From the Guidelines
Benzodiazepines should be avoided or used with extreme caution in elderly patients due to their potential for severe side effects, including increased sedation, confusion, impaired coordination, and dizziness, which can significantly raise the risk of falls and fractures. The use of benzodiazepines in elderly patients is associated with a range of concerning side effects, as highlighted in a systematic review 1. Common side effects include:
- Increased sedation
- Confusion
- Impaired coordination
- Dizziness These effects can significantly raise the risk of falls and fractures in elderly patients. Additionally, elderly patients may experience more pronounced cognitive impairment, including memory problems and delirium, as well as respiratory depression, especially when benzodiazepines are combined with other sedating medications or in patients with underlying respiratory conditions. Paradoxical reactions, such as increased anxiety, agitation, or aggression, may also develop, and long-term use can lead to physical dependence and withdrawal symptoms if stopped abruptly. Benzodiazepines also interact with many medications commonly prescribed to older adults, potentially causing enhanced sedation or reduced effectiveness of other drugs. These effects are more severe in the elderly due to age-related changes in drug metabolism, reduced clearance from the body, increased brain sensitivity to these medications, and the presence of multiple medical conditions. If benzodiazepines must be used in elderly patients, they should be prescribed at the lowest effective dose for the shortest possible duration, with close monitoring for adverse effects, as recommended by the work group based on 4 fair-quality systematic reviews 1.
From the FDA Drug Label
The following adverse reactions have occurred with benzodiazepine abuse and/or misuse: abdominal pain, amnesia, anorexia, anxiety, aggression, ataxia, blurred vision, confusion, depression, disinhibition, disorientation, dizziness, euphoria, impaired concentration and memory, indigestion, irritability, muscle pain, slurred speech, tremors, and vertigo Acute Withdrawal Signs and Symptoms Acute withdrawal signs and symptoms associated with benzodiazepines have included abnormal involuntary movements, anxiety, blurred vision, depersonalization, depression, derealization, dizziness, fatigue, gastrointestinal adverse reactions (e.g., nausea, vomiting, diarrhea, weight loss, decreased appetite), headache, hyperacusis, hypertension, irritability, insomnia, memory impairment, muscle pain and stiffness, panic attacks, photophobia, restlessness, tachycardia, and tremor Protracted Withdrawal Syndrome Protracted withdrawal syndrome associated with benzodiazepines is characterized by anxiety, cognitive impairment, depression, insomnia, formication, motor symptoms (e.g., weakness, tremor, muscle twitches), paresthesia, and tinnitus that persists beyond 4 to 6 weeks after initial benzodiazepine withdrawal.
The potential side effects of benzodiazepine (BZD) therapy in the elderly population include:
- Abuse and misuse: risk of abuse, misuse, and addiction
- Adverse reactions: abdominal pain, amnesia, anorexia, anxiety, aggression, ataxia, blurred vision, confusion, depression, disinhibition, disorientation, dizziness, euphoria, impaired concentration and memory, indigestion, irritability, muscle pain, slurred speech, tremors, and vertigo
- Acute withdrawal symptoms: abnormal involuntary movements, anxiety, blurred vision, depersonalization, depression, derealization, dizziness, fatigue, gastrointestinal adverse reactions, headache, hyperacusis, hypertension, irritability, insomnia, memory impairment, muscle pain and stiffness, panic attacks, photophobia, restlessness, tachycardia, and tremor
- Protracted withdrawal symptoms: anxiety, cognitive impairment, depression, insomnia, formication, motor symptoms, paresthesia, and tinnitus that persists beyond 4 to 6 weeks after initial benzodiazepine withdrawal 2 3
From the Research
Potential Side Effects of Benzodiazepine Therapy in the Elderly
The use of benzodiazepines in the elderly population has been associated with several potential side effects, including:
- Falls, which can be enhanced by the use of benzodiazepines, particularly those with long half-lives 4, 5, 6
- Cognitive impairment, including confusion and disorientation, which can be particularly problematic in multimorbid elderly patients 5, 6
- Sedation, which can increase the risk of falls and other accidents 5
- Impairment of driving skills, which can be a significant concern for elderly patients who are still driving 4, 7
- Dependence, which can lead to serious medical complications, including withdrawal symptoms such as anxiety, insomnia, and perceptual changes 5, 7
- Delirium and other cognitive dysfunction, which can be caused by the inappropriate use of benzodiazepines in the elderly 7
- Acute respiratory failure, which can be a consequence of benzodiazepine misuse in the elderly 7
- Car accidents, which can be caused by the impairment of driving skills associated with benzodiazepine use 7
- Increased risk of dementia, which has been suggested as a potential consequence of chronic benzodiazepine use in the elderly 7
Risk Factors for Benzodiazepine-Related Side Effects
Several risk factors have been identified as increasing the likelihood of benzodiazepine-related side effects in the elderly, including:
- Polypharmacy, which can increase the risk of adverse interactions between benzodiazepines and other medications 7
- Comorbidities, which can increase the risk of adverse reactions to benzodiazepines 5, 7
- Long-term use of benzodiazepines, which can lead to dependence and increase the risk of withdrawal symptoms 5, 7
- Use of benzodiazepines with long half-lives, which can increase the risk of accumulation and adverse reactions 4, 5, 6
- Female sex, which has been identified as a risk factor for benzodiazepine use and misuse in the elderly 4, 6