The association between benzodiazepine use and greater risk of neurocognitive impairment is moderated by medical burden in people with HIV

Abstract

Benzodiazepine use is linked to neurocognitive impairment (NCI) in the general population and people with HIV (PWH); however, this relationship may depend on age-related factors such as medical comorbidities, which occur at an elevated rate and manifest earlier in PWH. We retrospectively examined whether chronological age or medical burden, a clinical marker for aging, moderated the relationship between benzodiazepine use and NCI in PWH. Participants were 435 PWH on antiretroviral therapy who underwent neurocognitive and medical evaluations, including self-reported current benzodiazepine use. A medical burden index score (proportion of accumulated multisystem deficits) was calculated from 28 medical deficits. Demographically corrected cognitive deficit scores from 15 neuropsychological tests were used to calculate global and domain-specific NCI based on established cut-offs. Logistic regressions separately modeled global and domain-specific NCI as a function of benzodiazepine x age and benzodiazepine x medical burden interactions, adjusting for current affective symptoms and HIV disease characteristics. A statistically significant benzodiazepine x medical burden interaction (p = .006) revealed that current benzodiazepine use increased odds of global NCI only among those who had a high medical burden (index score > 0.3 as indicated by the Johnson-Neyman analysis), which was driven by the domains of processing speed, motor, and verbal fluency. No age x benzodiazepine interactive effects on NCI were present. Findings suggest that the relationship between BZD use and NCI among PWH is specific to those with greater medical burden, which may be a greater risk factor for BZD-related NCI than chronological age.

Keywords: Benzodiazepines; Comorbidities; HIV; Medical burden; Neurocognitive impairment.

Fig. 1

Region of significance analysis for the quadratic effect of age on medical burden index. Age exhibits a significant positive association with medical burden index until age 63, at which point the slope flattens and the relationship between age and medical burden is no longer significant

Fig. 2

Johnson–Neyman region of significance analysis indicating an adverse effect of benzodiazepine use on NCI only when medical burden index is ≥ 0.3. NCI = neurocognitive impairment. BZD- = benzodiazepine non-user. BZD +  = benzodiazepine user