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Deprescribing Benzodiazepines in Older Patients: Impact of Interventions Targeting Physicians, Pharmacists, and Patients

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Abstract

Benzodiazepines (BZDs; including the related Z-drugs) are frequently targets for deprescribing; long-term use in older people is harmful and often not beneficial. BZDs can result in significant harms, including falls, fractures, cognitive impairment, car crashes and a significant financial and legal burden to society. Deprescribing BZDs is problematic due to a complex interaction of drug, patient, physician and systematic barriers, including concern about a potentially distressing but rarely fatal withdrawal syndrome. Multiple studies have trialled interventions to deprescribe BZDs in older people and are discussed in this narrative review. Reported success rates of deprescribing BZD interventions range between 27 and 80%, and this variability can be attributed to heterogeneity of methodological approaches and limited generalisability to cognitively impaired patients. Interventions targeting the patient and/or carer include raising awareness (direct-to-consumer education, minimal interventions, and ‘one-off’ geriatrician counselling) and resourcing the patient (gradual dose reduction [GDR] with or without cognitive behavioural therapy, teaching relaxation techniques, and sleep hygiene). These are effective if the patient is motivated to cease and is not significantly cognitively impaired. Interventions targeted to physicians include prescribing interventions by audit, algorithm or medication review, and providing supervised GDR in combination with medication substitution. Pharmacists have less frequently been the targets for studies, but have key roles in several multifaceted interventions. Interventions are evaluated according to the Behaviour Change Wheel. Research supports trialling a stepwise approach in the cognitively intact older person, but having a low threshold to use less-consultative methods in patients with dementia. Several resources are available to support deprescribing of BZDs in clinical practice, including online protocols.

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References

  1. Reeve E, Ong M, Wu A, Jansen J, Petrovic M, Gnjidic D. A systematic review of interventions to deprescribe benzodiazepines and other hypnotics among older people. Eur J Clin Pharmacol. 2017;73(8):927–35.

    Article  PubMed  CAS  Google Scholar 

  2. Gould RL, Coulson MC, Patel N, Highton-Williamson E, Howard RJ. Interventions for reducing benzodiazepine use in older people: meta-analysis of randomised controlled trials. Br J Psychiatry. 2014;204(2):98–107.

    Article  PubMed  Google Scholar 

  3. Paquin AM, Zimmerman K, Rudolph JL. Risk versus risk: a review of benzodiazepine reduction in older adults. Expert Opin Drug Saf. 2014;13(7):919–34.

    Article  PubMed  CAS  Google Scholar 

  4. Glass J, Lanctôt KL, Herrmann N, Sproule BA, Busto UE. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. Br Med J. 2005;331(7526):1169.

    Article  Google Scholar 

  5. Dell’osso B, Lader M. Do benzodiazepines still deserve a major role in the treatment of psychiatric disorders? A critical reappraisal. Eur Psychiatry. 2013;28(1):7–20.

    Article  PubMed  Google Scholar 

  6. Cook PJ, Huggett A, Graham-Pole R, Savage IT, James IM. Hypnotic accumulation and hangover in elderly inpatients: a controlled double-blind study of temazepam and nitrazepam. Br Med J (Clin Res Ed). 1983;286(6359):100–2.

    Article  CAS  Google Scholar 

  7. Vinkers CH, Olivier B. Mechanisms underlying tolerance after long-term benzodiazepine use: a future for subtype-selective gaba(a) receptor modulators? Adv Pharmacol Sci. 2012;2012:416864.

    PubMed  PubMed Central  Google Scholar 

  8. Donoghue J, Lader M. Usage of benzodiazepines: a review. Int J Psychiatry Clin Pract. 2010;14:78–87.

    Article  PubMed  CAS  Google Scholar 

  9. Maust DT, Blow FC, Wiechers IR, Kales HC, Marcus SC. National trends in antidepressant, benzodiazepine, and other sedative-hypnotic treatment of older adults in psychiatric and primary care. J Clin Psychiatry. 2017;78(4):e363–71.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Jackson G, Gerard C, Minko N, Parsotam N. Variation in benzodiazepine and antipsychotic use in people aged 65 years and over in New Zealand. N Z Med J. 2014;127(1396):67–78.

    PubMed  Google Scholar 

  11. Mell T, Jacob L, Fuhr I, Dick S, Rapp MA, Kostev K. Patterns of benzodiazepine prescribing by neuropsychiatrists and general practitioners for elderly patients in Germany in 2014. Int J Clin Pharmacol Ther. 2017;55(6):466–71.

    Article  PubMed  Google Scholar 

  12. Johnson CF, Frei C, Downes N, McTaggart SA, Akram G. Benzodiazepine and z-hypnotic prescribing for older people in primary care: a cross-sectional population-based study. Brit J Gener Pract. 2016;66(647):e410–5.

    Article  Google Scholar 

  13. Sgnaolin V, Engroff P, Andrade CP, Loureiro F, Nogueira EL, Cataldo Neto A, et al. Patterns of chronic benzodiazepine use in the elderly. Archi Clin Psychiatry (São Paulo). 2016;43:79–82.

    Article  Google Scholar 

  14. Alessi-Severini S, Bolton JM, Enns MW, Dahl M, Collins DM, Chateau D, et al. Use of benzodiazepines and related drugs in Manitoba: a population-based study. CMAJ Open. 2014;2(4):E208–16.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Smith AJ, Tett SE. How do different age groups use benzodiazepines and antidepressants? Analysis of an Australian administrative database, 2003–6. Drugs Aging. 2009;26(2):113–22.

    Article  PubMed  CAS  Google Scholar 

  16. Jorm AF, Grayson D, Creasey H, Waite L, Broe GA. Long-term benzodiazepine use by elderly people living in the community. Aust N Z J Public Health. 2000;24(1):7–10.

    Article  PubMed  CAS  Google Scholar 

  17. Iqbal SP, Ahmer S, Farooq S, Parpio Y, Tharani A, Khan RAM, et al. Benzodiazepine use among adults residing in the urban settlements of Karachi, Pakistan: a cross sectional study. Subst Abuse Treat Prev Policy. 2011;6:19.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Naja WJ, Pelissolo A, Haddad RS, Baddoura R, Baddoura C. A general population survey on patterns of benzodiazepine use and dependence in Lebanon. Acta Psychiatr Scand. 2000;102(6):429–31.

    Article  PubMed  CAS  Google Scholar 

  19. Peterson JF, Kripalani S, Danciu I, Harrell D, Marvanova M, Mixon AS, et al. Electronic surveillance and pharmacist intervention for vulnerable older inpatients on high-risk medication regimens. J Am Geriatr Soc. 2014;62(11):2148–52.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Fond G, Fajula C, Dassa D, Brunel L, Lançon C, Boyer L. Potentially inappropriate psychotropic prescription at discharge is associated with lower functioning in the elderly psychiatric inpatients. A cross-sectional study. Psychopharmacology (Berl). 2016;233(13):2549–58.

    Article  CAS  Google Scholar 

  21. Pek EA, Remfry A, Pendrith C, Fan-Lun C, Bhatia RS, Soong C. high prevalence of inappropriate benzodiazepine and sedative hypnotic prescriptions among hospitalized older adults. J Hosp Med. 2017;12(5):310–6.

    Article  PubMed  Google Scholar 

  22. Williams F, Mahfouz C, Bonney A, Pearson R, Seidel B, Dijkmans-Hadley B, et al. A circle of silence: The attitudes of patients older than 65 years of age to ceasing long-term sleeping tablets. Aust Fam Physician. 2016;45:506–11.

    PubMed  Google Scholar 

  23. Parr J, Kavanagh D, Cahill L, Mitchell G, McD Young R. Effectiveness of current treatment approaches for benzodiazepine discontinuation: a meta-analysis. Addiction. 2009;104(1):13–24.

    Article  PubMed  Google Scholar 

  24. Bourgeois J, Elseviers MM, Azermai M, Van Bortel L, Petrovic M, Vander Stichele RR. Benzodiazepine use in Belgian nursing homes: a closer look into indications and dosages. Eur J Clin Pharmacol. 2012;68(5):833–44.

    Article  PubMed  CAS  Google Scholar 

  25. Chen L, Bell JS, Visvanathan R, Hilmer SN, Emery T, Robson L, et al. The association between benzodiazepine use and sleep quality in residential aged care facilities: a cross-sectional study. BMC Geriatr. 2016;16:196.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  26. Batty G, Hooper R, Oborne C, Jackson S. Investigating intervention strategies to increase the appropriate use of benzodiazepines in elderly medical in-patients. Br J Clin Gov. 2001;6(4):252–8.

    Article  Google Scholar 

  27. Maust DT, Kales HC, Wiechers IR, Blow FC, Olfson M. No End in Sight: Benzodiazepine Use in Older Adults in the United States. J Am Geriatr Soc. 2016;64(12):2546–53.

    Article  PubMed  PubMed Central  Google Scholar 

  28. American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015;63(11):2227–46.

    Article  Google Scholar 

  29. O’Mahony D, O’Sullivan D. S B, O’Connor M, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: Version 2. Age Ageing. 2015;44(2):213–8.

    Article  PubMed  Google Scholar 

  30. Butler JM, Begg EJ. Free drug metabolic clearance in elderly people. Clin Pharmacokinet. 2008;47(5):297–321.

    Article  PubMed  CAS  Google Scholar 

  31. McLachlan AJ, Pont LG. Drug Metabolism in Older People: a key consideration in achieving optimal outcomes with medicines. J Gerontol A Biol Sci Med Sci. 2012;67A(2):175–80.

    Article  CAS  Google Scholar 

  32. Greenblatt DJ, Shader RI, Harmatz JS. Implications of altered drug disposition in the elderly: studies of benzodiazepines. J Clin Pharmacol. 1989;29(10):866–72.

    Article  PubMed  CAS  Google Scholar 

  33. DeVane CL. Clinical pharmacokinetics and pharmacodynamics of anxiolytics and sedative/hypnotics. In: Jann MW, Penzak SR, Cohen LJ, editors. Applied Clinical pharmacokinetics and pharmacodynamics of psychopharmacological agents. Cham: Springer International Publishing; 2016. p. 247–66.

    Chapter  Google Scholar 

  34. Rissman RA, Mobley WC. Implications for treatment: GABAA receptors in aging, Down syndrome and Alzheimer’s disease. J Neurochem. 2011;117(4):613–22.

    PubMed  PubMed Central  CAS  Google Scholar 

  35. Markota M, Rummans TA, Bostwick JM, Lapid MI. Benzodiazepine use in older adults: dangers, management, and alternative therapies. Mayo Clin Proc. 2016;91(11):1632–9.

    Article  PubMed  CAS  Google Scholar 

  36. Canham SL, Gallo J, Simoni-Wastila L. Perceptions of benzodiazepine dependence among women age 65 and older. J Gerontol Soc Work. 2014;57(8):872–88.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Iliffe S, Curran H, Collins R, Yuen Kee SC, Fletcher S, Woods B. Attitudes to long-term use of benzodiazepine hypnotics by older people in general practice: findings from interviews with service users and providers. Aging Ment Health. 2004;8(3):242–8.

    Article  PubMed  CAS  Google Scholar 

  38. Brett J, Murnion B. Management of benzodiazepine misuse and dependence. Aust Prescr. 2015;38(5):152–5.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Couvee JE, Zitman FG. The benzodiazepine withdrawal symptom questionnaire: psychometric evaluation during a discontinuation program in depressed chronic benzodiazepine users in general practice. Addiction. 2002;97:337–45.

    Article  PubMed  Google Scholar 

  40. Rickels K, Schweizer E, Case WG, Greenblatt DJ. Long-term therapeutic use of benzodiazepines. I. Effects of abrupt discontinuation. Arch Gen Psychiatry. 1990;47(10):899–907.

    Article  PubMed  CAS  Google Scholar 

  41. Schweizer E, Rickels K, Case G, Greenblatt D. Long-term therapeutic use of benzodiazepines. II: Effects of gradual taper. Arch Gen Psychiatry. 1990;47(10):908–15.

    Article  PubMed  CAS  Google Scholar 

  42. Cormack MA, Sweeney KG, Hughes-Jones H, Foot GA. Evaluation of an easy, cost-effective strategy for cutting benzodiazepine use in general practice. Br J Gen Pract. 1994;44(378):5–8.

    PubMed  PubMed Central  CAS  Google Scholar 

  43. Petrovic M, Pevernagie D, Mariman A, Van Maele G, Afschrift M. Fast withdrawal from benzodiazepines in geriatric inpatients: a randomised double-blind, placebo-controlled trial. Eur J Clin Pharmacol. 2002;57(11):759–64.

    Article  PubMed  CAS  Google Scholar 

  44. Schweizer E, Case WG, Rickels K. Benzodiazepine dependence and withdrawal in elderly patients. Am J Psychiatry. 1989;146(4):529–31.

    Article  PubMed  CAS  Google Scholar 

  45. O’Connor KP, Marchand A, Belanger L, Mainguy N, Landry P, Savard P, et al. Psychological distress and adaptational problems associated with benzodiazepine withdrawal and outcome: a replication. Addict Behav. 2004;29(3):583–93.

    Article  PubMed  Google Scholar 

  46. Pérodeau G, Grenon É, Grenier S, O’Connor K. Systemic model of chronic benzodiazepine use among mature adults. Aging Ment Health. 2016;20(4):380–90.

    Article  PubMed  Google Scholar 

  47. Xing D, Ma XL, Ma JX, Wang J, Yang Y, Chen Y. Association between use of benzodiazepines and risk of fractures: a meta-analysis. Osteoporos Int. 2014;25(1):105–20.

    Article  PubMed  CAS  Google Scholar 

  48. Panneman MJ, Goettsch WG, Kramarz P, Herings RM. The costs of benzodiazepine-associated hospital-treated fall injuries in the EU: a Pharmo study. Drugs Aging. 2003;20(11):833–9.

    Article  PubMed  Google Scholar 

  49. Skinner BW, Johnston EV, Saum LM. Benzodiazepine initiation and dose escalation. Ann Pharmacother. 2017;51(4):281–5.

    Article  PubMed  CAS  Google Scholar 

  50. Ballokova A, Peel NM, Fialova D, Scott IA, Gray LC, Hubbard RE. Use of Benzodiazepines and association with falls in older people admitted to hospital: a prospective cohort study. Drugs Aging. 2014;31(4):299–310.

    Article  PubMed  CAS  Google Scholar 

  51. Cumming RG, Le Couteur DG. Benzodiazepines and risk of hip fractures in older people: a review of the evidence. CNS Drugs. 2003;17(11):825–37.

    Article  PubMed  CAS  Google Scholar 

  52. Donnelly K, Bracchi R, Hewitt J, Routledge PA, Carter B. Benzodiazepines, Z-drugs and the risk of hip fracture: a systematic review and meta-analysis. PLoS One. 2017;12(4):e0174730.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  53. Yu NW, Chen PJ, Tsai HJ, Huang CW, Chiu YW, Tsay WI, et al. Association of benzodiazepine and Z-drug use with the risk of hospitalisation for fall-related injuries among older people: a nationwide nested case–control study in Taiwan. BMC Geriatr. 2017;17:140.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  54. Brandt J, Leong C. Benzodiazepines and Z-Drugs: an updated review of major adverse outcomes reported on in epidemiologic research. Drugs R D. 2017;17:493–507.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Salkeld G, Cameron ID, Cumming RG, Easter S, Seymour J, Kurrle SE, et al. Quality of life related to fear of falling and hip fracture in older women: a time trade off study. BMJ. 2000;320(7231):341–6.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  56. Cumming RG, Salkeld G, Thomas M, Szonyi G. Prospective study of the impact of fear of falling on activities of daily living, SF-36 scores, and nursing home admission. J Gerontol A Biol Sci Med Sci. 2000;55(5):M299–305.

    Article  PubMed  CAS  Google Scholar 

  57. van der Meulen E, Zijlstra GAR, Ambergen T, Kempen GIJM. Effect of fall-related concerns on physical, mental, and social function in community-dwelling older adults: a prospective cohort study. J Am Geriatr Soc. 2014;62(12):2333–8.

    PubMed  Google Scholar 

  58. Hatton J. Fear of falling and its relationship to depression and anxiety in older adults living in the community and in extended care facilities in Australia [professional Doctorate]. Perth: Murdoch University; 2016.

    Google Scholar 

  59. Sirdifield C, Chipchase SY, Owen S, Siriwardena AN. A systematic review and meta-synthesis of patients’ experiences and perceptions of seeking and using benzodiazepines and Z-Drugs: towards safer prescribing. Patient. 2017;10(1):1–15.

    Article  PubMed  Google Scholar 

  60. Roth T, Eklov SD, Drake CL, Verster JC. meta-analysis of on-the-road experimental studies of hypnotics: effects of time after intake, dose, and half-life. Traffic Inj Pre. 2014;15(5):439–45.

    Article  CAS  Google Scholar 

  61. Dassanayake T, Michie P, Carter G, Jones A. Effects of benzodiazepines, antidepressants and opioids on driving: a systematic review and meta-analysis of epidemiological and experimental evidence. Drug Saf. 2011;34(2):125–56.

    Article  PubMed  CAS  Google Scholar 

  62. Barker MJ, Greenwood KM, Jackson M, Crowe SF. Cognitive effects of long-term benzodiazepine use: a meta-analysis. CNS Drugs. 2004;18(1):37–48.

    Article  PubMed  CAS  Google Scholar 

  63. Islam MM, Iqbal U, Walther B, Atique S, Dubey NK, Nguyen PA, et al. Benzodiazepine use and risk of dementia in the elderly population: a systematic review and meta-analysis. Neuroepidemiology. 2016;47(3–4):181–91.

    Article  PubMed  Google Scholar 

  64. Pariente A, de Gage SB, Moore N, Begaud B. The benzodiazepine-dementia disorders link: current state of knowledge. CNS Drugs. 2016;30(1):1–7.

    Article  PubMed  CAS  Google Scholar 

  65. Zhong G, Wang Y, Zhang Y, Zhao Y. Association between benzodiazepine use and dementia: a meta-analysis. PLoS One. 2015;10(5):e0127836.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  66. de Gage BS, Pariente A, Bégaud B. Is there really a link between benzodiazepine use and the risk of dementia? Expert Opin Drug Saf. 2015;14(5):733–47.

    Article  CAS  Google Scholar 

  67. Gray SL, Dublin S, Yu O, Walker R, Anderson M, Hubbard RA et al. Benzodiazepine use and risk of incident dementia or cognitive decline: prospective population based study. Br Med J. 2016;352:i90.

    Article  CAS  Google Scholar 

  68. Palmaro A, Dupouy J, Lapeyre-Mestre M. Benzodiazepines and risk of death: results from two large cohort studies in France and UK. Eur Neuropsychopharmacol. 2015;25(10):1566–77.

    Article  PubMed  CAS  Google Scholar 

  69. Weich S, Pearce HL, Croft P, Singh S, Crome I, Bashford J, et al. Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: retrospective cohort study. BMJ. 2014;348:g1996.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  70. Parsaik AK, Mascarenhas SS, Khosh-Chashm D, Hashmi A, John V, Okusaga O, et al. Mortality associated with anxiolytic and hypnotic drugs-A systematic review and meta-analysis. Aust N Z J Psychiatry. 2016;50(6):520–33.

    Article  PubMed  Google Scholar 

  71. Patorno E, Glynn RJ, Levin R, Lee MP, Huybrechts KF. Benzodiazepines and risk of all cause mortality in adults: cohort study. BMJ. 2017;358:j2941.

    Article  PubMed  PubMed Central  Google Scholar 

  72. Watts JJ, Abimanyi-Ochom J, Saunders KM. Osteoporosis costing all Australians a new burden of disease analysis—2012 to 2022. Melbourne: Osteoporosis Australia; 2013.

    Google Scholar 

  73. Kanis JA, Borgström F, Compston J, Dreinhöfer K, Nolte E, Jonsson L, et al. SCOPE: a scorecard for osteoporosis in Europe. Arch Osteoporos. 2013;8(1–2):144.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  74. Dionne P-A, Vasiliadis H-M, Latimer E, Berbiche D, Preville M. Economic impact of inappropriate benzodiazepine prescribing and related drug interactions among elderly persons. Psychiatr Serv. 2013;64(4):331–8.

    Article  PubMed  Google Scholar 

  75. Singh S, Sarkar S. Benzodiazepine abuse among the elderly. J Geriatr Ment Health. 2016;3(2):123–30.

    Article  Google Scholar 

  76. Reeve E, Gnjidic D, Long J, Hilmer S. A systematic review of the emerging definition of ‘deprescribing’ with network analysis: implications for future research and clinical practice. Br J Clin Pharmacol. 2015;80(6):1254–68.

    Article  PubMed  PubMed Central  Google Scholar 

  77. Farrell B, Tsang C, Raman-Wilms L, Irving H, Conklin J, Pottie K. What are priorities for deprescribing for elderly patients? Capturing the voice of practitioners: a modified delphi process. PLoS One. 2015;10(4):e0122246.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  78. Busto U, Sellers EM, Naranjo CA, Cappell H, Sanchez-Craig M, Sykora K. Withdrawal reaction after long-term therapeutic use of benzodiazepines. N Engl J Med. 1986;315(14):854–9.

    Article  PubMed  CAS  Google Scholar 

  79. Tsunoda K, Uchida H, Suzuki T, Watanabe K, Yamashima T, Kashima H. Effects of discontinuing benzodiazepine-derivative hypnotics on postural sway and cognitive functions in the elderly. Int J Geriatr Psychiatry. 2010;25(12):1259–65.

    Article  PubMed  Google Scholar 

  80. Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Intern Med. 2014;174(6):890–8.

    Article  PubMed  CAS  Google Scholar 

  81. Bashir K, King M, Ashworth M. Controlled evaluation of brief intervention by general practitioners to reduce chronic use of benzodiazepines. Br J Gen Pract. 1994;44(386):408–12.

    PubMed  PubMed Central  CAS  Google Scholar 

  82. Salonoja M, Salminen M, Aarnio P, Vahlberg T, Kivela SL. One-time counselling decreases the use of benzodiazepines and related drugs among community-dwelling older persons. Age Ageing. 2010;39(3):313–9.

    Article  PubMed  Google Scholar 

  83. Heather N, Bowie A, Ashton H, McAvoy B, Spencer I, Brodie J, et al. Randomised controlled trial of two brief interventions against long-term benzodiazepine use: outcome of intervention. Add Res Theory. 2004;12(2):141–54.

    Article  Google Scholar 

  84. Curran H, Collins R, Fletcher S, Kee S, Woods B, Iliffe S. Older adults and withdrawal from benzodiazepine hypnotics in general practice: effects on cognitive function, sleep, mood and quality of life. Psychol Med. 2003;33(7):1223–37.

    Article  PubMed  CAS  Google Scholar 

  85. Baillargeon L, Landreville P, Verreault R, Beauchemin J-P, Gregoire J-P, Morin C. Discontinuation of benzodiazepines among older insomniac adults treated with cognitive-behavioural therapy combined with gradual tapering: a randomized trial. CMAJ. 2003;169(10):1015–20.

    PubMed  PubMed Central  Google Scholar 

  86. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42.

    Article  PubMed  PubMed Central  Google Scholar 

  87. Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, et al. The Behavior Change Technique Taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change Interventions. Ann Behav Med. 2013;46(1):81–95.

    Article  PubMed  Google Scholar 

  88. Salzman C, Fisher J, Nobel K, Glassman R, Wolfson A, Kelley M. Cognitive improvement following benzodiazepine discontinuation in elderly nursing home residents. Int J Geriatr Psychiatry. 1992;7(2):89–93.

    Article  Google Scholar 

  89. Morin CM, Bastien C, Guay B, Radouco-Thomas M, Leblanc J, Vallieres A. Randomized clinical trial of supervised tapering and cognitive behavior therapy to facilitate benzodiazepine discontinuation in older adults with chronic insomnia. Am J Psychiatry. 2004;161(2):332–42.

    Article  PubMed  Google Scholar 

  90. Lopez-Peig C, Mundet X, Casabella B, del Val J, Lacasta D, Diogene E. Analysis of benzodiazepine withdrawal program managed by primary care nurses in Spain. BMC Res Notes. 2012;5:684.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  91. Vaapio S, Puustinen J, Salminen M, Vahlberg T, Salonoja M, Lyles A, et al. Symptoms associated with long-term benzodiazepine use in elderly individuals aged 65 years and older: A longitudinal descriptive study. Int J Gerontol J. 2015;9(1):34–9. https://doi.org/10.1016/j.ijge.2014.03.009.

    Article  Google Scholar 

  92. Mugunthan K, McGuire T, Glasziou P. Minimal interventions to decrease long-term use of benzodiazepines in primary care: a systematic review and meta-analysis. Br J Gen Pract. 2011;61(590):e573–8.

    Article  PubMed  PubMed Central  Google Scholar 

  93. Garfinkel D, Zisapel N, Wainstein J, Laudon M. Facilitation of benzodiazepine discontinuation by melatonin: A new clinical approach. Arch Intern Med. 1999;159(20):2456–60.

    Article  PubMed  CAS  Google Scholar 

  94. Hopkins DR, Sethi KB, Mucklow JC. Benzodiazepine withdrawal in general practice. J R Coll Gen Pract. 1982;32(245):758–62.

    PubMed  PubMed Central  CAS  Google Scholar 

  95. Nakao M, Takeuchi T, Nomura K, Teramoto T, Yano E. Clinical application of paroxetine for tapering benzodiazepine use in non-major-depressive outpatients visiting an internal medicine clinic. Psychiatry Clin Neurosci. 2006;60(5):605–10.

    Article  PubMed  CAS  Google Scholar 

  96. Petrovic M, Pevernagie D, Van Den Noortgate N, Mariman A, Michielsen W, Afschrift M. A program for short-term withdrawal from benzodiazepines in geriatric hospital inpatients: Success rate and effect on subjective sleep quality. Int J Geriatr Psychiatry. 1999;14(9):754–60.

    Article  PubMed  CAS  Google Scholar 

  97. Martin P, Tannenbaum C. A realist evaluation of patients’ decisions to deprescribe in the EMPOWER trial. BMJ Open. 2017;7(4):e015959.

    Article  PubMed  PubMed Central  Google Scholar 

  98. Martin P, Tamblyn R, Ahmed S, Tannenbaum C. A drug education tool developed for older adults changes knowledge, beliefs and risk perceptions about inappropriate benzodiazepine prescriptions in the elderly. Patient Educ Couns. 2013;92(1):81–7.

    Article  PubMed  Google Scholar 

  99. Martin P, Tannenbaum C, Tamblyn R, Benedetti A, Ahmed S. D-prescribe overtakes empower in patient-centered deprescribing of benzodiazepines: preliminary results from a pragmatic cluster-randomized community-based trial in Canada. J Am Geriatr Soc. 2017;65:S1–2.

    Article  Google Scholar 

  100. Voshaar RC, Gorgels WJ, Mol AJ, van Balkom AJ, van de Lisdonk EH, Breteler MH, et al. Tapering off long-term benzodiazepine use with or without group cognitive-behavioural therapy: Three-condition, randomised controlled trial. Br J Psychiatry. 2003;182:498–504.

    Article  PubMed  Google Scholar 

  101. de Gier NA, Gorgels WJ, Lucassen PL, Oude Voshaar R, Mulder J, Zitman F. Discontinuation of long-term benzodiazepine use: 10-year follow-up. Fam Pract. 2011;28(3):253–9.

    Article  PubMed  Google Scholar 

  102. Joester J, Vogler CM, Chang K, Hilmer SN. Hypnosedative use and predictors of successful withdrawal in new patients attending a falls clinic: a retrospective, cohort study. Drugs Aging. 2010;27(11):915–24.

    Article  PubMed  Google Scholar 

  103. Vicens C, Bejarano F, Sempere E, Mateu C, Fiol F, Socias I, et al. Comparative efficacy of two interventions to discontinue long-term benzodiazepine use: cluster randomised controlled trial in primary care. Br J Psychiatry. 2014;204(6):471–9.

    Article  PubMed  CAS  Google Scholar 

  104. Vicens C, Sempere E, Bejarano F, Socias I, Mateu C, Fiol F, et al. Efficacy of two interventions on the discontinuation of benzodiazepines in long-term users: 36-month follow-up of a cluster randomised trial in primary care. Br J Gen Pract. 2016;66(643):e85–91.

    Article  PubMed  PubMed Central  Google Scholar 

  105. Yokoi Y, Misal M, Oh E, Bellantoni M, Rosenberg PB. Benzodiazepine discontinuation and patient outcome in a chronic geriatric medical/psychiatric unit: a retrospective chart review. Geriatr Gerontol Int. 2014;14(2):388–94.

    Article  PubMed  Google Scholar 

  106. Darker CD, Sweeney BP, Barry JM, Farrell MF, Donnelly-Swift E. Psychosocial interventions for benzodiazepine harmful use, abuse or dependence. Cochrane Database Syst Rev. 2015;(5):CD009652. https://doi.org/10.1002/14651858.CD009652.pub2.

  107. Voshaar RCO, Krabbe PFM, Gorgels WJMJ, Adang EMM, van Balkom AJLM, van de Lisdonk EH, et al. Tapering off benzodiazepines in long-term users. Pharmacoeconomics. 2006;24(7):683–94.

    Article  Google Scholar 

  108. Morin C, Belanger L, Bastien C, Vallieres A. Long-term outcome after discontinuation of benzodiazepines for insomnia: a survival analysis of relapse. Behav Res Ther. 2005;43(1):1–14.

    Article  PubMed  Google Scholar 

  109. Gilbert A, Innes JM, Owen N, Sansom L. Trial of an intervention to reduce chronic benzodiazepine use among residents of aged-care accommodation. Aust N Z J Med. 1993;23(4):343–7.

    Article  PubMed  CAS  Google Scholar 

  110. Parr JM, Kavanagh DJ, Young RM, Mitchell G. Acceptability of cognitive-behaviour therapy via the internet for cessation of benzodiazepine use. Drug Alcohol Rev. 2011;30(3):306–14.

    Article  PubMed  Google Scholar 

  111. Yeung WF, Chung KF, Zhang ZJ, Chan WC, Zhang SP, Ng RMK, et al. Electroacupuncture for tapering off long-term benzodiazepine use: study protocol of randomized controlled trial. BMC Complement Altern Med. 2017;17:183.

    Article  PubMed  PubMed Central  Google Scholar 

  112. Kwok T, Leung PC, Wing YK, Ip I, Wong B, Ho DWH, et al. The effectiveness of acupuncture on the sleep quality of elderly with dementia: a within-subjects trial. Clin Interv Aging. 2013;8:923–9.

    Article  PubMed  PubMed Central  Google Scholar 

  113. Gil-Montoya J-A, Silvestre F-J, Barrios R, Silvestre-Rangil J. Treatment of xerostomia and hyposalivation in the elderly: A systematic review. Med Oral Patol Oral Cir Bucal. 2016;21(3):e355–66.

    Article  PubMed  PubMed Central  Google Scholar 

  114. Kwon YD, Pittler MH, Ernst E. Acupuncture for peripheral joint osteoarthritisA systematic review and meta-analysis. Rheumatology. 2006;45(11):1331–7.

    Article  PubMed  CAS  Google Scholar 

  115. Chen L, Farrell B, Ward N, Russell G, Eisener-Parsche P, Dore N. Discontinuing benzodiazepine therapy: An interdisciplinary approach at a geriatric day hospital. Can Pharm J (Ott). 2010;143(6):286–95.

    Article  Google Scholar 

  116. Heather N, Paton J, Ashton H. Predictors of response to brief intervention in general practice against long-term benzodiazepine use. Addict Res Theory. 2011;19(6):519–27.

    Article  Google Scholar 

  117. Belanger L, Morin C, Bastien C, Ladouceur R. Self-efficacy and compliance with benzodiazepine taper in older adults with chronic insomnia. Health Psychol. 2005;24(3):281–7.

    Article  PubMed  Google Scholar 

  118. Mol AJ, Oude Voshaar RC, Gorgels WJ, Breteler MH, van Balkom AJ, van de Lisdonk EH, et al. The role of craving in relapse after discontinuation of long-term benzodiazepine use. J Clin Psychiatry. 2007;68(12):1894–900.

    Article  PubMed  Google Scholar 

  119. Self-efficacy Bandura A. In: Ramachauduran VS, editor. Encyclopedia of human behavior. New York: Academic Press; 1994. p. 71–81.

    Google Scholar 

  120. Cook JM, Marshall R, Masci C, Coyne JC. Physicians’ perspectives on prescribing benzodiazepines for older adults: a qualitative study. J Gen Intern Med. 2007;22(3):303–7.

    Article  PubMed  PubMed Central  Google Scholar 

  121. Kouladjian L, Gnjidic D, Reeve E, Chen TF, Hilmer SN. Health care practitioners’ perspectives on deprescribing anticholinergic and sedative medications in older adults. Ann Pharmacother. 2016;50(8):625–36.

    Article  PubMed  Google Scholar 

  122. Orgeta V, Qazi A, Spector A, Orrell M. Psychological treatments for depression and anxiety in dementia and mild cognitive impairment: systematic review and meta-analysis. Br J Psychiatry. 2015;207(4):293–8.

    Article  PubMed  PubMed Central  Google Scholar 

  123. Wennberg AM, Canham SL, Smith MT, Spira AP. Optimizing sleep in older adults: treating insomnia. Maturitas. 2013;76(3):247–52.

    Article  PubMed  Google Scholar 

  124. Spector A, Charlesworth G, King M, Lattimer M, Sadek S, Marston L, et al. Cognitive-behavioural therapy for anxiety in dementia: pilot randomised controlled trial. Br J Psychiatry. 2015;206(6):509–16.

    Article  PubMed  Google Scholar 

  125. Martin P, Tannenbaum C. Use of the EMPOWER brochure to deprescribe sedative-hypnotic drugs in older adults with mild cognitive impairment. BMC Geriatr. 2017;17(1):37.

    Article  PubMed  PubMed Central  Google Scholar 

  126. Garfinkel D, Zur-Gil S, Ben-Israel J. The war against polypharmacy: a new cost-effective geriatric-positive approach for improving drug therapy in disabled elderly people. Isr Med Assoc J. 2007;9(6):430–4.

    PubMed  Google Scholar 

  127. Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Arch Intern Med. 2010;170(18):1648–54.

    Article  PubMed  Google Scholar 

  128. Batty GM, Oborne CA, Swift CG, Jackson SH. Development of an indicator to identify inappropriate use of benzodiazepines in elderly medical in-patients. Int J Geriatr Psychiatry. 2000;15(10):892–6.

    Article  PubMed  CAS  Google Scholar 

  129. Elliott RA, Woodward MC, Oborne CA. Improving benzodiazepine prescribing for elderly hospital inpatients using audit and multidisciplinary feedback. Intern Med J. 2001;31(9):529–35.

    Article  PubMed  CAS  Google Scholar 

  130. Ivers NM, Sales A, Colquhoun H, Michie S, Foy R, Francis JJ, et al. No more ‘business as usual’ with audit and feedback interventions: towards an agenda for a reinvigorated intervention. Implement Sci. 2014;9(1):14.

    Article  PubMed  PubMed Central  Google Scholar 

  131. Pimlott NJG, Hux JE, Wilson LM, Kahan M, Li C, Rosser WW. Educating physicians to reduce benzodiazepine use by elderly patients: a randomized controlled trial. Can Med Assoc J. 2003;168(7):835–9.

    Google Scholar 

  132. Chung KF. Benzodiazepine prescribing trend after its inclusion as a dangerous drug under the hong kong dangerous drugs ordinance. Hong Kong Med J. 1997;3(1):16–20.

    PubMed  CAS  Google Scholar 

  133. Weintraub M, Singh S, Byrne L, Maharaj K, Guttmacher L. Consequences of the 1989 New York State triplicate benzodiazepine prescription regulations. JAMA. 1991;266(17):2392–7.

    Article  PubMed  CAS  Google Scholar 

  134. Ong MK, Xu H, Zhang L, Azocar F, Ettner SL. Effect of Medicare Part D benzodiazepine exclusion on psychotropic use in benzodiazepine users. J Am Geriatr Soc. 2012;60(7):1292–7.

    Article  PubMed  PubMed Central  Google Scholar 

  135. Zitman FG, Couvee JE. Chronic benzodiazepine use in general practice patients with depression: an evaluation of controlled treatment and taper-off: report on behalf of the Dutch Chronic Benzodiazepine Working Group. Br J Psychiatry. 2001;178:317–24.

    Article  PubMed  CAS  Google Scholar 

  136. Rickels K, DeMartinis N, Garcia-Espana F, Greenblatt DJ, Mandos LA, Rynn M. Imipramine and buspirone in treatment of patients with generalized anxiety disorder who are discontinuing long-term benzodiazepine therapy. Am J Psychiatry. 2000;157(12):1973–9.

    Article  PubMed  CAS  Google Scholar 

  137. Garzon C, Guerrero JM, Aramburu O, Guzman T. Effect of melatonin administration on sleep, behavioral disorders and hypnotic drug discontinuation in the elderly: a randomized, double-blind, placebo-controlled study. Aging Clin Exp Res. 2009;21(1):38–42.

    Article  PubMed  CAS  Google Scholar 

  138. Denis C, Fatseas M, Lavie E, Auriacombe M. Pharmacological interventions for benzodiazepine mono-dependence management in outpatient settings. Cochrane Database Syst Rev. 2006;(3):CD005194.

  139. Bobes J, Rubio G, Teran A, Cervera G, Lopez-Gomez V, Vilardaga I, et al. Pregabalin for the discontinuation of long-term benzodiazepines use: an assessment of its effectiveness in daily clinical practice. Eur Psychiatry. 2012;27(4):301–7.

    Article  PubMed  CAS  Google Scholar 

  140. Voshaar RC, Couvee JE, van Balkom AJ, Mulder PG, Zitman FG. Strategies for discontinuing long-term benzodiazepine use: meta-analysis. Br J Psychiatry. 2006;189:213–20.

    Article  PubMed  Google Scholar 

  141. Baandrup L, Ebdrup BH, Lindschou J, Gluud C, Glenthøj BY. Pharmacological interventions for benzodiazepine discontinuation in chronic benzodiazepine users. Cochrane Database Syst Rev. 2015;(1):CD011481.

  142. Sirdifield C, Anthierens S, Creupelandt H, Chipchase SY, Christiaens T, Siriwardena AN. General practitioners’ experiences and perceptions of benzodiazepine prescribing: systematic review and meta-synthesis. BMC Fam Pract. 2013;14(1):191.

    Article  PubMed  PubMed Central  Google Scholar 

  143. Anderson K, Stowasser D, Freeman C, Scott I. Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis. BMJ Open. 2014;4(12):e006544.

    Article  PubMed  PubMed Central  Google Scholar 

  144. Reeve E, To J, Hendrix I, Shakib S, Roberts MS, Wiese MD. Patient barriers to and enablers of deprescribing: a systematic review. Drugs Aging. 2013;30(10):793–807.

    Article  PubMed  Google Scholar 

  145. Halme AS, Beland SG, Preville M, Tannenbaum C. Uncovering the source of new benzodiazepine prescriptions in community-dwelling older adults’. Int J Geriatr Psychiatry. 2013;28(3):248–55.

    Article  PubMed  Google Scholar 

  146. Sawan M, Jeon Y-H, Fois RA, Chen TF. Exploring the link between organizational climate and the use of psychotropic medicines in nursing homes: a qualitative study. Res Social Adm Pharm. 2017;13(3):513–23.

    Article  PubMed  Google Scholar 

  147. Gallagher H. Addressing the issue of chronic, inappropriate benzodiazepine use: how can pharmacists play a role? Pharmacy. 2013;1(2):65.

    Article  Google Scholar 

  148. Westbury J, Jackson S, Gee P, Peterson G. An effective approach to decrease antipsychotic and benzodiazepine use in nursing homes: the RedUSe project. Int Psychogeriatr. 2010;22(1):26–36.

    Article  PubMed  Google Scholar 

  149. Westbury J, Tichelaar L, Peterson G, Gee P, Jackson S. A 12-month follow-up study of “RedUSe”: A trial aimed at reducing antipsychotic and benzodiazepine use in nursing homes. Int Psychogeriatr. 2011;23(8):1260–9.

    Article  PubMed  Google Scholar 

  150. Towle I, Adams J. A novel, pharmacist-led strategy to reduce the prescribing of benzodiazepines in Paisley. Pharm J. 2006;276(7386):136–8.

    Google Scholar 

  151. Monane M, Matthias DM, Nagle BA, Kelly MA. Improving prescribing patterns for the elderly through an online drug utilization review intervention: a system linking the physician, pharmacist, and computer. J Am Med Assoc. 1998;280(14):1249–52.

    Article  CAS  Google Scholar 

  152. van de Steeg-van Gompel CHPA, Wensing M, De Smet PAGM. Implementation of a discontinuation letter to reduce long-term benzodiazepine use: a cluster randomized trial. Drug Alcohol Depend. 2009;99(1–3):105–14.

    Article  CAS  Google Scholar 

  153. Furbish S, Kroehl M, Loeb D, Lam H, Lewis C, Nelson J, et al. A pharmacist-physician collaboration to optimize benzodiazepine use for anxiety and sleep symptom control in primary care. J Pharm Pract. 2017;30(4):425–33.

    Article  PubMed  Google Scholar 

  154. Dollman WB, LeBlanc VT, Stevens L, O’Connor PJ, Roughead EE, Gilbert AL. Achieving a sustained reduction in benzodiazepine use through implementation of an area-wide multi-strategic approach. J Clin Pharm Ther. 2005;30(5):425–32.

    Article  PubMed  CAS  Google Scholar 

  155. Smith AJ, Tett SE. An intervention to improve benzodiazepine use: a new approach. Fam Pract. 2010;27(3):320–7.

    Article  PubMed  Google Scholar 

  156. Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348:g1687.

    Article  PubMed  Google Scholar 

  157. Albrecht L, Archibald M, Arseneau D, Scott SD. Development of a checklist to assess the quality of reporting of knowledge translation interventions using the Workgroup for Intervention Development and Evaluation Research (WIDER) recommendations. Implement Sci. 2013;8(1):52.

    Article  PubMed  PubMed Central  Google Scholar 

  158. Pollmann AS, Murphy AL, Bergman JC, Gardner DM. Deprescribing benzodiazepines and Z-drugs in community-dwelling adults: a scoping review. BMC Pharmacol Toxicol. 2015;16:19.

    Article  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Faculty of Medicine, University of Sydney, Sydney, NSW, Australia

    Brendan J. Ng, David G. Le Couteur & Sarah N. Hilmer

  2. Departments of Aged Care and Clinical Pharmacology, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia

    Brendan J. Ng & Sarah N. Hilmer

  3. Ageing and Alzheimers Institute, Concord Hospital, Concord, NSW, Australia

    Brendan J. Ng & David G. Le Couteur

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  1. Brendan J. Ng
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  2. David G. Le Couteur
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Correspondence to Sarah N. Hilmer.

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Funding

BN is supported by scholarships funded by the Ageing and Alzheimers Institute, Concord Hospital, the Penney Ageing Research Unit, Royal North Shore Hospital, and the Australia New Zealand Society for Geriatric Medicine. SH and DLC are investigators on a related research project, ‘Reducing Inappropriate Polypharmacy in Older Inpatients’, which is funded by the New South Wales Health Translational Research Grants Scheme, grant TRG274. Role of the Funder/Sponsor The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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Brendan Ng, David Le Couteur and Sarah Hilmer declare that they have no conflicts of interest directly relevant to the content of this article.

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Ng, B.J., Le Couteur, D.G. & Hilmer, S.N. Deprescribing Benzodiazepines in Older Patients: Impact of Interventions Targeting Physicians, Pharmacists, and Patients. Drugs Aging 35, 493–521 (2018). https://doi.org/10.1007/s40266-018-0544-4

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