Friday, June 29, 2012

Xanax Schmanax

As geriatricians and providers who work with older adults, many of whom are frail, we carry amongst our mantras the avoidance of benzodiazepines (xanax, halcion, ativan, valium to name a handful). Since the inception of the Beers Criteria on Potentially Inappropriate Medications for older adults, benzodiazepines have maintained their steady presence. (see post: http://www.geripal.org/2012/03/beers-criteria-contest-submit-craziest.html) Sadly, I see in my geriatrics practice that benzodiazepines also remain a common prescription for older adults in the community to treat everything from anxiety to insomnia, muscle aches and pain to fear of flying. The patient alluded to in the previous geripal post above who was on valium, halcion, ativan, and doxepin was only one of the MANY patients I encounter in my primary care and consult practice. While her combination of prescriptions was horrifying, I often feel equally depressed and frustrated when I see new patients who come to me with just one benzodiazepine. It is not uncommon that I have new patients who have been prescribed two: valium and restoril, ativan and clonazepam, ativan and restoril etc. Why does this upset me so? Just this week I met two new patients who were both on benzodiazepines. One was a 90 year old woman who was prescribed xanax a few years ago to help her with longstanding anxiety which has worsened as she has aged. She herself stated that her desire was to "not become addicted" to xanax (one of the RARE patients I meet on benzodiazepines who actually WANTS to come off). She has had a fall significant enough to cause a subdural hematoma. The second patient I saw was prescribed two benzodiazepines--because she moved here from Europe I had to look up the medication names she had been taking "for years" and, unfortunately, she has been on quite significant doses of both. She presented to me with what I see classically in long-standing benzodiazepine users--a tremendous relief when she takes the medication for her sleep but then a subsequent "wear off" effect where her anxiety rises through the day until she's in desperation by bedtime. Most of the new patients I see on benzodiazepines absolutely LOVE their benzos. The majority of them also complain to me of unsteadiness on their feet, history of falls, depression, trouble with memory. Benzos may not be directly correlated with all of these complaints, or even with my 90yo woman's prior fall above. But they sure raise my concern. While some of these patients have had a trial of SSRIs--and fewer a trial of therapy, sleep training, meditation or other treatment--many of these patients coming to me have not had a trial of ANY OTHER treatment for their anxiety, insomnia, etc. My concern about how widely benzodiazepines are doled out to patients in their 70s, 80s, 90s is that this may seem like a quick fix for a patient's anxiety, insomnia, or whatever is ailing them. (And I fully recognize that some patients may directly approach their primary care provider with a request for xanax, valium or ativan.) But the downstream sequelae is that these patients (almost always) become incredibly attached to their benzos and inevitably are at risk, as they age, of significant adverse effects. And almost all of them are reluctant to come off the medication--even if their anxiety or insomnia are not as well-managed as they themselves would like. Indeed, a number of patients on longstanding benzos develop WORSENING of anxiety, sleep and depression over time. I shudder when I see a new patient in my practice who is frail, wobbly, and cognitively impaired who complains to me not only of anxiety or insomnia but that their walking is unsteady, they keep falling, or they just can't think the way they used to. Most of the time, these patients also have the usual combination of chronic illness which need to be addressed--hypertension, diabetes, heart failure, COPD etc. The quick fix medication becomes the locus of what often ends up being a months-long (sometimes years-long) process of educating my patient (or their family/caregiver) about how we can better treat their anxiety and insomnia, and carefully taper them down. I am not always successful (yet) with some patients. But I (and many families and patients) do often find success at the end of a LONG road to taper benzodiazepines. What is unfortunate is that the time and effort to slowly, carefully and always reassuringly taper someone down off a medication they have long-perceived to be a lifeline to calm and peace, is arduous and often takes up significant time in clinic sessions such that addressing their chronic conditions, or even acute illnesses, have to constantly be re-triaged. I do not have a 100% avoidance policy against benzodiazedines. There are a small number of indications for which benzodiazepines can be very appropriate. And, certainly, within the more palliative-hospice goal-directed care I provide for patients approaching death, benzodiazepines can be incredibly helpful. But how do we educate our patients and colleagues in health care that benzodiazepines should NEVER be the firstline prescription handed to an older adult for anxiety or insomnia. by: Helen Kao

3 comments:

Helen Chen, MD said...

Helen, I've definitely seen this disturbing benzo phenomenon too. Unfortunately, there are many competing pressures/problems that may not be entirely soluble with just education. There are many people who believe in "better living through pharmaceuticals" prescribed or otherwise. I would also argue that many physicians want to say "yes" to patient requests--we are after all in a helping profession--and I wonder if the bonus-related effects of Press-Ganey, HCAHPS scores, and other patient satisfaction incentive programs also potentiate this problem.

That being said, it has always been my contention that 21st century medicine addresses the question "can we?" while 21st century geriatricians/geriatrics focused healthcare professionals attempt to reframe the question as "should we?" Saying no in a positive way takes courage, stamina, and in some cases, institutional support.

Helen C.

Carole Larkin MAG, CMC, CAEd, QDCS, EICS said...

Amen and right on to both Helens. As a Geriatric Care Manager specializing in the Dementias, when I go into a home, far,far too often I see one or more bottles of benzos for the person with dementia. What's worse is it is seen as the answer by the family, rather than having to put more effort into caregiving that engages the person, not sedates them.

Anonymous said...

This is very interesting. I'm in a situation where an elderly in-law is having very serious anxiety as well as many other geriatric issues, including unsteadiness. We're a long ways away from her and there really are no more local family caregivers, so we're very dependent on the professional medical support she can receive through various assistance programs. She's on xanax at the moment. I'm reluctant therefore to question their judgment and yet I'm also wary personally of psychiatric medicines and the propensity to overmedicate. I just don't know how plausible the alternative you suggest here is in our situation or many others--e.g., if the alternative involves extensive clinic sessions, it's just not going to happen for all sorts of reasons. She was experiencing fragility and acute anxiety before being medicated as well, so it's terrible hard to even guess what part might involve pharmaceutical effects and what else is involved.