them dangerous drugs. Dr. Hoffer once said, ‘Drugs make a well person sick. Why would they make a sick person well?’ …

Vitamins are not the problem. They’re the solution. If we had better-nourished Americans, we’d save a pile on our $3 trillion-plus disease care bill. It’s good that older Americans take supplements. I don’t mean to do it foolishly. If you take a look, most people are actually smarter than we give them credit for. Taking a multivitamin for instance, especially if it’s a good-quality natural multivitamin, is just a really good idea.”

Growing Your Own Food Is Part of the Solution

As a general rule, most Americans are not getting enough vitamins, minerals and micronutrients from their foods, in large part thanks to the prevalence of processed foods. Dietary supplements, especially if your diet is largely processed, is generally advisable. In the long term, growing more nutrient-dense food is a big part of the answer.

Garden-grown organic vegetables and fruits are nutrient-rich and represent the freshest produce available. Growing your own crops not only improves your diet, but it also:

  • Enhances and protects precious topsoil
  • Encourages composting, which can be used to feed and nourish your plants
  • Minimizes your exposure to synthetic fertilizers, pesticides and other toxins
  • Promotes biodiversity by creating a natural habitat for animals, birds, insects and other living organisms
  • Improves your fitness level, mood and sense of well-being, making gardening a form of exercise

While gardens have many benefits, the most important reason you should plant a garden (especially given the many issues associated with industrial agriculture) is because gardening helps create a more sustainable global food system, giving you and others access to fresh, healthy, nutrient-dense food. If you are new to gardening and unsure about where to start, consider sprouts.

Sprouts are an easy-to-grow, but often overlooked, superfood with a superior nutritional profile. You can grow sprouts even if you don’t have an outdoor garden, and you should consider them if you live in an apartment or condo where space is limited.

“No matter where you are, there’s a way that we can [grow our own food]. We’ve been taught to be consumers of medical care instead of self-reliant people. We’ve been taught to be patients and not persons. To change this around, we have to give ourselves permission to take the power, to do what our body should have been doing all along. We’ve been misled.

I think maybe profit has a little bit to do with this. The pharmaceutical industry is making an awful lot of dough these days. I know people who take pills that cost $1,000 apiece. Don’t tell me I’m hooked on vitamins and I’m wasting my money and having expensive urine. I don’t need to hear that. I find that taking vitamins is very helpful to me, my children and my grandchildren …

For people who think they can’t, you’re wrong. You can. You can do this right away. You can eat better. One of the few free decisions we make every day is whether we will or will not exercise, whether we will or not eat this or that, whether we will or not say no to pharmaceutical drugs or over-the-counter drugs. Every single incremental advancement that you make is going to make your body happy. You’re going to see the difference. All you’ve got to do is try it.”

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Diabetes Medications: Should You Deprescribe Them in the Elderly?

Deprescribing Antihyperglycemics

Researchers at the deprescribing project based at the Bruyère Research Institute in Ottawa, Canada, have just published another deprescribing algorithm, this one focused on antihyperglycemic agents.[1] The aims is to guide healthcare professionals in stopping, switching, or lowering the dose of these drugs in patients at risk for hypoglycemia or other antihyperglycemic adverse effects or in whom the drug’s benefit is uncertain due to frailty, dementia, or limited life expectancy. Lead author Barbara Farrell, PharmD, spoke with Medscape about the guideline and its recommendations.

Recent studies in the United States and Canada have shown that many older patients with diabetes are still being treated to A1c <7%.

“The intensity of glycemic control needed in older people is quite controversial, with different diabetes guidelines recommending different targets,” explained Dr Farrell. Around 5 years ago, treatment guidelines, which had previously favored a glycated hemoglobin (A1c) target of <7% (53 mmol/mol) for most people, set less stringent targets for the elderly (age ≥65 years). Many current international and national guidelines now recommend approximate treatment goals of <7.5% (58 mmol/mol) in healthy older adults and <8.5% (69 mmol/mol) in the very frail elderly.[2,3,4,5,6] These changes in targets result from clinical trials showing that compared with conventional glycemic control, intensive control did not significantly reduce all-cause or cardiovascular mortality.[7] It did, however, increase the risk for hypoglycemia and serious adverse events,[8,9] especially in elderly patients.[10,11]Hypoglycemia is associated with cardiovascular events, cognitive impairment, fractures, death, and reduced quality of life.[12,13] It is a leading cause of emergency department visits in older adults in the United States.[14]Hospitalization for hypoglycemia is associated with a poor prognosis.[15]

Need for New Guidelines

Despite the new guidelines and “Choosing Wisely” campaigns specifically cautioning against intensive glycemic control in the elderly,[16,17] recent studies in the United States and Canada have shown that many older patients with diabetes are still being treated to A1c <7%.[18,19,20,21,22]

“In the United States and Canada, the concept of treating to specific number targets has been very entrenched in the medical communities and among the public, so it is a difficult thing to change,” Dr Farrell stressed. “The diabetes guidelines all talk about how to start these drugs, and some of them discuss how to adjust doses for kidney function or for age, but they don’t specifically address how to reduce a dose or how often to monitor while you are reducing it. That is why we developed the deprescribing guideline, to fill that gap,” Dr Farrell explained. “For patients with low blood sugar, in particular the frail elderly, we wanted to be able to provide guidance to prescribers about when it might be appropriate to start reducing doses or just stopping some of those medications that can contribute to low blood sugar. What we are most concerned about is ensuring that people are switched off those medications and either continue on their remaining medications or with safer ones substituted. We need to be looking at safety as an increasing priority over the potential long-term benefits of keeping blood sugar very low. It is challenging because every person is different in terms of identifying when the balance of risk of medication versus benefit changes.”

The guideline does not set specific glycemic targets, referring to Canadian Diabetes Association and other, similar guidelines that address the need for less stringent targets in the elderly.

Which Drugs to Stop?

“There was a particular worry about glyburide, the long-acting sulfonylurea that frequently causes hypoglycemia,” Dr Farrell said. This usually happens because glyburide was started when patients were younger, and they have been taking it for many years, she explained. Switching glyburide to short- or long-acting gliclazide may reduce but will not eliminate the risk for hypoglycemia. Options other than a sulfonylurea should be considered.

“The other medication that can cause hypoglycemia is insulin, so cut back on the doses if the blood sugar is too low,” Dr Farrell added. The highest risk is with neutral protamine Hagedorn (NPH) insulin, and the guideline advises switching NPH insulin or mixed insulin to insulin detemir or glargine to reduce nocturnal hypoglycemia.

The guideline also lists the antihyperglycemic medications with no or low risk for hypoglycemia (Table).

Table. Medications With Low or No Risk for Hypoglycemia

Drug Risk for Hypoglycemia
Alpha-glucosidase inhibitors No
Dipeptidyl peptidase-4 (DPP-4) inhibitors No
Glucagon-like peptide-1 (GLP-1) agonists No
Meglitinides (glinides) Yes (low risk)
Metformin No
Sodium-glucose linked transporter 2 (SGLT2) inhibitors No
Thiazolidinediones No
Data from Farrell B, et al.[1]

Tapering and Monitoring

“There is no evidence that one tapering approach is better than another,” Dr Farrell noted. “With antihyperglycemic drugs, the only adverse effect from stopping is a rise in blood sugar that needs to be monitored. So if we have a patient who has very low blood sugar and no real problems with high blood sugar, we would just stop the sulfonylurea. If it’s a low dose of insulin, we would stop that. In other cases, we might gradually reduce the dose, either because we think the patient would still benefit from having the drug even at a lower dose, or sometimes the patient is reluctant to just stop suddenly.”

Frequency of monitoring the effects of deprescribing these drugs is highly individualized, depending on the patient’s blood sugar levels and on the drugs that have been changed.

Frequency of monitoring the effects of deprescribing these drugs is highly individualized, depending on the patient’s blood sugar levels and on the drugs that have been changed, Dr Farrell added. Monitoring need not be done daily unless insulin is being deprescribed. “If we are stopping glyburide or switching from glyburide to gliclazide, we might check once a week for a couple of weeks. Typically after most antihyperglycemic drugs are stopped, changes in blood glucose will be seen within 1 or 2 weeks,” she said.

Other Causes of Hypoglycemia

Another unique aspect of the new guideline is the inclusion of different situations that can contribute to hypoglycemia, such as taking insulin and then not eating, taking other drugs that cause hyper- or hypoglycemia, or drug interactions with antihyperglycemic medication. “Sometimes we see that a patient has recently stopped a drug that causes hyperglycemia, but the dose of the diabetes drug has not been reduced,” she explained. “For example, someone who is taking high-dose prednisone for a short period of time might experience a steep rise in blood sugar, and the dose of insulin or other antihyperglycemic drug is increased to cope with that. Then the prednisone is stopped, and the patient’s blood sugar plummets. We might simply avoid the particular drug that causes that drug interaction, or we would probably consider lowering the dose of the antihyperglycemic drug.”

Discussion With Patients and Families

One of the goals of the guideline is to encourage healthcare providers to discuss the rationale and benefits of deprescribing with patients and their families. “One of the biggest challenges is to explain the targets and the need to focus on safety versus not always focusing on preventing the long-term problems of diabetes,” Dr Farrell said. “This can be especially difficult with older people who may have had diabetes for 30 years, and it may seem as though suddenly, out of the blue, we’re not concerned about their blood sugar any longer. It is not an easy conversation to have, and it can be time-consuming,” she acknowledged.

“When these medications are first prescribed to a newly diagnosed person, and targets are discussed, it would be helpful to also explain that when they are older or if they start having hypoglycemic episodes, these targets may change,” she suggested. “We would establish that very intensive control is important in a younger person to prevent long-term complications but that as they get older we will revisit these targets, so they would know that modifying their targets as they get older is a normal part of the program.”

Updating the Guidelines

Dr Farrell pointed out that the systematic review of evidence done for preparation of the new guideline[23] identified only two relevant studies of deprescribing antihyperglycemic agents.[24,25] Both studies concluded that the approach is safe and feasible, but the quality of the evidence was low, the guideline authors commented. “We would benefit from having more studies of deprescribing so that we can get a better understanding about whether there is an optimal approach to tapering, monitoring, and follow-up,” Dr Farrell said. “Our eventual goal is that all prescribing guidelines will include deprescribing sections, so that specialists, family physicians, and all other healthcare professionals are on board with the approach.”

Virtual reality treadmills help prevent falls in elderly

Adding a virtual reality obstacle course to treadmill workouts may help prevent more falls among vulnerable adults than using a treadmill on its own, a small study suggests.

Researchers asked about 300 adults aged 60 to 90 who had already experienced at least one prior fall to exercise on a treadmill three times a week for six weeks, randomly assigning half of them to use virtual reality systems during the workouts.

When training started, both groups had similar experiences with falls – the treadmill-only group had an incident rate of 10.7 falls in the previous six months compared with rate of 11.9 for the virtual reality group.

Six months after training, however, the incident rate dropped significantly only in the virtual reality group – to six falls in six months – while it was little changed for the treadmill-only group, researchers report in The Lancet.

“Our idea was to use the virtual reality environment to safely train both the motor or gait aspects that are important to fall risk, while also implicitly teaching the participants to improve the cognitive functions that are important for safe ambulation,” said lead study author Anat Mirelman of Tel Aviv University in Israel.

“The study showed that this type of training is effective in reducing falls and fall risk in a large diverse population,” Mirelman added by email. “Thus the findings support the use of motor cognitive training to enhance health and reduce fall risk in a growing older population.”

In addition to a history of falls, the participants also had other risk factors for repeat tumbles such as impaired motor skills or cognitive function.

Participants were around 73 to 74 years old on average.

About 130 of them had Parkinson’s disease, which can rob people of motor control, 43 had mild cognitive impairment and 109 had a history of falls without a clear medical reason.

Researchers asked each participant to move at a comfortable pace during 45-minute sessions on the treadmill.

Half of the participants also used virtual reality systems consisting of a motion-capture camera and a computer-generated simulation projected on to a large screen.

This virtual reality experience was designed to lower the risk of falls by improving how well participants could navigate obstacles, multiple pathways and distractions that required a constant adjustment in the way they stepped on the treadmills.

Immediately after the six weeks of training, participants in both groups had improvements in walking speed in usual situations as well as those with obstacles.

But the virtual reality group generally had a more varied gait while maneuvering around obstacles, the study found. Obstacle clearance was also better in the virtual reality group.

While this technology appeared effective, the study didn’t assess how much it would cost to provide virtual reality treadmill training to a broad population of older adults at risk for falls.

One limitation of the study is its reliance on self-reported data on falls before training, which makes it possible that the measurement of improvements attributed to the training may have been inaccurate, the authors note.

Even so, the study adds to growing evidence suggesting fall prevention for the elderly needs to address both motor skills and cognitive skills necessary to safely navigate an environment that may not always include perfectly flat, well-lit paths.

Studies in Europe, the U.S. and Australia show that roughly a third of people aged 65 years or older living outside institutions fall at least once per year, with half of this number having multiple falls in this period, writes Stephen Lord, a researcher at the University of New South Wales in Australia, in an accompanying commentary.

“There have been several pilot studies that have found exergames involving balance and step training have improved balance reaction time, stepping performance and cognitive function – known risk factors for falls,” Lord told Reuters health by email.

“The published study is the first with a sufficiently large sample to show an effect on falls themselves,” he added.

SPRINT: Lower BP Goals Better for Elderly

For people age 75 and older, a blood pressure goal under 120 mm Hg systolic substantially lowered the risk of major cardiovascular events and death from any cause without increasing risks, a SPRINT sub-analysis showed.

Compared with a goal of less than 140 mm Hg, intensive treatment yielded a 34% relatively lower risk of the composite primary endpoint of nonfatal myocardial infarction or other acute coronary syndrome, nonfatal stroke, nonfatal acute decompensated heart failure, and death from cardiovascular causes (2.59% versus 3.85%, hazard ratio 0.66, 95% CI 0.51-0.85).

All-cause mortality likewise was 33% reduced by intensive treatment over a median follow-up of 3.14 years (73 versus 107 deaths, respectively; HR 0.67 [95% CI 0.49-0.91]).

The number needed to treat was 27 to prevent one composite endpoint event and 41 to forestall one death over that period, Jeff D. Williamson, MD, MHS, of Wake Forest School of Medicine in Winston-Salem, N.C., and colleagues reported online in the Journal of the American Medical Association and at the American Geriatrics Society meeting in Long Beach, Calif.

Although safety has been the major concern holding back aggressive treatment for older adults, SPRINT showed a nearly identical 48.4% versus 48.3% rate of serious adverse event rates between the intensive and standard treatment groups for the participants 75 and older.

“Small increases in incidence of hypotension, syncope, or acute changes in renal function were observed, but these appeared to be more than offset by the large benefits of treatment,” noted an accompanying editorial by Aram V. Chobanian, MD, of Boston University.

“Everybody is afraid of treating these people; they don’t want them to keel over or have some untoward event,” Joseph L. Izzo MD, of New York’s University at Buffalo, toldMedPage Today. The SPRINT data “pretty strongly refute that concept that these older people who have very high risk for debilitating strokes can’t be treated effectively. It is not a good idea to gauge therapy based on the age of the patient.”

Although the event rates were higher with increasing frailty across the board, the intervention improved outcomes in every frailty stratum (P=0.84 for interaction). Results were similar considering gait speed as a marker of frailty.

Likewise, serious adverse events were more common with greater frailty but did not differ significantly by treatment group across frailty strata. The analysis included 2,636 participants age 75 and older (mean of 79.9, and 37.9% were women), randomized to a systolic treatment goal of less than 120 or less than 140 mm Hg.

The high adverse effect rate in both groups was not surprising for this age group, John Bisognano, MD, PhD, of New York’s University of Rochester Medical Center and president of the American Society of Hypertension, told MedPage Today. “The incidence of adverse events is really not anything to worry about.”

He predicted that the findings would change practice.

“If [patients] are having side effects, we’re not going to push through them. But we will push a little harder on blood pressure,” he said. “We do a lot of other heroic things for elderly people, but this is a standard therapy that can have a big effect. We can’t ignore that data.”

Izzo agreed: “Remember that you’re going to be more likely to prevent an event by treating somebody who is 80 than you are by treating somebody who is 40, because the event rate is so much higher in people 80 years old — Age being the number one cardiovascular risk factor.”

There are important caveats to keep in mind in applying SPRINT to practice, such as the exclusion of patients with prior stroke, diabetes, or serious frailty, or those who are institutionalized, trial investigator Suzanne Oparil, MD, of the University of Alabama at Birmingham, had cautioned earlier in the week regarding another subanalysis on frailty.

Izzo, though, noted that a study on people in long-term care facilities is unlikely to be finished and suggested that the findings of a good risk-to-benefit ratio would likely generalize to those elderly people as well. It would take “a leap of faith, but how big a leap is it? Not much, not to me,” he said.

Also, there were measures taken to ensure the safety of the approach, Oparil toldMedPage Today. “When the drugs were titrated to get to the goal, people were seen every month. Within the first 6 months, some people were seen every month — and that’s more than some doctors would want to do.”

She urged clinicians to:

  • Be patient with titrating drugs.
  • Monitor blood pressure, electrolytes, serum potassium, kidney function, and standing blood pressures.
  • Measure blood pressure in the same way that SPRINT did, “with a device that’s programmed to take the blood pressure after a lag time of 5 minutes.”

Chobanian concluded that even if it is challenging for clinicians, “the important results reported … cannot be discounted, and unless unexpected adverse effects are observed on further examination of the trial data, then major changes in treatment goals for patients 75 years or older with hypertension will be warranted.”