Noiseinduced hearing loss and blood pressure R.E.M. LEES,* MD; J. HATCHER ROBERTS,t RN From a group of industrial workers who had a noise-induced hearing loss of at least 30 dB at 4000 Hz 62 were randomly selected after stratification. Controls matched for age and duration of employment were also selected. Resting blood pressures were measured and audiometry was repeated. The findings are presented by age group and for the two groups as a whole. No relation between systolic or diastolic blood pressure and hearing loss was found, and equal proportio.is of each group had blood pressures exceeding 140/90 mm Hg. Persons with greater hearing loss (more than 60 dB at 4000 Hz) did not have significantly higher blood pressures than their matched controls.
Recently two conflicting reports of significant differences in the blood a relation between elevated blood pressures of the two groups. pressure and noise-induced hearing In neither of the reports did the loss have been published. In the first authors state the levels of noise to of these reports Jonsson and Hans- which the men had been exposed, son2 described their study of 44 male nor did there appear to have been industrial workers in Sweden with exact age-matching or matching for noise-induced hearing loss. The cri- duration of exposure to noise. These conflicting reports stimuterion for entry to their study group was auditory impairment of 65 dB lated us to look for evidence of a or greater at 3000, 4000 or 6000 Hz relation between hypertension and but less than 20 dB at other fre- noise-induced hearing loss in the quencies. The systolic and diastolic work force of a local industrial plant. blood pressures of these men were In the Swedish and Finnish studies compared with those of 74 others one of the criteria for inclusion in from the same plant who had "nor- the study group was a hearing loss Soixante.deux travailleurs Industriels mal hearing". The investigators found of 65 dB or greater at 4000 Hz. If parmi un groupe ayant subi une perte significantly higher blood pressures hypertension is etiologically imporde l'ou.e provoquee par ie bruit, d'au in the study group and a higher pro- tant in the early development of moms 30 dB a 4000 Hz, ont et6 choisis portion of individuals whom they noise-induced hearing loss or in the au hasard apres stratification. Des classed as having hypertension. degree to which the loss develops, t6moins apparies pour l'&ge et Ia dur6e d'emploi ont aussi 6t6 choisis. Les In the second study Takala and evidence of the relation should be tensions art6rielles au repos ont ete colleagues3 measured blood pressures apparent at hearing losses of less than mesurees et i'epreuve d'audiom6trie and hearing acuity in a group of in- 65 dB. Similarly, any other associaa 6te repetee. Les constatations sont dividuals in Finland. They identified tion between hypertension and noisepr6sent6es par groupes d'iges et pour 32 men who had noise-induced hear- induced hearing loss should be demles deux groupes dans leur ensemble. Aucun rapport entre les tensions ing losses of 65 dB or greater at 4000 onstrable at lower levels of hearing arterleiles systoliques et diastoliques and 6000 Hz and a history of noise loss. The relation between the two et Ia perte de l'ouie n'a et6 observe, et exposure at work. Their blood pres- conditions might not involve causaldes proportions 6gales de cheque sures were compared with those of ity for one or other. groupe avaient des tensions art.rielles A case-control study involving a 67 men in the same age group (40 sup6rieures a 140/90 mm Hg. Les personnes ayant les pertes de l'ouie les to 59 years) who had "normal hear- wide range of ages and durations of plus consid6rables (plus de 60 dB & ing". These investigators found no noise exposure was considered to be 4000 Hz) n'avaient pas des tensions Frequency art6rielles significativement superieures
A ceiles de leurs t6moins appari6s.
Since Stein1 hypothesized that degenerative cardiovascular conditions and hypertension might be causally related to the onset and degree of presbycusis there has been debate on the etiologic relation between hypertension and some types of sensorineural hearing loss.
-10 0
10 20 30 40 50 60 70
From the department of community health and epidemiology, Queen's University, Kingston, Oat.
*Professor IFormer research assistant Reprint requests to: Dr. R.E.M. Lees, Director, Occupational Health and Safety Resource Centre, Queen's University, 25 Union St., Kingston, Ont. K7L 2N6
80 90 100 110 120 FIG. 1-Typical audiogram patterns of noise-induced hearing loss.
the most appropriate approach to the
resolution of the conflict. Method To follow the study method of Jonsson and Hansson2 and of Takala and colleagues3 we selected evidence of noise-induced hearing loss as the essential condition for allocation to the study group. From the health records of a group of industrial workers, persons with a hearing loss of greater than 30 dB at 4000 Hz according to their most recent audiogram were identified from among those who worked in high-noise areas of the plant. The audiograms were studied and subjects included in the potential study group if the pattern of hearing loss was consistent with a noise-induced loss - that is, the attenuation of hearing was greatest at 4000 Hz and was at least 20 dB greater than the attenuation at any frequency less than 3000 Hz. Typical audiogram patterns of noise-induced hearing loss are shown in Fig. 1. Steady-state noise of between 95 and 98 dBA* was measured in the work areas classed as noisy for purposes of this study. There was no impact noise in the plant. A combination of steady-state and impact noise *The decibel A (dBA) scale is an electronically weighted measurement of sound pressure designed to respond to noise in a manner similar to the human ear in terms of subjective loudness, intensity and damage potential. Because the ear does not respond equally to equal sound pressures at different frequencies, the scale is weighted to take more account of pressures above 1000 Hz than of those below that frequency. It is the accepted scale for measuring ambient industrial noise.
can produce atypical audiogram patterns of noise-induced hearing loss in which the 4000-Hz notch is absent and attenuation of hearing is demonstrable across a wider range of frequencies.4 The persons potentially acceptable for inclusion in the study group were arranged in the following age groups: 30 years or less, 31 to 40 years, 41 to 50 years and more than 50 years. When the group had been stratified by age a random sample of 62 subjects was drawn. The subjects were matched for age and duration of employment with a control group of 62 individuals drawn at random from workers employed in quiet areas of the plant - those in which the ambient noise level was less than 85 dBA according to the records of the company's safety engineer. Audiograms for the plant's workers were routinely made with an automatic machine. Persons in the potential study group had their auditory acuity measured manually by one technician before they were included in the study group. In both the study group and the control group the audiograms were made after the individual had been away from the work environment a minimum of 12 hours and had not been exposed in that period to loud noise during leisure or recreation. The systolic and diastolic blood pressures of the two groups were measured by one individual using a mercury manometer fitted with a standard cuff. The individual was unaware of the group to which each subject had been assigned. Measurements were made after the subject
had been sitting at rest for 7 minutes. The data were recorded and arranged by age group, and means and standard deviations were calculated. Results The ages of the persons in the study ranged from 25 to 63 years; the mean ages (± 1 standard deviation) were 42.5 ± 11.2 and 41.0 ± 10.8 years in the study and control groups respectively. The hearing losses at 4000 Hz in the study group ranged from 30 to 95 dB. Considering a blood pressure of 140/90 mm Hg as the upper limit of the normal range we found no difference between the two groups in the number of persons with hypertension, nor was there a significant difference between the groups in the mean systolic or diastolic blood pressure or either of the standard deviations. The systolic blood pressures ranged from 80 to 220 mm Hg and the diastolic from 45 to 115 mm Hg. The findings with respect to hearing loss and systolic and diastolic blood pressures by age group are summarized in Table I. Hearing loss in excess of 60 dB was detected in 22 members of the study group, whose mean age was 46.8 years, mean hearing loss 70.7 dB, mean systolic blood pressure 117.3 mm Hg and mean diastolic blood pressure 72.0 mm Hg. The mean blood pressures were not significantly different from those of their controls. Discussion At lower levels of noise-induced hearing loss than those used by
CMA JOURNAL/MAY 5, 1979/VOL 120 1083
Jonsson and Hansson2 and by Takala and colleagues3 as criteria for entry to their studies we could find no evidence of a relation between increased systolic or diastolic blood pressure and hearing loss. Both of the cited studies used a hearing loss of 65 dB at 4000 Hz as the criterion for entry. Our entry criterion was set much lower on the hypothesis that if elevation of blood pressure was etiologically important in the development of noise-induced hearing loss, differences in blood pressure between the study and control groups would be apparent, and that the elevation of blood pressure would be evident in the younger members of the study group and would increase with the progression of hearing loss and age. The hypothesis was not substantiated on any of these grounds. The mean systolic and diastolic blood pressures did not change significantly with age, although the standard deviations increased. This indicates that more persons with higher blood pressures were to be found in the older groups. This trend was similar in the two groups. There was no difference in the number of persons with hypertension identified in the two groups when we used 140/90 mm Hg as the upper limit of normal blood pressure. If a relation between blood pressure and noise-induced hearing loss does exist at high levels of hearing loss, it may be that elevation of blood pressure is secondary to the stress of a long period in a noisy work environment. The results of this study suggest that the reverse is not the case. Jonsson and Hansson2 did not analyse their results by age group and did not match their study subjects with control subjects. Matching for age and duration of employment is essential if a conclusion such as theirs is to be drawn from the data. It is essential that audiometry in industrial workers be performed after the worker has spent at least 12 hours in a non-noisy environment to eliminate the effects of a temporary shift in the auditory threshold. The studies conducted by Cuesdean and associates5 have indicated that the timing of blood pressure measure-
ment should also be carefully controlled. These investigators found that when blood pressure was measured after 1 hour's exposure to industrial noise 13 of 160 workers could be classed as having hypertension (blood pressure in excess of 140/90 mm Hg), whereas at the end of an 8-hour shift only 4 of the 160 had hypertensive blood pressure levels. This finding substantiates the claim of Catlin6 and others that adaptation occurs with prolonged exposure to noise at high levels. We found, as we expected, that the levels of hearing loss increased with age in both groups. This reflected increasing noise-induced hearing loss with increasing duration of industrial exposure to noise and presbycusis in those not so exposed. The apparently small but consistent increase in mean blood pressures with age was accompanied by a greater increase in the standard deviations. This too was expected and confirmed that the matching of the study group with controls randomly selected from a larger unaffected group was appropriate. We thank Mitchell Loeb for assistance with analysis of the data collected in this study, and gratefully acknowledge the cooperation of the management and employees of the Kingston Works of Dupont Canada Ltd. and the members of the plant's medical department.
References 1. STEIN C: Die Arterioskierose des Geh6rorganes. Handb Neurol Ohres (Teil 1) 2: 641, 1928 2. JoNssoN A, HANSSON L: Prolonged exposure to a stressful stimulus (noise) as a cause of raised blood pressure
in man. Lancet 1: 86, 1977 3. TAKALA J, VARKE 5, VAHERI E, et al:
Noise and blood pressure. Lancet 2: 974, 1977 4. GRABOWSKI RR, MILLER MH: Audio-
metric configurations of drop forge hammermen and helpers. J Occup Med 19: 333, 1977 S. CUESDEAN L, TEGANEANU 5, Turu C,
et al: Study of cardiovascular and auditory pathophysiological implications in a group of operatives working
in noisy industrial surroundings. Physiologie 14: 53, 1977
6. CATLIN Fl: Noise and emotional stress. J Chronic Dis 18: 509, 1965
1084 CMA JOURNAL/MAY 5, 1979/VOL. 120
Ativan* (lorazepem)
An Uncomplicated Benzodiazepine COMPOSITION: Ativan 1 mg-Each white, oblong, scored tablet contains: Lorazepam 1 mg. (DIN 348325) Ativan 2 mg-Each white, ovoid, scored tablet contains: Lorazepam 2 mg. (DIN 348333) INDICATIONS: Ativan is useful for the short-term relief of manifestations of excessive anxiety in patients with anxiety neurosis. CONTRAINDICATIONS: Ativan is contraindicated in patients with known hypersensitivity to benzodiazepines and in patients with myasthenia gravis or acute narrow angle glaucoma. DOSAGE: The dosage of ATI VAN must be individualized and carefully titrated in order to avoid excessive sedation or mental and motor impairment. As with other anxiolytic sedatives, it is not recommended to prescribe or administer ATIVAN for periods in excess of six weeks, without followup and establishing the need for more prolonged administration in individual patients. Usual Adult Dosage: The recommended initial adult daily dosage is 2 mg in divided doses of 0.5 mg, 0.5 mg and 1.0 mg, or of 1 mg and 1 mg. The daily dosage should be carefully increased or decreased by 0.5 mg depending upon tolerance and response. The usual daily dosage is 2 to 3 mg. However, the optimal dosage may range from 1 to 4 mg daily in individual patients. Usually, a daily dosage of 6 mg should not be exceeded. Elderly and Debilitated Patients: The initial daily dose in these patients should not exceed 0.5 mg and should be very carefully and gradually adjusted, depending upon tolerance and response. PRECAUTIONS: Use in the Elderly: Elderly and debilitated patients, or those with organic brain syndrome, have been found to be prone to CNS depression after even low doses of benzodiazepines. Therefore, medication should be initiated in these patients with very low initial doses, and increments should be made gradually, depending on the response of the patient, in order to avoid oversedation or neurological impairment. Dependence Liability: Ativan should not be administered to individuals prone to drug abuse. Caution should be observed in patients who are considered to have potential for psychological dependence. It is suggested that the drug should be withdrawn gradually if it has been used in high dosage. Use In Mental and Emotional Disorde,s: Ativan is not recommended for the treatment of psychotic or depressed patients. Since excitement and other paradoxical reactions can result from the use of these drugs in psychotic patients, they should not be used in ambulatory patients suspected of having psychotic tendencies. ADVERSE EFFECTS: The side effect most frequently reported was drowsiness. Other reported side effects were dizziness, weakness, fatigue and lethargy, disorientation, ataxia, anterograde amnesia, nausea, change in appetite, change in weight, depression, blurred vision and diplopia, psychomotor agitation, sleep disturbance, vomiting, sexual disturbance, headache, skin rashes, gastrointestinal, ear, nose and throat, musculoskeletal and respiratory disturbances. Full product intormation available on request.
Wyeth L.di
* F.IKK.1 WyethLtd., Downsview,
ntario M3M 3A8
.Regd Trade Mark
Recently two conflicting reports of significant differences in the blood a relation between elevated blood pressures of the two groups. pressure and noise-induced hearing In neither of the reports did the loss have been published. In the first authors state the levels of noise to of these reports Jonsson and Hans- which the men had been exposed, son2 described their study of 44 male nor did there appear to have been industrial workers in Sweden with exact age-matching or matching for noise-induced hearing loss. The cri- duration of exposure to noise. These conflicting reports stimuterion for entry to their study group was auditory impairment of 65 dB lated us to look for evidence of a or greater at 3000, 4000 or 6000 Hz relation between hypertension and but less than 20 dB at other fre- noise-induced hearing loss in the quencies. The systolic and diastolic work force of a local industrial plant. blood pressures of these men were In the Swedish and Finnish studies compared with those of 74 others one of the criteria for inclusion in from the same plant who had "nor- the study group was a hearing loss Soixante.deux travailleurs Industriels mal hearing". The investigators found of 65 dB or greater at 4000 Hz. If parmi un groupe ayant subi une perte significantly higher blood pressures hypertension is etiologically imporde l'ou.e provoquee par ie bruit, d'au in the study group and a higher pro- tant in the early development of moms 30 dB a 4000 Hz, ont et6 choisis portion of individuals whom they noise-induced hearing loss or in the au hasard apres stratification. Des classed as having hypertension. degree to which the loss develops, t6moins apparies pour l'&ge et Ia dur6e d'emploi ont aussi 6t6 choisis. Les In the second study Takala and evidence of the relation should be tensions art6rielles au repos ont ete colleagues3 measured blood pressures apparent at hearing losses of less than mesurees et i'epreuve d'audiom6trie and hearing acuity in a group of in- 65 dB. Similarly, any other associaa 6te repetee. Les constatations sont dividuals in Finland. They identified tion between hypertension and noisepr6sent6es par groupes d'iges et pour 32 men who had noise-induced hear- induced hearing loss should be demles deux groupes dans leur ensemble. Aucun rapport entre les tensions ing losses of 65 dB or greater at 4000 onstrable at lower levels of hearing arterleiles systoliques et diastoliques and 6000 Hz and a history of noise loss. The relation between the two et Ia perte de l'ouie n'a et6 observe, et exposure at work. Their blood pres- conditions might not involve causaldes proportions 6gales de cheque sures were compared with those of ity for one or other. groupe avaient des tensions art.rielles A case-control study involving a 67 men in the same age group (40 sup6rieures a 140/90 mm Hg. Les personnes ayant les pertes de l'ouie les to 59 years) who had "normal hear- wide range of ages and durations of plus consid6rables (plus de 60 dB & ing". These investigators found no noise exposure was considered to be 4000 Hz) n'avaient pas des tensions Frequency art6rielles significativement superieures
A ceiles de leurs t6moins appari6s.
Since Stein1 hypothesized that degenerative cardiovascular conditions and hypertension might be causally related to the onset and degree of presbycusis there has been debate on the etiologic relation between hypertension and some types of sensorineural hearing loss.
-10 0
10 20 30 40 50 60 70
From the department of community health and epidemiology, Queen's University, Kingston, Oat.
*Professor IFormer research assistant Reprint requests to: Dr. R.E.M. Lees, Director, Occupational Health and Safety Resource Centre, Queen's University, 25 Union St., Kingston, Ont. K7L 2N6
80 90 100 110 120 FIG. 1-Typical audiogram patterns of noise-induced hearing loss.
the most appropriate approach to the
resolution of the conflict. Method To follow the study method of Jonsson and Hansson2 and of Takala and colleagues3 we selected evidence of noise-induced hearing loss as the essential condition for allocation to the study group. From the health records of a group of industrial workers, persons with a hearing loss of greater than 30 dB at 4000 Hz according to their most recent audiogram were identified from among those who worked in high-noise areas of the plant. The audiograms were studied and subjects included in the potential study group if the pattern of hearing loss was consistent with a noise-induced loss - that is, the attenuation of hearing was greatest at 4000 Hz and was at least 20 dB greater than the attenuation at any frequency less than 3000 Hz. Typical audiogram patterns of noise-induced hearing loss are shown in Fig. 1. Steady-state noise of between 95 and 98 dBA* was measured in the work areas classed as noisy for purposes of this study. There was no impact noise in the plant. A combination of steady-state and impact noise *The decibel A (dBA) scale is an electronically weighted measurement of sound pressure designed to respond to noise in a manner similar to the human ear in terms of subjective loudness, intensity and damage potential. Because the ear does not respond equally to equal sound pressures at different frequencies, the scale is weighted to take more account of pressures above 1000 Hz than of those below that frequency. It is the accepted scale for measuring ambient industrial noise.
can produce atypical audiogram patterns of noise-induced hearing loss in which the 4000-Hz notch is absent and attenuation of hearing is demonstrable across a wider range of frequencies.4 The persons potentially acceptable for inclusion in the study group were arranged in the following age groups: 30 years or less, 31 to 40 years, 41 to 50 years and more than 50 years. When the group had been stratified by age a random sample of 62 subjects was drawn. The subjects were matched for age and duration of employment with a control group of 62 individuals drawn at random from workers employed in quiet areas of the plant - those in which the ambient noise level was less than 85 dBA according to the records of the company's safety engineer. Audiograms for the plant's workers were routinely made with an automatic machine. Persons in the potential study group had their auditory acuity measured manually by one technician before they were included in the study group. In both the study group and the control group the audiograms were made after the individual had been away from the work environment a minimum of 12 hours and had not been exposed in that period to loud noise during leisure or recreation. The systolic and diastolic blood pressures of the two groups were measured by one individual using a mercury manometer fitted with a standard cuff. The individual was unaware of the group to which each subject had been assigned. Measurements were made after the subject
had been sitting at rest for 7 minutes. The data were recorded and arranged by age group, and means and standard deviations were calculated. Results The ages of the persons in the study ranged from 25 to 63 years; the mean ages (± 1 standard deviation) were 42.5 ± 11.2 and 41.0 ± 10.8 years in the study and control groups respectively. The hearing losses at 4000 Hz in the study group ranged from 30 to 95 dB. Considering a blood pressure of 140/90 mm Hg as the upper limit of the normal range we found no difference between the two groups in the number of persons with hypertension, nor was there a significant difference between the groups in the mean systolic or diastolic blood pressure or either of the standard deviations. The systolic blood pressures ranged from 80 to 220 mm Hg and the diastolic from 45 to 115 mm Hg. The findings with respect to hearing loss and systolic and diastolic blood pressures by age group are summarized in Table I. Hearing loss in excess of 60 dB was detected in 22 members of the study group, whose mean age was 46.8 years, mean hearing loss 70.7 dB, mean systolic blood pressure 117.3 mm Hg and mean diastolic blood pressure 72.0 mm Hg. The mean blood pressures were not significantly different from those of their controls. Discussion At lower levels of noise-induced hearing loss than those used by
CMA JOURNAL/MAY 5, 1979/VOL 120 1083
Jonsson and Hansson2 and by Takala and colleagues3 as criteria for entry to their studies we could find no evidence of a relation between increased systolic or diastolic blood pressure and hearing loss. Both of the cited studies used a hearing loss of 65 dB at 4000 Hz as the criterion for entry. Our entry criterion was set much lower on the hypothesis that if elevation of blood pressure was etiologically important in the development of noise-induced hearing loss, differences in blood pressure between the study and control groups would be apparent, and that the elevation of blood pressure would be evident in the younger members of the study group and would increase with the progression of hearing loss and age. The hypothesis was not substantiated on any of these grounds. The mean systolic and diastolic blood pressures did not change significantly with age, although the standard deviations increased. This indicates that more persons with higher blood pressures were to be found in the older groups. This trend was similar in the two groups. There was no difference in the number of persons with hypertension identified in the two groups when we used 140/90 mm Hg as the upper limit of normal blood pressure. If a relation between blood pressure and noise-induced hearing loss does exist at high levels of hearing loss, it may be that elevation of blood pressure is secondary to the stress of a long period in a noisy work environment. The results of this study suggest that the reverse is not the case. Jonsson and Hansson2 did not analyse their results by age group and did not match their study subjects with control subjects. Matching for age and duration of employment is essential if a conclusion such as theirs is to be drawn from the data. It is essential that audiometry in industrial workers be performed after the worker has spent at least 12 hours in a non-noisy environment to eliminate the effects of a temporary shift in the auditory threshold. The studies conducted by Cuesdean and associates5 have indicated that the timing of blood pressure measure-
ment should also be carefully controlled. These investigators found that when blood pressure was measured after 1 hour's exposure to industrial noise 13 of 160 workers could be classed as having hypertension (blood pressure in excess of 140/90 mm Hg), whereas at the end of an 8-hour shift only 4 of the 160 had hypertensive blood pressure levels. This finding substantiates the claim of Catlin6 and others that adaptation occurs with prolonged exposure to noise at high levels. We found, as we expected, that the levels of hearing loss increased with age in both groups. This reflected increasing noise-induced hearing loss with increasing duration of industrial exposure to noise and presbycusis in those not so exposed. The apparently small but consistent increase in mean blood pressures with age was accompanied by a greater increase in the standard deviations. This too was expected and confirmed that the matching of the study group with controls randomly selected from a larger unaffected group was appropriate. We thank Mitchell Loeb for assistance with analysis of the data collected in this study, and gratefully acknowledge the cooperation of the management and employees of the Kingston Works of Dupont Canada Ltd. and the members of the plant's medical department.
References 1. STEIN C: Die Arterioskierose des Geh6rorganes. Handb Neurol Ohres (Teil 1) 2: 641, 1928 2. JoNssoN A, HANSSON L: Prolonged exposure to a stressful stimulus (noise) as a cause of raised blood pressure
in man. Lancet 1: 86, 1977 3. TAKALA J, VARKE 5, VAHERI E, et al:
Noise and blood pressure. Lancet 2: 974, 1977 4. GRABOWSKI RR, MILLER MH: Audio-
metric configurations of drop forge hammermen and helpers. J Occup Med 19: 333, 1977 S. CUESDEAN L, TEGANEANU 5, Turu C,
et al: Study of cardiovascular and auditory pathophysiological implications in a group of operatives working
in noisy industrial surroundings. Physiologie 14: 53, 1977
6. CATLIN Fl: Noise and emotional stress. J Chronic Dis 18: 509, 1965
1084 CMA JOURNAL/MAY 5, 1979/VOL. 120
Ativan* (lorazepem)
An Uncomplicated Benzodiazepine COMPOSITION: Ativan 1 mg-Each white, oblong, scored tablet contains: Lorazepam 1 mg. (DIN 348325) Ativan 2 mg-Each white, ovoid, scored tablet contains: Lorazepam 2 mg. (DIN 348333) INDICATIONS: Ativan is useful for the short-term relief of manifestations of excessive anxiety in patients with anxiety neurosis. CONTRAINDICATIONS: Ativan is contraindicated in patients with known hypersensitivity to benzodiazepines and in patients with myasthenia gravis or acute narrow angle glaucoma. DOSAGE: The dosage of ATI VAN must be individualized and carefully titrated in order to avoid excessive sedation or mental and motor impairment. As with other anxiolytic sedatives, it is not recommended to prescribe or administer ATIVAN for periods in excess of six weeks, without followup and establishing the need for more prolonged administration in individual patients. Usual Adult Dosage: The recommended initial adult daily dosage is 2 mg in divided doses of 0.5 mg, 0.5 mg and 1.0 mg, or of 1 mg and 1 mg. The daily dosage should be carefully increased or decreased by 0.5 mg depending upon tolerance and response. The usual daily dosage is 2 to 3 mg. However, the optimal dosage may range from 1 to 4 mg daily in individual patients. Usually, a daily dosage of 6 mg should not be exceeded. Elderly and Debilitated Patients: The initial daily dose in these patients should not exceed 0.5 mg and should be very carefully and gradually adjusted, depending upon tolerance and response. PRECAUTIONS: Use in the Elderly: Elderly and debilitated patients, or those with organic brain syndrome, have been found to be prone to CNS depression after even low doses of benzodiazepines. Therefore, medication should be initiated in these patients with very low initial doses, and increments should be made gradually, depending on the response of the patient, in order to avoid oversedation or neurological impairment. Dependence Liability: Ativan should not be administered to individuals prone to drug abuse. Caution should be observed in patients who are considered to have potential for psychological dependence. It is suggested that the drug should be withdrawn gradually if it has been used in high dosage. Use In Mental and Emotional Disorde,s: Ativan is not recommended for the treatment of psychotic or depressed patients. Since excitement and other paradoxical reactions can result from the use of these drugs in psychotic patients, they should not be used in ambulatory patients suspected of having psychotic tendencies. ADVERSE EFFECTS: The side effect most frequently reported was drowsiness. Other reported side effects were dizziness, weakness, fatigue and lethargy, disorientation, ataxia, anterograde amnesia, nausea, change in appetite, change in weight, depression, blurred vision and diplopia, psychomotor agitation, sleep disturbance, vomiting, sexual disturbance, headache, skin rashes, gastrointestinal, ear, nose and throat, musculoskeletal and respiratory disturbances. Full product intormation available on request.
Wyeth L.di
* F.IKK.1 WyethLtd., Downsview,
ntario M3M 3A8
.Regd Trade Mark
