What is the relationship between dementia and benzodiazepines (BZD)?

From the Guidelines

Benzodiazepines should be avoided in patients with dementia whenever possible due to their significant risks, as they can worsen cognitive impairment, increase fall risk, and lead to paradoxical agitation in dementia patients. These medications (including diazepam, lorazepam, alprazolam, and clonazepam) affect GABA receptors in the brain, which can exacerbate cognitive deficits in an already compromised brain, and have a higher risk of dependence and withdrawal symptoms, and their sedative effects can lead to respiratory depression, especially in elderly patients with multiple comorbidities 1. If absolutely necessary for severe anxiety or agitation, use the lowest effective dose for the shortest possible duration, preferably less than 2-4 weeks. For example, if needed, lorazepam 0.25-0.5mg once or twice daily would be preferable to higher doses. Non-pharmacological approaches should be tried first, including environmental modifications, caregiver education, and behavioral interventions. When medication is required for behavioral symptoms, consider alternatives like low-dose trazodone (25-50mg) for sleep or selective serotonin reuptake inhibitors for anxiety.

Some key points to consider when managing patients with dementia and benzodiazepines include:

• The potential for benzodiazepines to worsen cognitive impairment and increase fall risk 1
• The importance of using non-pharmacological approaches as first-line treatment for behavioral symptoms 1
• The need to carefully evaluate the risks and benefits of benzodiazepine use in patients with dementia, and to consider alternative medications when possible 1
• The importance of gradual tapering and withdrawal of benzodiazepines when discontinuing use, to minimize the risk of withdrawal symptoms and rebound effects 1

Overall, the use of benzodiazepines in patients with dementia should be approached with caution, and alternative treatments should be considered whenever possible. By prioritizing non-pharmacological approaches and carefully evaluating the risks and benefits of benzodiazepine use, healthcare providers can help to minimize the risks associated with these medications and improve outcomes for patients with dementia.

From the Research

Dementia and Benzodiazepines

• The relationship between benzodiazepine use and dementia risk is complex and has been investigated in several studies 2, 3.
• A case-control study found that benzodiazepine exposure 5 to 10 years previously was statistically significantly more frequent among those who developed Alzheimer's disease 2.
• However, other studies have found no significant association between benzodiazepine use and dementia risk 3.
• The use of benzodiazepines has been linked to cognitive impairment and confusion, particularly in elderly patients 2.
• Imaging studies have found that current use of benzodiazepines is associated with lower brain volumes of the hippocampus, amygdala, and thalamus, and accelerated volume loss of the hippocampus and amygdala 3.

Treatment of Dementia Symptoms

• Antipsychotics have historically been used to treat behavioral and psychological symptoms of dementia, but their use is associated with significant adverse effects 4, 5.
• Selective serotonin reuptake inhibitors (SSRIs) have been investigated as an alternative treatment for neuropsychiatric symptoms of dementia, with some studies suggesting their efficacy in reducing symptoms of agitation 6.
• However, the evidence base for using SSRIs in the treatment of dementia symptoms is still growing, and further studies are needed to determine their safety and efficacy 4, 6.

Benzodiazepine Use in Dementia

• Benzodiazepines are sometimes prescribed to patients with dementia for anxiety and agitation, but their use is generally not recommended due to the risk of adverse effects 2, 3.
• The possibility of irreversible cognitive impairment is another reason to avoid prescribing benzodiazepines to patients with dementia 2.
• Alternative treatments, such as behavioral and psychosocial interventions, may be more effective and safer for patients with dementia 4, 6.