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An Increased Risk of Reversible Dementia May Occur After Zolpidem Derivative Use in the Elderly Population a Population-Based Case-Control Study

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An Increased Risk of Reversible Dementia May Occur After Zolpidem Derivative Use in the Elderly Population a Population-Based Case-Control Study An Increased Risk of Reversible Dementia May Occur After Zolpidem Derivative Use in the Elderly Population A Population-Based Case-Control Study Hsin-I Shih, Che-Chen Lin, Yi-Fang Tu, Chia-Ming Chang, Hsiang-Chin Hsu, Chih-Hsien Chi, and Chia-Hung Kao Abstract: We evaluate the effects of zolpidem use to develop demen- artery disease, diabetes, anti-hypertension drugs, stroke, anticholesterol tia or Alzheimer disease from the Taiwan National Health Insurance statin drugs, depression, anxiety, benzodiazepine, anti-psychotic, and Research Database (NHIRD). anti-depressant agents’ use (Adjusted OR ¼ 1.33, 95% CI 1.24–1.41). A retrospective population-based nested case–control study. Newly Zolpidem use also has significant dose–response effects for most of the diagnosed dementia patients 65 years and older and controls were types of dementia. In patient with Alzheimer diseases, the effects of sampled. A total of 8406 dementia and 16,812 control subjects were zolpidem among patients with Alzheimer’s disease remained obscure. enrolled from Taiwan NHIRD during 2006 to 2010. The relationships The adjusted OR for patients whose cumulative exposure doses were between zolpidem use and dementia were measured using odds and between 170 and 819 mg/year (adjusted OR: 1.65, 95% CI 1.08–2.51, adjusted odds ratios. The relationship between the average cumulative P ¼ 0.0199) was significant; however, the effects for lower and higher doses for zolpidem and dementia was also analyzed. cumulative dose were not significant. Zolpidem alone or with other underlying diseases, such as hyper- Zolpidem used might be associated with increased risk for dementia tension, diabetes, and stroke, was significantly associated with dementia in elderly population. Increased accumulative dose might have higher after controlling for potential confounders, such as age, sex, coronary risk to develop dementia, especially in patients with underlying diseases such as hypertension, diabetes, and stroke. Editor: Robert Barkin. (Medicine 94(17):e809) Received: March 4, 2015; revised and accepted: April 1, 2015. From the Department of Emergency Medicine, National Cheng Kung Abbreviations: AORs = adjusted odds ratios, ATC = anatomical University Hospital (H-IS, H-CH); Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National therapeutic chemical, BZD = benzodiazepine, CI = confidence Cheng Kung University, Tainan, Taiwan (H-IS, C-HC); Department of interval, GABA = g-aminobutyric acid, ICD-9-CM = International Pediatrics, National Cheng Kung University Hospital, College of Medicine, Classification of Diseases, Ninth Revision, Clinical Modification, National Cheng Kung University, Tainan, Taiwan (Y-FT); Management NHIRD = National Health Insurance Research Database, OR = Office for Health Data, China Medical University Hospital, Taichung (C-CL); Department of Internal Medicine, Division of Geriatrics and odds ratio. Gerontology, National Cheng Kung University Hospital (C-MC); Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan (C-MC); Graduate Institute of Clinical Medical Science and School of Medicine, College of Medicine, China Medical University (C-HK); and INTRODUCTION Department of Nuclear Medicine and PET Center, China Medical ementia is a clinical syndrome characterized by ‘‘a global University Hospital, Taichung, Taiwan (C-HK). D deterioration of mental functioning in its cognitive, Correspondence: Chia-Hung Kao, Graduate Institute of Clinical Medical 1 Science and School of Medicine, College of Medicine, China Medical emotional, and cognitive aspects.’’ Dementia typically involves University, No. 2, Yuh-Der Road, Taichung 404, Taiwan (e-mail: a long period of progressive decline in memory and other [email protected]). cognitive abilities secondary to brain dysfunction and is a major Contributors: conception/design: H-IS, C-HK; provision of study materials: cause of disability in elderly people.2 Alzheimer disease is the Y-FT, C-MC, H-CH, C-HC; collection and/or assembly of data: C-CL, C-HK; data analysis and interpretation: H-IS, C-HK; most common dementing disorder, followed by vascular demen- manuscript writing: All authors; final approval of manuscript: all authors. tia, frontal lobe dementia, and dementia with Lewy bodies. An This study is supported in part by Taiwan Ministry of Health and Welfare expert panel estimated that the global prevalence of dementia is Clinical Trial and Research Center of Excellence (MOHW104-TDU-B- 3.9% in people over 60 years of age, and the estimated global 212–113002); China Medical University Hospital, Academia Sinica annual incidence of dementia is approximately 7.5 per 1000 Taiwan Biobank, Stroke Biosignature Project (BM104010092); NRPB 3,4 Stroke Clinical Trial Consortium (MOST 103–2325-B-039 -006); people. The incidence of dementia ranges from approximately Tseng-Lien Lin Foundation, Taichung, Taiwan; Taiwan Brain Disease 1 per 100 person-years in people aged 60 to 64 years to >70 per Foundation, Taipei, Taiwan; Katsuzo and Kiyo Aoshima Memorial 1000 person-years in people older than 90 years.4 Because of an Funds, Japan; and Health, and welfare surcharge of tobacco products, China Medical University Hospital Cancer Research Center of Excel- increased life expectancy in modern years, the number of people lence (MOHW104-TDU-B-212–124–002, Taiwan). The funders had no suffering from dementia has rapidly increased, potentially reach- role in study design, data collection and analysis, decision to publish, or ing up to 63 million people by 2030.5 preparation of the manuscript. No additional external funding received The risk factors for dementia include an apolipoprotein E4 for this study. The authors report no conflicts of interest. genotype, cardiovascular comorbidities, diabetes mellitus, Copyright # 2015 Wolters Kluwer Health, Inc. All rights reserved. cerebrovascular diseases, alcohol consumption, and a lower This is an open access article distributed under the Creative Commons education level.6 Benzodiazepine (BZD) and other non-selec- Attribution-NoDerivatives License 4.0, which allows for redistribution, tive g-aminobutyric acid (GABA) agonists with hypnotic commercial and non-commercial, as long as it is passed along unchanged effects similar to those of zolpidem have been shown to disrupt and in whole, with credit to the author. 7 ISSN: 0025-7974 the memory in both human participants and animal subjects. DOI: 10.1097/MD.0000000000000809 The results of previous studies have suggested that BZDs are Medicine Volume 94, Number 17, May 2015 www.md-journal.com | 1 Shih et al Medicine Volume 94, Number 17, May 2015 FIGURE 1. The flow chart demonstrates the selection process used in this study. associated with an increased risk of dementia in the elderly The Taiwan National Health Insurance Research Database population, and these risks decreased when BZD use is dis- (NHIRD) contains reimbursement claims data from the Taiwan continued.8–12 However, the possibility that zolpidem used National Health Insurance (NHI) system, which was established independently of benzodiazepine derivatives, increases the risk in 1996 and has provided coverage for approximately 99% of the for dementia has not been proposed. population since 1998. The National Health Research Institute Zolpidem and its derivatives (the Z drugs) are non-BZD (NHRI) manages the annual claims data in the NHIRD, and the hypnotic agent belonging to the imidazopyridine family. Zol- Longitudinal Health Insurance Database (LHID) was established pidem acts as an agonist of the benzodiazepine v1 receptor for use in medical research. The demographic data, medications, component of the GABAA receptor complex and is commonly treatments (including operations), and disease diagnoses (based used in patients with insomnia, including elderly patients.13 on the International Classification of Diseases, Ninth Revision, Zolpidem is well known for having a rapid onset (usually Clinical Modification [ICD-9-CM]) of patients are recorded in several minutes), short duration of action (the peak time is 2 the NHIRD. The health facilities enrolled in the Taiwan NHI hours, half time is 1.5–5.5 hours), low tolerance, and a low include local clinics, community hospitals, regional hospitals, incidence of adverse effects in treating insomnia.13,14 The most and medical centers. With the exception of some local clinics, the frequent adverse effects associated with zolpidem are nausea, Taiwanese NHI includes almost all the primary, secondary, headache, dizziness, drowsiness, hallucination, and short-term tertiary, and quaternary health care facilities in Taiwan. The memory loss. A 3-week clinical trial revealed psychomotor LHID comprises historical claims data for 1 million patients retardation in 2% of patients receiving zolpidem and in 0% of randomly selected from the NHIRD. The NHRI encrypts the patients in the placebo group.15 However, there are limited patients’ personal information for privacy protection and provides clinical data concerning the effects of long-term zolpidem use researchers with anonymous identification numbers associated on psychomotor or cognitive functions. Thus, the relationship with the relevant claim information, which includes the patient’s between the use of zolpidem and the potential risk of developing sex, date of birth, registry of medical services, and medication dementia remains unknown. In the present study, we used a prescriptions. The patient consent is not required for accessing the national
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