From the Guidelines
Benzodiazepines (BZDs) should be used with caution in the elderly population due to their potential for adverse effects, such as cognitive impairment, falls, and increased risk of dementia.
Key Considerations
- Increased sensitivity to sedative effects: Elderly patients are more sensitive to the sedative effects of BZDs, which can lead to increased risk of falls, cognitive impairment, and other adverse effects 1.
- Risk of dementia: Observational data suggests that BZDs, particularly those with half-lives exceeding 24 hours (e.g., diazepam, flurazepam, and chlordiazepoxide), may be associated with an increased risk of dementia in older adults 1.
- Cognitive impairment and falls: BZDs can cause cognitive impairment, including delirium, and increase the risk of falls in elderly patients, particularly when used in combination with other medications or in patients with underlying medical conditions 1.
- Dependence and withdrawal: Long-term use of BZDs can lead to dependence and withdrawal symptoms, which can be particularly challenging to manage in elderly patients 1.
- Pharmacokinetic changes: Elderly patients may experience changes in BZD pharmacokinetics, including reduced clearance and increased elimination half-life, which can increase the risk of adverse effects 1.
Recommendations
- Use short-acting BZDs: When using BZDs in elderly patients, consider using short-acting agents, such as lorazepam, to minimize the risk of adverse effects 1.
- Monitor closely: Closely monitor elderly patients for signs of adverse effects, such as cognitive impairment, falls, and increased risk of dementia, when using BZDs 1.
- Consider alternative treatments: Consider alternative treatments for insomnia and anxiety, such as non-pharmacologic therapies or other medications with a more favorable safety profile, before using BZDs in elderly patients 1.
From the Research
Considerations for Using Benzodiazepines in the Elderly Population
- The use of benzodiazepines (BZDs) in older adults is a concern due to the potential risks of falls, fractures, cognitive impairment, and car crashes, as well as financial and legal burdens to society 2.
- Long-term use of BZDs in older people is often not beneficial and can result in significant harms, making deprescribing a crucial consideration 2, 3.
- Deprescribing BZDs can be problematic due to complex interactions between drug, patient, physician, and systematic barriers, including concerns about withdrawal syndrome 2.
- Interventions to deprescribe BZDs in older people have been trialed, with reported success rates ranging from 27 to 80%, and variability attributed to heterogeneity of methodological approaches and limited generalizability to cognitively impaired patients 2.
- Effective interventions for deprescribing BZDs include raising awareness, resourcing the patient, and targeting physicians and pharmacists, with a stepwise approach recommended for cognitively intact older adults and less-consultative methods for patients with dementia 2, 3.
- Alternative therapies for treating insomnia and anxiety in older adults, such as nonpharmacological approaches and alternative pharmacological agents, have been proposed 3, 4.
- The available evidence suggests that BZD prescribing to older adults is significantly in excess of what is appropriate, and future trials should focus on reducing both acute and chronic BZD use while improving access to effective non-pharmacologic treatment alternatives 4.
- BZD reduction protocols among older adults are feasible and successful, with common elements including taper alone, taper plus cognitive behavioral therapy, and taper plus medication substitution, and a patient-centered approach is needed to address unique cognitive and functional abilities and comorbidities 5.