November 2006

Dear Readers Here's the Article for this Month:

The use of benzodiazepines in palliative care

Author(s): Henderson M, MacGregor E, Sykes N, Hotopf  M

Journal: Palliative Medicine 2006; 20: 407-412

Benzodiazepines are a class of drugs widely used in palliative care. In the last week of life 82% of the patients receive midazolam at least once. Benzodiazepines can cause cognitive impairment, somnolence, loss of memory, and dependence. Their use can make accurate assessment of depression and psychological management of anxiety more difficult. When administered together with opioid analgesics, or with other psychotropic drugs, there may be additive adverse effects at the central nervous system level thus causing a worsening of the morbidity.

This study was carried out at the St. Christopher Hospice with the aim to evaluate the number and the characteristic of the patients, the nature of and indications for the use of benzodiazepines and other psychotropic medication prescriptions. The length of benzodiazepine administration, the association with other drugs such as opioids and antidepressants and their efficacy and tolerability were also evaluated.

Start ing 30 September 2002 , the previous 100 consecutive patients who ended their hospice care either in hospice or at home were evaluated. Ninety-three patients were included in the study. All patients had cancer, their median age was 73 years and 45% were male. Sixty-seven percent were referred from the hospital or other hospices, and 20% had a past psychiatric history.

Fifty-eight per cent of the patients studied received benzodiazepines (54/93); about 8% of them were already being prescribed benzodiazepines at time of referral; about 50% of them received the drugs during their time in palliative care and received prescriptions for 69 benzodiazepines, 45 on an as “required basis”, 19 regular dosing (14 received them for more than one week) and 5 patients received benzodiazepines given by a syringe driver.

There were no differences between the patients receiving and not receiving a benzodiazepine with regard to gender, type of primary cancer, presence/absence of metastases, or past psychiatric history. Younger patients, patients who had spent a period in hospice, and patients on opioids (83%) were more likely to have been on a benzodiazepine prescription. Many patients on antidepressants (28%) and/or on anti-psychotropic drugs (28%) received a benzodiazepine treatment.

From the “notes” in the clinical charts it was not possible to know the exact reason for the prescription, however anxiety/agitation was considered the most frequent cause (25 pts) followed by distress (9 pts), sleep disturbance (8 pts) and dyspnoea (7 pts). Midazolam (30 pts), lorazepam (21 pts) and temazepam (13 pts) were the benzodiazepines most frequently used with a recorded effectiveness of 70%. The number of patients on benzodiazepine increased from 19% at assessment time to 34% at 2 weeks before death, and 55% at death. No significant adverse effects were recorded.

Why I chose this article

According to the data in the literature, benzodiazepine administration is widely used in palliative care. This study shows that their use increases when death approaches.

Further research is necessary to better understand the exact role of the use of benzodiazepines in palliative care, the reasons for their administration, their efficacy and tolerability when administered alone and /or in combination with other drugs acting at the CNS. A comprehensive study of the psychosocial support given to the patients, their family members, and their caregivers is also necessary.

The original article may be viewed at the following website:
http://pmj.sagepub.com/content/vol20/issue4/

Regards,

Carla Ripamonti, MD
Member of the Board of Directors, IAHPC