Which benzodiazepine (benzo) is recommended for use in the elderly population?

From the Guidelines

When prescribing benzodiazepines to the elderly population, temazepam is recommended due to its short- to intermediate-acting properties and lower risk of residual daytime drowsiness compared to long-acting benzodiazepines, with a recommended dosage of 7.5 mg hs in elderly or debilitated patients 1.

Key Considerations

• The choice of benzodiazepine in the elderly should prioritize shorter-acting agents to minimize the risk of accumulation and prolonged sedation.
• Temazepam, with its short- to intermediate-acting profile, is a preferable option, especially considering the recommended dosage for elderly patients is 7.5 mg hs, which helps mitigate risks associated with higher doses or longer-acting benzodiazepines.
• It's crucial to start with the lowest effective dose and titrate slowly as needed, monitoring for signs of toxicity or excessive sedation.
• Non-pharmacological approaches and non-benzodiazepine alternatives should always be considered first due to the significant risks associated with benzodiazepine use in the elderly, including falls, cognitive impairment, delirium, and dependence.

Safety and Efficacy

• The FDA has issued warnings regarding the adverse effects of benzodiazepine receptor agonistic modulators, including sleepwalking, eating, driving, and sexual behavior, emphasizing the need for caution and patient education 1.
• Administration on an empty stomach is advised to maximize effectiveness, and caution is advised in patients with signs/symptoms of depression, compromised respiratory function, or hepatic heart failure.
• Rapid dose decrease or abrupt discontinuance of benzodiazepines can produce withdrawal symptoms, including rebound insomnia, highlighting the need for careful management of benzodiazepine therapy.

Clinical Guidance

• Given the potential risks, benzodiazepines should be used with caution in the elderly, with a preference for short-acting agents like temazepam when a benzodiazepine is deemed necessary.
• The dosage should be carefully managed, starting with the lowest recommended dose for elderly patients (7.5 mg hs for temazepam) and adjusting as necessary to balance efficacy with safety.
• Regular monitoring for adverse effects and consideration of alternative treatments are essential components of benzodiazepine management in the elderly population.

From the FDA Drug Label

In general, dose selection for oxazepam for elderly patients should be cautious, usually starting at the lower end of the dosing range Elderly or debilitated patients may be more susceptible to the sedative effects of lorazepam. Therefore, these patients should be monitored frequently and have their dosage adjusted carefully according to patient response; the initial dosage should not exceed 2 mg.

Oxazepam is recommended for use in the elderly population, as it appears to have a more favorable profile in this age group, with cautious dose selection and monitoring recommended 2.

• Key considerations for use in the elderly include:
  • Starting at the lower end of the dosing range
  • Monitoring for sedative effects and other adverse reactions
  • Careful dosage adjustment according to patient response Lorazepam may also be used in the elderly, but with similar cautious dose selection and monitoring 3.

From the Research

Benzodiazepine Use in the Elderly Population

The use of benzodiazepines in the elderly population is a topic of concern due to the potential risks and adverse effects associated with these medications.

• Benzodiazepines are widely prescribed to older adults for the management of anxiety and insomnia, despite the risks of adverse effects such as falls, cognitive impairment, and dependence 4, 5, 6, 7, 8.
• The choice of benzodiazepine is crucial, with some studies recommending the use of benzodiazepines with a short elimination half-life, such as lorazepam or temazepam, to minimize the risk of adverse effects 5.
• The use of benzodiazepines with a long duration of action is associated with an increased risk of hip fracture, motor vehicle crash, and other adverse events 8.
• Alternative therapeutic strategies, such as nonpharmacological approaches and alternative pharmacological agents, should be considered for the treatment of anxiety and insomnia in older adults 6, 7.

Recommended Benzodiazepines for Elderly Population

Based on the available evidence, the following benzodiazepines are recommended for use in the elderly population:

• Lorazepam 5
• Temazepam 5 It is essential to note that benzodiazepines should be used with caution and at the lowest effective dose for the shortest possible duration to minimize the risk of adverse effects.