What are the guidelines for using benzodiazepines (BZD) in older adults?

Guidelines for Using Benzodiazepines in Older Adults

Benzodiazepines should generally be avoided in older adults due to substantial risks of adverse effects including falls, fractures, cognitive impairment, delirium, and increased mortality. 1

Risks of Benzodiazepines in Older Adults

Benzodiazepines pose significant risks to older adults:

• Increased risk of falls and fractures due to sedation, impaired balance, and coordination problems 1, 2
• Cognitive impairment that can mimic or worsen dementia 1
• Delirium - benzodiazepines can both cause and worsen delirium 1
• Motor vehicle accidents due to impaired reaction time and coordination 3
• Respiratory depression, especially when combined with opioids or in patients with respiratory conditions 4, 5
• Dependence and withdrawal - more difficult to manage in older adults 6

Appropriate Indications (Limited)

Benzodiazepines should only be used in older adults for:

• Alcohol or benzodiazepine withdrawal 1
• Severe, acute anxiety that threatens patient safety when non-pharmacological approaches have failed 1
• Periprocedural sedation for brief periods 1
• Seizure disorders when other treatments have failed

Prescribing Guidelines When Necessary

If a benzodiazepine must be used in an older adult:

1. Use the lowest effective dose - start at approximately 50% of the usual adult dose 4, 5
2. Choose shorter-acting agents with no active metabolites (e.g., lorazepam) 3
3. Limit duration - prescribe for the shortest possible time (ideally less than 2-4 weeks) 6
4. Avoid combining with other CNS depressants especially opioids 4, 5
5. Monitor closely for adverse effects including cognitive changes, falls, and respiratory depression 5
6. Document clear indication and plan for discontinuation 6

Deprescribing Algorithm

For older adults already on benzodiazepines:

1. Assess necessity and risk - determine if continued use is justified given the risks 6

2. Educate the patient about risks - patient education alone increases discontinuation rates 6

3. Implement gradual tapering:

   • Reduce dose by approximately 25% every 1-2 weeks 6
   • For long-term users, consider an even slower taper (e.g., 10-25% reduction every 2-4 weeks) 6, 4
   • If withdrawal symptoms occur, slow the taper further or temporarily return to previous dose 6
   • Complete tapering may take 2-4 months or longer 6

4. Provide non-pharmacological alternatives during and after tapering:

   • Cognitive behavioral therapy for insomnia or anxiety 6, 7
   • Sleep hygiene education 6
   • Relaxation techniques 6

Alternative Treatments

For anxiety:

• SSRIs or SNRIs as first-line pharmacological options 7
• Buspirone for generalized anxiety 6
• Cognitive behavioral therapy 7

For insomnia:

• Sleep restriction therapy 7
• Sleep hygiene education 6
• Low-dose trazodone (if pharmacotherapy needed) 7
• Melatonin (limited evidence) 6

Common Pitfalls to Avoid

• Tapering too quickly in elderly patients, which increases withdrawal symptoms 6
• Failing to recognize or address withdrawal symptoms promptly 6
• Substituting one potentially inappropriate medication for another 6
• Underestimating psychological dependence many older adults have developed 6
• Not providing adequate education and support during the tapering process 6

By following these guidelines, clinicians can minimize the risks associated with benzodiazepine use in older adults while effectively managing conditions that might otherwise warrant their prescription.