With the known dangers of sleeping pills and anti-anxiety medications to the elderly, doctors risk doing more harm than good when they prescribe such drugs to patients aged 65 and older for insomnia and other disorders.

Continuous ingestion of such drugs over a long period vastly increases the chances of elderly patients developing serious side effects, typically marked by frequent falls that result in bone fractures or decreased cognitive functions.

An Asahi Shimbun study on the issue, based on health ministry data, found that the largest doses of high-risk medication tend to be prescribed to patients in their 80s.

Many researchers argue that Depas, Halcion and other benzodiazepine drugs potentially increase the chances of people collapsing or developing cognitive issues if such medications are taken over many years.

There is also the issue of dependence and early death if patients are unable to end their reliance on particular medication, according to some studies.

The issue is further exacerbated by the fact that elderly patients are less able than younger people to flush out chemicals from their bodies, which adds to the risk of serious side effects developing.

For these reasons, the Japan Geriatrics Society’s guidelines on safe pharmacotherapy stipulate that elderly patients should try to shun such medications. At the same time, it urged doctors to be stingy in prescribing such drugs.

Citing multiple instances of elderly inpatients who were taking benzodiazepines and suffered fatal head injuries through falls, a third-party entity called the Medical Accident Investigation and Support Center issued a call in June for doctors to be extra vigilant about prescribing such drugs.

The Asahi Shimbun enlisted the advice of Kensuke Yoshimura, a specially appointed professor of medical policy at Chiba University, for help in conducting the survey.

Yoshimura was involved in a health ministry project started three years ago to ascertain the amounts of frequently prescribed drugs by gender and age group. This was done through the National Database Open Data system based on health insurance claims by doctors for their services.

The Asahi Shimbun tallied prescriptions of benzodiazepines for outpatients for fiscal 2017 per 1,000 people by age group, and also perused statistics kept by the internal affairs ministry.

Data on 3.98 billion benzodiazepine-type sleeping and anti-anxiety pills was analyzed on the basis of gender and age.

The results showed that 2.1 billion pills, or 53 percent of the total, were prescribed to those aged 65 or older, while 1.31 billion tablets, or 33 percent, were prescribed to patients aged 75 or older.

By gender, more pills were prescribed to women. Female patients aged 80 to 84 were prescribed 97,000 tablets per 1,000 people, the most compared with other age groups. That breaks down to nearly 100 pills being consumed annually on average per person.

Those aged 85 to 89 and 75 to 79 consumed the second and third largest volumes of drugs, respectively.

Among men, the 85-89 age group was prescribed the largest number of pills at 62,000.

DOUBLE PRESCRIPTIONS

“Many people consume an unnecessary amount of chemicals because the same sorts of sleeping and anti-anxiety medicines are prescribed by different clinics,” noted Yasuyuki Okumura, a senior researcher at the Tokyo Metropolitan Institute of Medical Science.

Benzodiazepines relax muscles to control pain, so they are often prescribed to treat depression.

Given that elderly patients often complain about more than one condition, the same types of agents are occasionally prescribed to deal with different problems; for example, lumbago at an orthopedic clinic, depression at a psychiatric department and insomnia at a section for internal medicine--without paying due consideration to safety issues.

“Given the situation that exists with regard to prescriptions, we need to bolster efforts to call on geriatrics departments, internal medicine divisions, regular doctors and a wide range of parties involving elderly patients to be more careful in prescribing medicines and urge patients to reflect deeply on whether they really need to continue taking certain medications,” said Masahiro Akishita, a geriatrics professor at the University of Tokyo, who serves as chairman of the Japan Geriatrics Society.

“In particular, I want elderly individuals and their families to understand there are risks associated with taking these medications.”

IMPROVED HEALTH

A woman in her 70s in Tokyo’s Ota Ward summoned ambulances on six occasions between June and September in 2019.

She had been taking a benzodiazepine, the anti-anxiety drug Solanax widely known as alprazolam, for more than 10 years. When the medicine stops working, she experiences chest pains, shortness of breath and headaches.

When those symptoms occur, the woman invariably panics and reaches for the phone to call emergency services.

Yet, once she is examined in hospital, doctors are unable to detect that anything is wrong. The woman has repeatedly suffered from the side-effects of the medication.

A man in his 90s, who also lives in the ward and has been taking Depas, a benzodiazepine that commonly goes by the name of etizolam, for 12 years became unable to meet the eyes of his wife or speak to her due to lowered cognitive function two years ago.

The drug is the most frequently prescribed of all benzodiazepines on an annual basis.

The man took three pills a day to combat insomnia and sometimes took more to ease his condition. He ended up feeling more anxious, dizzy and experienced walking difficulties.

The patient also developed hyperventilation, a disorder characterized by rapid breaths when the medication wore off. He complained that he could not sleep and felt disorientated.

Yoshimasa Takase, a physician at the Takase Clinic in Tokyo's Ota Ward, which promotes home medical care, is working to reduce the volume of benzodiazepines that his patients take.

Takase urged the female patient who suffered the panic attacks to “call me anytime if you feel worried” and replaced the drug in question with an antidepressant with much less severe side effects. The male Depas user was also advised to lower his intake and eventually replaced it with an antidepressant.

After the changes in prescriptions, the health condition of the two patients improved and allowed them to continue living at home, Takase said.

“Patients develop a strong dependence on benzodiazepines, so they are frequently stricken by anxiety and panic attacks when the medication stops working,” said Takase. “The drugs even make people feel addicted at times.”

Realizing that a problem exists, the health ministry in 2016 designated etizolam as a psychotropic agent that should be restricted under the Narcotics and Psychotropics Control Law. Now physicians can only prescribe the drug for up to 30 days at a time.

In a fiscal 2018 revision to medical treatment remuneration standards, prescription charges for benzodiazepine receptor agonists, including non-benzodiazepine drugs, were effectively slashed in cases where patients took the same drug dosages for a year or longer.

Patients are supposed to contact their doctors or pharmacists if they use the same medications for prolonged periods. The idea is to tackle health problems before they occur by reviewing their prescriptions.

Guidelines released by the health ministry in May 2018 on the proper use of medicines for elderly individuals state that “guidance on sleep hygiene should be provided before pharmacotherapy.”

Patients can also take steps to reduce their dependence on an excessive intake of benzodiazepines, the most frequently used drug among elderly patients to combat insomnia.

If patients exercise during the daytime, go to bed later and get up earlier to be exposed to sunlight in lieu of sticking to the idea that “one must sleep long,” their health problems could be eased.

Those suffering from lumbago are advised to undergo therapeutic exercise. Individuals with depression or anxiety disorder are urged to try counseling and other cognitive behavior therapies, although that type of treatment is not hugely popular because only “sessions by doctors that last 30 minutes or longer” are covered by health insurance.

(This article was written by Senior Staff Writer Kenji Tamura and Yuko Matsuura.)