[Which alternative to benzodiazepines, Z-pills and other hypnotics for aged people ? Melatonin, valerian, or clomethiazole]. / Quelle alternative aux benzodiazépines, Z-pills et autres hypnotiques pour les personnes âgées ?: Mélatonine, valériane ou clométhiazole.

Sleep disorders are a recurrent complaint in geriatrics. Of multifactorial origin, they have a significant impact on health and quality of life. However, the answer is (too) often the prescription of benzodiazepines or related-drugs (Z-pills), sedative antidepressant, or another psychotropic medication. More recently, melatonin, valerian and, in Switzerland, clomethiazol are widely considered as effective and more suitable alternatives for aged people. We present a systematic review of the literature on the efficacy and tolerance of these molecules, of which the main objective is to demonstrate that non-pharmacological approach must remain the first-line therapy of insomnia in geriatrics.

Les troubles du sommeil sont une plainte récurrente en gériatrie. D'origine multifactorielle, ils ont un retentissement significatif sur la santé et la qualité de vie. Cependant la réponse est (trop) souvent la prescription de benzodiazépines ou apparentés (Z-pills), d'un antidépresseur sédatif ou d'un autre psychotrope. Plus récemment, la mélatonine, la valériane et, en Suisse, le clométhiazole sont largement utilisés car considérés comme des alternatives efficaces et plus adaptées aux personnes âgées. Nous présentons une revue systématique de la littérature sur l'efficacité et la tolérance de ces molécules dont l'objectif principal est de montrer que les mesures non pharmacologiques doivent rester le traitement de première intention des insomnies en gériatrie.

Alcohol withdrawal syndrome: how to predict, prevent, diagnose and treat it.

(1) When people who are physically dependent on alcohol stop drinking, they experience an alcohol withdrawal syndrome. The symptoms generally resolve spontaneously within a week, but more severe forms may be associated with generalised seizures, hallucinations and delirium tremens, which can be fatal. (2) We carried out a literature review in order to obtain answers to the following questions: how to predict or rapidly diagnose a severe alcohol withdrawal syndrome; how to prevent and treat this syndrome; how to manage severe forms; and how to deal with the risk of vitamin B1 deficiency. (3) The main risk factors for severe withdrawal syndrome are: chronic heavy drinking; a history of generalised seizures; and a history of delirium tremens. (4) Anxiety, agitation, tremor, excessive sweating, altered consciousness and hallucinations are signs of a severe withdrawal syndrome. (5) Individual support and effective communication seem to reduce the risk of severe withdrawal syndrome. (6) Oral benzodiazepines are the best-assessed drugs for preventing a severe alcohol withdrawal syndrome, particularly the risk of seizures. When given for a maximum of 7 days, the adverse effects are usually mild. (7) Clinical trials of other antiepileptics suggest they are less effective than benzodiazepines, and their addition to benzodiazepine therapy offers no tangible advantage. (8) Betablockers increase the risk of hallucinations, and clonidine increases the risk of nightmares, and the efficacy of these two drugs is not well documented. Neuroleptics increase the risk of seizures. There are no convincing data to support the use of magnesium sulphate or meprobamate (the latter carries a risk of serious adverse effects). Acamprosate, naltrexone and disulfiram are not beneficial in alcohol withdrawal. (9) Gradual withdrawal, i.e. ingestion of decreasing amounts of alcohol, has not been compared with other methods but is generally not recommended. (10) There are no specific recommendations on hydration. Note that excessive water-sodium intake carries a risk of pulmonary oedema in patients with heart disease. (11) As vitamin B1 deficiency is frequent and can lead to serious complications in alcohol-dependent patients, oral vitamin B1 supplementation is widely recommended, despite the absence of comparative trials. High doses must be used to compensate for poor absorption. Intravenous administration is best if patients have very poor nutritional status or severe complications such as Gayet-Wernicke encephalopathy (a medical emergency), even though rare anaphylactic reactions have been reported after vitamin B1 injection. (12) Planned alcohol withdrawal in specialised hospital units has been extensively studied. Outpatient withdrawal may be more appropriate for patients who are at low risk of developing severe withdrawal syndrome. (13) A large proportion of alcohol-dependent patients were excluded from trials of withdrawal strategies. These include elderly patients, patients with serious psychiatric or somatic disorders, and patients who are also dependent on other substances. (14) An oral benzodiazepine is the best-assessed treatment for a single episode of generalised seizures or hallucinations during alcohol withdrawal. (15) In randomised comparative trials benzodiazepines were more effective than neuroleptics in preventing delirium-related mortality. Currently, with appropriate fluid-electrolyte support, continuous monitoring of vital signs, and respiratory support if necessary, the mortality rate for delirium tremens is under 3%. (16) In practice, patients who are attempting to stop drinking alcohol need close personal support and communication, and a reassuring environment, as well as regular monitoring for early signs of a withdrawal syndrome; the latter may require benzodiazepine therapy.

The treatment of sundowning. A selective review of pharmacological and nonpharmacological studies.

Sundowning refers to episodes of agitated behaviour that are more frequent or are more severe at night. Although the effects of different psychoactive medications on agitated behaviour in dementia patients have been documented in hundreds of reports over the last 30 years, less than 20 studies make explicit reference to time of day for which outcome measures were derived, and even fewer have also examined sleep as an outcome. Thus, despite varying claims of efficacy and effectiveness for various medications, there are few data to support informed management of disruptive nocturnal behaviour in these patients. In this brief article, we selectively review those few studies explicitly mentioning temporal dimensions of behavioural outcome, including some newer studies of unconventional types of treatment that may be useful for the treatment of sundowning. We conclude that future pharmacological studies should systematically assess behaviour throughout the 24-hour day to provide outcome data relevant to this phenomenon.

Nimodipine in acute alcohol withdrawal state.

The effect of the calcium channel blocker, nimodipine, in acute alcohol withdrawal was investigated in a randomized, placebo controlled, double blind study. Thirty-two male patients with a history of alcohol dependence according to DSM-III criteria, but no other substance abuse, were included. A new rating instrument which fulfilled theoretical test criteria was applied to determine the severity of the alcohol withdrawal state. The patients received nimodipine or a placebo on four separate occasions (4 x 60 mg) and, in addition, clomethiazole, according to a standardized procedure. Our investigation has shown that, in the first 48-72 h of alcohol withdrawal, both groups consumed similar amounts of additional clomethiazole medication. Thus, no significant effect of nimodipine on the acute alcohol withdrawal state could be demonstrated. There was some tendency for nimodipine to ameliorate psychosensory dysfunction.

The treatment of anxiety states by drugs and other means.

The place of pharmacotherapy, behaviour therapy and biofeedback techniques in the general strategy of treating anxiety states is critically discussed. The dangers and disadvantages of barbiturates are described and the value and limitations of other drugs are considered. Beta-adrenergic receptor blocking drugs have a limited but valuable role in some patients, neuroleptics have a strictly limited place in treatment, and the role of antidepressants of various kinds is considered when anxiety is part of a depressive illness. The benzodiazepines are the most important group of drugs available for the treatment of anxiety states. The differences between various benzodiazepines are presented, with particular reference to their onset of action, half-life and the relevance of active metabolites of some of these drugs. A knowledge of the pharmacokinetics of the benzodiazepine drugs is of practical importance to the clinician. Emphasis is placed on the doctor-patient relationship and psychotherpeutic management in which drugs and other treatment serve as tactical aids in the general strategy of care.