Table 1: Detailed Description of Empirical Articles
# Article Objectives Study Design Main Findings Discussion
7 Lenze et al. To describe and assess: Study type: Cross-sectional. 70 of the 182 subjects were taking at Compared to other studies, the
Current and lifetime Setting: Primary care and psychiatric least one psychotropic medication: BZs results of this study found a relative
“Comorbid anxiety rates and associated settings. (37 subjects). high rate of current and lifetime
disorders in clinical features of Study Population: 35% of subjects with depressive anxiety disorders in elderly
depressed elderly anxiety disorders in Size: N = 182. disorders had at least one lifetime depressed individuals. Comorbid
patients” depressed elderly 60 years and older. anxiety disorder diagnosis. anxiety disorders and symptoms of
patients. 23.1% Male. 23% had a current diagnosis. generalized anxiety disorder were
American Journal of Most common current comorbid associated with a more severe
Psychiatry Assessments included: 17-item anxiety disorders were panic disorder presentation of depressive illness
Hamilton Depression Rating Scale, (9.3%), specific phobias (8.8%), and in elderly subjects.
2000;157:722-728. the Global Assessment Scale (GAS), social phobia (6.6%).
the Medical Outcomes Study 36-item Symptoms that met inclusion criteria Limitations included:
Short-Form Health Survey, the for generalized anxiety disorder, A rate for diagnosis of
Cumulative Illness Rating Scale- measured separately, were present in generalized anxiety disorder
Geriatrics, the UKU Side Effect 27.5% of depressed subjects. was not available.
Rating Scale. Presence of comorbid anxiety disorder Cross-sectional design cannot
was associated with poorer social address the effects of
NOTE: This study was not performed function (p = 0.01) and a higher level of comorbid anxiety disorders on
in a long-term care setting. somatic symptoms (p = 0.02). outcomes of depression.
Symptoms of generalized anxiety Study was not performed in a
disorder were associated with a higher long-term care setting.
level of suicidality (p
American Geriatric short-acting agents. Study population: 8 mg. These findings underscore
Society Size: N = 2510. For cohort members beginning an recommendations to use BZs very
Mean age 83 years. episode of BZ use during follow-up, the cautiously in frail older patients,
2000;48:682-685. 75% were female. rate of falls was greatest in the 7 days and countermeasures to prevent
after the BZ was started, but remained falls should be taken.
Outcome measures were falls during elevated by 30% after the first 30 days
study follow-up. of therapy. Limitations included:
Short-acting drugs were those that The rate of falls increased with BZ Generalizability of study
had a half-life 28 day use (80% increase in may have limited the
risk). generalizability of the results.
Study was not performed in a
long-term care setting.
19
Table 1: Detailed Description of Empirical Articles
# Article Objectives Study Design Main Findings Discussion
30 McAndrews et al. To describe and assess: Study type: Prospective, controlled After controlling for differences in There may be subtle and reversible
Whether cognitive trial. affective status between BZ-users and effects of long-term BZ use on
“Cognitive effects of dysfunction and its Setting: Sleep Disorders Clinic at the controls, there were no significant speed-dependent tasks in older
long-term reversal following BZ Toronto Western Hospital. group differences in cognitive adults. However, the magnitude of
benzodiazepine use discontinuation could Study population: performance. these effects is quite small and
in older adults” be documented in Size: N = 51, with N = 25 subjects BZ-users showed greater gains on may be of little clinical significance
community-dwelling and N = 26 controls. tests of attention and speed of in the healthy elderly.
Human older adults. 47.1% Female. processing at repeat testing compared
Psychopharmacology: Aged 50 and older. with controls. The authors commented that their
Clinical and History of BZ use for more than 6 findings may conflict with other
Experimental months studies.
2003;18:51-57. NOTE: This study was not performed Limitations included:
in a long-term care setting. High dropout rate.
Generalizability of study
findings.
Study was not performed in a
long-term care setting.
20
Table 1: Detailed Description of Empirical Articles
# Article Objectives Study Design Main Findings Discussion
31 Paterniti et al. To describe and assess: Study type: Longitudinal. Study participants were classified as Chronic use of BZs is a risk factor
Whether chronic use of Setting: Volunteers in the nonusers (67%), episodic (10%), for increased cognitive decline in
“Long-term BZs over a 4-year Epidemiology of Vascular Aging recurrent (6%), and chronic (7%). the elderly. These findings showed
benzodiazapine use period was associated (EVA) Study in Nantes, France Recurrent and chronic BZ use was that chronic or recurrent use of BZs
and cognitive decline with an increased risk Time period: Baseline data were associated with lower MMSE (Mini- had an apparent deleterious effect
in the elderly: The of cognitive decline. collected between June 1991 and Mental State Examination), DSS (Digit upon several cognitive functions.
Epidemiology of June 1993. Two follow-up Symbol Substitution Test), and TMT-B People who reported taking BZs at
Vascular Aging examinations were conducted 2 and (Trail Making Test, part B) scores only one of the three examinations
Study” 4 years after baseline. compared with nonuse. did not differ from nonusers.
Study population: Chronic use was also associated
Journal of Clinical Size: N = 1176. with a lower FTT (Finger Tapping Limitations included:
Psychopharmacology Age 60-70 years. Test) score. Not having information on the
Episodic BZ use did not alter dose or half-life at baseline and
2002;22:285-293. Nonusers = those who did not report cognitive and psychomotor at the 4-year follow-up.
taking BZs at any of the three performances. Subjects were classified on the
examinations Over the 4-year period, episodic or basis of current use of drugs.
Chronic users = those who reported recurrent use of BZs was not a No objective measure of BZ
use of BZs at all three examinations significant risk factor for cognitive and exposure such as plasma
Recurrent users = those who psychomotor decline. level.
reported use at two examinations Chronic users had a significantly No knowledge about the delay
Episodic users = those who reported higher risk of cognitive decline for between last intake on BZs
use at one examination the MMSE, DSS, and TMT-B and cognitive testing.
compared to nonusers. Having no information about
NOTE: This study was not performed Results were independent of age, sex, psychiatric diagnosis and
in a long-term care setting. education, alcohol and tobacco use, history.
anxiety and depression scores, and Study does not permit
use of psychotropic drugs other than conclusions about a causal
BZs. effect of BZs on cognitive
decline.
Study was not performed in a
long-term care setting.
21
Table 1: Detailed Description of Empirical Articles
# Article Objectives Study Design Main Findings Discussion
32 Cohen-Mansfield et To describe and assess: Study type: Random, placebo- 35 (60.3%) of 58 patients completed Long-term use of haloperidol,
al. The effects of controlled, double-blind crossover the study. thioridazine, and lorazepam in
discontinuing treatment study. For the primary outcomes, all analytic nursing homes to manage agitation
“Withdrawal of with haloperidol, Setting: 550-bed skilled, nonprofit approaches resulted in non-significant should be closely monitored for
haloperidol, thioridazine, and nursing facility. differences for all variables and no their efficacy.
thioridazine, and lorazepam among Study population: consistent trends were observed.
lorazepam in the residents of a large Size: N = 58. Comparison of the variables assessing Routine attempts at drug
nursing home” suburban nursing 74.1% Female. functioning, adverse effects, and global withdrawal should be considered
home. Mean age 86 years. impression all resulted in non- for most residents taking
Archives of Internal significant differences between drug psychotropic medication.
Medicine Half of the residents continued to and placebo.
take the psychotropic medication The medications were effective in
1999;159(15):1733- they had been prescribed, whereas controlling verbal agitation during the Limitations included:
1740. the other half were tapered to evening (p = 0.03) and cognitive Small sample size.
placebo. functioning improved during the taking
After 6 weeks of taking placebo or of placebo compared with the taking of
original drug, patients were tapered a drug (p = 0.05).
to the reverse schedule and
remained on it for 6 weeks.
Primary assessments included
informant ratings by the nursing staff
who completed the Brief Psychiatric
Rating Scale and the Cohen-
Mansfield Agitation Inventory.
22
Table 1: Detailed Description of Empirical Articles
# Article Objectives Study Design Main Findings Discussion
33 Salzman et al. To describe and assess: Study type: Prospective, single blind, Measures of memory and cognitive BZ-related cognitive impairment is
Cognitive, affective, controlled trial functioning improved significantly after reversible. The residents
“Cognitive behavioral, and sleep Setting: Nursing home. discontinuation of BZs. significantly improved in memory
improvement function after Study population: There was no associated increase in and cognitive functioning in
following discontinuation of BZs. Size: N = 25. anxiety, agitation, or sleeplessness. comparison with residents who
benzodiazepine Mean age 86 years. 60% of the subjects who had continued taking BZs.
discontinuation in discontinued use of BZs remained off
elderly nursing home Results of 12 subjects assessed them 1 year later. Limitations included:
residents” before and after discontinuation of Generalizability of results.
BZs were compared with those of 13
International Journal subjects who had not discontinued
of Geriatric Psychiatry BZ use.
1992;7:89-93.
34 Campbell et al. To describe and assess: Study type: Randomized controlled After 44 weeks, the relative hazard for Withdrawal of psychotropic
The effectiveness of trial with a two by two factorial falls in the medication withdrawal medication significantly reduced
“Psychotropic psychotropic design. group compared with the group taking the risk of falling, but permanent
medication withdrawal medication withdrawal Setting: 17 general practices in their original medication was 0.34. withdrawal is very difficult to
and a home-based and a home-based Dunedin, New Zealand. The risk of falling for the exercise achieve.
exercise program to exercise program in Study population: program group compared with those
prevent falls: A reducing falls in older Size: N = 93. not receiving the exercise program was The authors recommended a larger
randomized controlled people. Mean age 74.6 years. not significantly reduced. study to confirm these findings.
trial” 76.3% Female. One month after completion of the
study, 47% of the participants from the Limitations included:
Journal of the Two interventions: 1) gradual medication withdrawal group who had Small sample size.
American Geriatrics withdrawal of psychotropic taken capsules containing placebo for Study was not performed in a
Society medication versus continuing to take the final 30 weeks of the trial had long-term care setting.
psychotropic medication (double restarted taking psychotropic
1999;47(7):850-853. blind) and 2) a home-based exercise medication.
program versus no exercise program
(single blind).
NOTE: This study was not performed
in a long-term care setting.
23
Table 1: Detailed Description of Empirical Articles
# Article Objectives Study Design Main Findings Discussion
35 Petrovic et al. To describe and assess: Study type: Prospective, single-blind Overall success rate was 77.6% in the The authors comment that
The hypothesis that a trial. group of volunteers and 67.9% in the stepwise BZ withdrawal is
“A programme for short-term program for Setting: Inpatient geriatric ward of total group of eligible patients. surprisingly well tolerated in elderly
short-term withdrawal withdrawal of BZs is University Hospital, Ghent, Belgium. No major withdrawal symptoms subjects.
from benzodiazepines feasible in hospitalized Study population: occurred.
in geriatric hospital geriatric patients. Size: N = 49. The subjective quality of sleep Two-thirds of all eligible subjects
inpatients: Success 73% Female. (measured using the Groningen Sleep were still free of BZ use 6 weeks
rate and effect on Mean age was 81.7 for Males and Quality scale) remained virtually after the start of the withdrawal
subjective sleep 81.2 for Females. unchanged in the course of the program. Deterioration of sleep
quality” program. quality or major withdrawal
NOTE: This study was not performed Sleep quality was not significantly symptoms were not observed.
International Journal in a long-term care setting. different in patients on trazodone vs.
of Geriatric Psychiatry patients on lormetazepam. Limitations included:
The success rate was similar in both Lack of a placebo arm to the
1999;14(9):754-760. drug substitution groups. trial.
Cannot predict the durability of
the withdrawal course in the
long term.
Study was not performed in a
long-term care setting.
24
Table 1: Detailed Description of Empirical Articles
# Article Objectives Study Design Main Findings Discussion
36 Petrovic et al. To describe and assess: Study type: Randomized, double- The success rate was higher in the Initial replacement therapy with a
The success of abrupt blind, placebo-controlled trial. lormetazepam substitution group (80% low-dose BZ is preferred over
“Fast withdrawal from cessation of BZ Setting: Inpatient geriatric ward of vs. 50% in the placebo group, p < placebo, since the latter alternative
benzodiazepines in treatment in the University Hospital, Ghent, Belgium. 0.05). is associated with worse sleep
geriatric inpatients: A elderly, comparing the Study population: Both the subjective quality of sleep and quality and a lower success rate.
randomised double- effects of placebo with Size: N = 40. withdrawal symptoms were Placebo must only be used under
blind, placebo- those of Inpatients had been taking BZs for significantly better in the lormatazepam medical scrutiny, given the
controlled trial” lormetazepam, at least 3 months. substitution group. potential for unmasking delirious
defining withdrawal Important withdrawal effects were symptoms, especially in patients
European Journal of success rate, sleep NOTE: This study was not performed observed in the control group in two with concomitant alcoholism.
Clinical quality, and withdrawal in a long-term care setting. patients with a history of chronic
Pharmacology symptoms as main alcohol abuse. Limitations included:
outcomes. One year after study termination, 46% Small number of included
2002;57(11):759-764. of the successful participants were still patients.
off regular BZ use. Potentially confounding effect
of the unequal dropout rate in
both treatment groups.
Study was not performed in a
long-term care setting.
37 Habraken et al. To describe and assess: Study type: Randomized, double- 34% of subjects dropped out before Gradual withdrawal from BZs is
The long-term effect of blind, placebo- controlled clinical trial the end of the study. possible in residents of homes for
“Gradual withdrawal gradual withdrawal . In the placebo group, the level of daily the elderly, and that it can have a
from benzodiazepines from BZs on the daily Setting: 10 homes for the elderly in functioning showed a mean positive effect on their daily
in residents of homes functioning of residents Ghent. improvement of 4 points at 6 months functioning. No major withdrawal
for the elderly: of homes for the Study population: compared to baseline, and of 1.6 symptoms were observed, although
Experience and elderly. Size: N = 55. points at 1 year compared to baseline. there was a decrease in sleep
suggestions for future 81.8% Female. In the lorazepam group, a deterioration quality during withdrawal.
research” Mean age 84 years. of 4.2 points and 6 points was found at
6 months and 1 year, respectively. Limitations included:
European Journal of The ANOVA for repeated Small sample size due to high
Clinical measurements of the level of daily dropout rate.
Pharmacology functioning showed a significant group Selective cooperation of
effect (p = 0.02), a significant time residents.
1997;51(5):355-358. effect (p = 0.03), and no interaction
effect (p = 0.74).
The subjective sleep quality decreased
in the placebo group compared to
baseline, while it increased in the
lorazepam group.
25
Table 2: Detailed Description of Review and Descriptive/Informational Articles
# Article Objectives Study Design Main Findings Discussion
1 Doraiswamy To describe and assess: Study type: Recognition and treatment of anxiety and The newer antidepressants
The presentation and Descriptive/Informational depression will likely gain more attention in the next can decrease symptoms,
“Contemporary management of article. 30 to 50 years because of the projected growth of improve quality of life, and
management of comorbid anxiety and the geriatric population. potentially promote healthier
comorbid anxiety and depression in elderly The most common presentation of anxiety in elderly outcomes in geriatric patients
depression in geriatric individuals. patients is comorbid anxiety and depression. who have comorbid anxiety
patients” Although age is not a risk factor for either anxiety or and depression and/or
depression, factors associate with aging are comorbid mental and physical
Journal of Clinical substantial risk factors for development of these illness.
Psychiatry conditions.
There is a close association in older people between
2001;62(Suppl 12):30- untreated mental illness and exacerbation of
35. physical illness.
Some of the newer antidepressants are more
appropriate long-term options for the treatment of
comorbid anxiety and depression than either BZs or
tricyclic antidepressants.
2 Kogan et al. To describe and assess: Study type: The age-related decline in prevalence of anxiety Assessment of anxiety in
The issues to consider Descriptive/Informational disorders must be interpreted with caution. older adults is in its infancy.
“Assessment of anxiety in assessing anxiety in article. Clinicians must realize that the presentation of The limitations of the anxiety
in older adults: Current older adults. anxiety in older adults is not necessarily the same assessment literature with
status” as it is in younger adults. older adults creates a
There are many factors that must be considered dilemma for practicing
Journal of Anxiety when assessing anxiety in older adults. clinicians who desire a means
Disorders More evidence is needed on the psychometric to assess anxiety in this
properties of self-report instruments and clinician- population. Clinicians must
2000;14(2):109-132. rated instruments for the assessment of anxiety in consider the strengths and
older adult populations. weaknesses of the
instruments that are available
and choose measures
cautiously.
26
Table 2: Detailed Description of Review and Descriptive/Informational Articles
# Article Objectives Study Design Main Findings Discussion
3 Sadavoy et al. To provide: Study type: Review Anxiety disorders and symptoms are a common Anxiety disorders and
A current review and article. presenting problem in the elderly. symptoms in old age,
“Treatment of anxiety synthesis of the present Data sources: Medline, Current knowledge and research findings are although common, have
disorders in late life” state of knowledge of references in key limited. received little research focus
anxiety disorders and textbook articles and Extrapolation from adult studies are of use, but to date. A comprehensive,
Canadian Journal of symptoms in the elderly. other papers, and clinical important limitations are evident because of the careful approach by the
Psychiatry empirical knowledge and nature, uniqueness, and complexity of the geriatric clinician to assessment and
experience of the psychiatry patient. management is required
1997;42(Suppl 1):28S- authors. Comorbidity, especially with depression, medical because anxiety is often a
34S. conditions, drugs, and dementia, remains an comorbid condition in the
important concept in assessment and approach to elderly. Effective treatments
management of anxiety in the older person. are available and should be
Comprehensive assessment of anxiety symptoms applied in a flexible,
requires consideration of physical, intellectual, integrated, and specific
environmental, and social determinants. manner.
Major anxiety disorders, as defined by DSM-IV, and
anxiety symptoms are significant problems in the
older adult population and are responsible for
significant morbidity and cost to the health care
network.
4 Verma et al. To describe and assess: Study type: Psychiatric disorders in long-term care facilities Agitation can occur as a
Some of the causes and Descriptive/Informational remain underdiagnosed and inappropriately or result of psychiatric and
“Management of the interventions that can article. inadequately treated. nonpsychiatric conditions,
agitated elderly patient assist physicians caring Disruptive behavior should not always be assumed and appropriate treatment
in the nursing home: for the agitated elderly to have a psychiatric etiology. needs to be directed at the
The role of the atypical in long-term care Description of different treatment strategies is target symptoms.
antipsychotics” settings. presented.
Journal of Clinical
Psychiatry
1998;59(Suppl 19):50-
55.
27
Table 2: Detailed Description of Review and Descriptive/Informational Articles
# Article Objectives Study Design Main Findings Discussion
5 Furniss et al. To describe and assess: Study type: Review Nursing home residents are prescribed more drugs The research reviewed
Medication use in article. than their counterparts living at home. highlighted the over-
“Medication use in elderly nursing home Data sources: Medline, Iatrogenic disease is high in the elderly and is prescribing of medication and
nursing homes for residents with specific Excerpta Medica, important in nursing home residents because they the potential for the
elderly people” reference to International are prescribed more drugs and have greater rationalization of prescription
psychotropics and aims Pharmaceutical Abstracts physical and mental illness. medication regimes in nursing
International Journal of to raise awareness of (IPA), and Pharmline. Nursing home residents are often taking home residents.
Geriatric Psychiatry the issue. Keywords included: inappropriate medication.
nursing home(s), drug Psychotropic drugs are often prescribed to nursing
1998;13:433-439. therapy, or drugs. home residents and laws have been passed in the
239 studies were USA to limit the use of neuroleptics with good effect.
reviewed. By law, pharmacists play an active role in
medication management in nursing homes in the
USA and have been shown to be cost-effective.
Small studies in the UK have shown pharmacists to
be of potential benefit.
6 Palmer et al. To describe and assess: Study type: Anxiety disorders are underdiagnosed in late life. Although it has commonly
The factors which may Descriptive/Informational A common problem in the literature is the application been thought that anxiety
“Anxiety disorders in the lead to under- or mis- article. of DSM-IV-like criteria developed from studies of disorders are less common in
elderly: DSM-IV and diagnosis of anxiety younger adults to geriatric samples without regard the elderly, there are several
other barriers to disorders in the elderly, for atypical symptom presentations, high occurrence reasons to question the data
diagnosis and and impede of depressive and medical comorbidity, and on which such assertions are
treatment” identification of influence of aging-related psychosocial changes on based. Further research is
appropriate treatment. the clinical picture. needed to determine the
Journal of Affective Diagnostic problems are further compounded by degree to which DSM-IV
Disorders therapeutic ones. criteria for specific anxiety
Clinicians are often forced to make treatment disorders need modification
1997;46:183-190. decisions for their elderly patients based on to better describe the typical
uncontrolled clinical observations or questionable patterns of clinically
extrapolation of treatment data in younger adults. significant anxiety in the
elderly.
The authors comment that
more research needs to be
conducted in geriatric
psychiatry to fill the existing
gaps.
28
Table 2: Detailed Description of Review and Descriptive/Informational Articles
# Article Objectives Study Design Main Findings Discussion
8 Schneider To describe and assess: Study type: Situational and pathological anxiety are common in This review of the
The issues involved with Descriptive/Informational the elderly. epidemiology, characteristics
“Overview of diagnosing and treating article. There is significant comorbidity between anxiety and of anxiety in late-life, patterns
Generalized Anxiety late-life anxiety. depression in the elderly. of medication use, and
Disorder in the Elderly” Differential diagnosis involves both distinguishing treatment of anxiety disorders
anxiety disorders from other medical and psychiatric in the elderly shows the
Journal of Clinical disorders and distinguishing among the various importance of proper
Psychiatry anxiety disorders. diagnosis and treatment to
Pharmacological treatments used to treaty various achieve desirable outcomes
1996;57(Suppl 7):34-45. anxiety disorders include benzodiazepines, in the management of anxiety
buspirone, tricyclics, MAOIs, and SSRIs. in elderly individuals.
11 Heffern To describe and assess: Study type: There are benefits and risks associated with the use The authors commented that
The Descriptive/Informational of electroconvulsive therapy for the treatment of this review highlights the
“Psychopharmacological pharmacotherapeutics article. depression and/or anxiety. importance of using empirical
and electroconvulsive of antianxiety and Other treatment options are discussed, such as knowledge, increased
treatment of anxiety and antidepressant pharmaceutical treatment and cognitive-behavioral autonomy and accountability,
depression in the medication in the therapy. and increased collaboration
elderly” elderly. with other health care
The benefits and risks clinicians to make significant
Journal of Psychiatric of electroconvulsive improvements and advances
and Mental Health therapy (ECT). in psychiatric patient care.
Nursing
2000;7:199-204.
13 Gurvich et al. To describe and assess: Study type: The Omnibus Budget Reconciliation Act (OBRA) of Psychotropic medications are
The appropriateness of Descriptive/Informational 1987 limited the use of psychotropic medications in sometimes required to
“Appropriate use of psychotropic drug use in article. residents of long-term care facilities. maximize quality of life and
psychotropic drugs in nursing homes. Updates of OBRA guidelines have liberalized some functional status in nursing
nursing homes” dosing restrictions, but documentation of necessity home residents. In tailoring
and periodic trials of medication withdrawal are still pharmacologic regimens for
American Family emphasized. these patients, physicians
Physician Antidepressants are typically underutilized and need to give careful attention
antipsychotics and BZs have been used to accurate diagnosis,
2000;61:1437-1446. excessively. appropriate dosing, side
Tricyclics have many side effects and are not effects, drug interactions, and
preferred treatment options. pertinent drug
Anxiety and insomnia are common problems. pharmacokinetics.
Antipsychotics should only be used for specific Reassessment at regular
diagnoses. intervals is necessary.
29