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Medicines management: Is it safe to prescribe both benzodiazepines and opiate analgesics for older people with Alzheimer’s?

Why nurse prescribers must take care in prescribing benzodiazepines and opiate analgesics together

Why nurse prescribers must take care in prescribing benzodiazepines and opiate analgesics together

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A study in Finland has raised concerns over the concomitant use of benzodiazepines and opiate analgesics in older people with Alzheimer’s disease.

The study, which involved more than 70,000 people in Finland diagnosed with Alzheimer’s disease between 2005 and 2011, found that one in five who use a benzodiazepine are also concomitant users of an opioid.

Around half of all concomitant users were long-term users of these medicines whose use of the drugs had continued for more than three consecutive months.

High-risk groups

The researchers found that prolonged use of both of these types of medicines was associated with previous hip fractures, osteoporosis and lung disease. The study also showed that in these high-risk groups the concomitant use of opioids and benzodiazepines or related drugs can increase the risk of drug misuse, fractures and pneumonia.

The study results confirm concerns in the UK regarding the use of hypnotics – benzodiazepines and ‘Z drugs’. According to guidelines from the National Institute for Health and Care Excellence (NICE), we are only supposed to prescribe these drugs for a period of three weeks, but in reality we prescribe them for much longer.

While working in general practice I regularly saw older patients on both benzodiazepines and opiates, often for years. Getting long-term users of these drugs to reduce their doses or stop them altogether was problematic.

Potential for abuse

As with many medicines, Z drugs were originally marketed as having fewer side effects than their predecessors, benzodiazepines. But the side effects and safety profiles are actually very similar, and their potential for abuse means they have all now been scheduled as controlled drugs.

The study also found that patients with Alzheimer’s disease are more commonly prescribed strong opioids than those without the disease. The researchers say this can partly be explained by the use of opioid patches, such as buprenorphine and fentanyl, which are more commonly used in patients with Alzheimer’s disease in Finland.

The risks to patients are well-known for both opioids and hypnotics. These include falls, confusion, delirium, respiratory depression and addiction. It might be asked why we are using these medicines as frequently as we do in older, often frail patients, let alone patients with the added complication of Alzheimer’s disease.

Issues to consider

Other issues that need to be considered before prescribing medicines for this patient group include renal and liver function.

Kidney function decreases as we get older, with the estimated glomerular filtration rate (eGFR) reducing. Older people should therefore be assumed to have at least mild renal impairment.

The ability of the liver to metabolise many substances also decreases with age, and many medicines cannot be metabolised as efficiently as they are in younger patients. This means that a drug that would not have any side effects in a younger person may have dose-related side effects in an older person.

When risks outweigh benefits

As an older person’s liver is also more likely to be more susceptible to a toxic agent than the same agent on a younger person’s liver, we need to reduce drug doses in older patients or perhaps consider prescribing alternative medicines.

As nurse prescribers we have a responsibility to be extremely cautious when starting patients on these medicines, reducing doses or stopping the medication if we believe the risks to the patient outweigh the benefits.

Prescribers also need to ensure that regular medication reviews are carried out, and all nurses who administer drugs can help keep patients safe by raising any concerns regarding medication with the prescriber.

Stopping these medicines can be traumatic for any patient, even more so in someone who has progressive mental deterioration. Prevention by careful prescribing in the first place is the best option.

Matt Griffiths is visiting professor of prescribing and medicines management at Birmingham City University



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