What is a significant concern when prescribing benzodiazepine (BZD) to an elderly patient with potential impaired renal function or other comorbidities?

From the Guidelines

Benzodiazepines should be prescribed with caution in elderly patients, particularly those with impaired renal function or other comorbidities, due to the increased risk of adverse effects, and alternative treatments or non-pharmacological approaches should be considered first. When prescribing benzodiazepines to elderly patients, it is essential to consider the potential risks and benefits, as they are more susceptible to adverse effects such as sedation, cognitive impairment, falls, and fractures 1. The increased sensitivity in older adults occurs because aging alters drug metabolism in the liver, reduces renal clearance, increases body fat, and decreases plasma proteins, leading to a higher risk of drug interactions and accumulation of active metabolites 1. Some key points to consider when prescribing benzodiazepines to elderly patients include:

• Using lower doses (typically 50% of the standard adult dose) for shorter durations when absolutely necessary
• Preferring short-acting benzodiazepines like lorazepam or oxazepam over long-acting ones like diazepam
• Tapering medications gradually when discontinuing to avoid withdrawal symptoms
• Considering non-pharmacological approaches or alternative medications with better safety profiles, such as psychological or pharmacological treatments, cognitive-behavioral therapy, or integrative strategies like prayer, massage, or music therapy 1. It is also crucial to educate patients about the risks and benefits of benzodiazepines and involve them in the decision-making process, as demonstrated by the EMPOWER trial, which showed success in tapering benzodiazepines in older adults through patient education and empowerment 1. Ultimately, the goal is to minimize the risk of adverse effects and optimize the quality of life for elderly patients, and a careful and individualized approach to prescribing benzodiazepines is necessary to achieve this goal.

From the FDA Drug Label

Metabolites of clonazepam are excreted by the kidneys; to avoid their excess accumulation, caution should be exercised in the administration of the drug to patients with impaired renal function In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy Because elderly patients are more likely to have decreased hepatic and/or renal function, care should be taken in dose selection, and it may be useful to assess hepatic and/or renal function at the time of dose selection. Metabolites of this drug are known to be substantially excreted by the kidney, and the risk of toxic reactions may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function

A significant concern when prescribing benzodiazepine (BZD) to an elderly patient with potential impaired renal function or other comorbidities is the risk of toxic reactions due to decreased renal function and metabolite accumulation.

• Key considerations include:
  • Decreased hepatic, renal, or cardiac function
  • Concomitant disease or other drug therapy
  • Potential for toxic reactions and oversedation
  • Need for cautious dose selection and monitoring of renal function 2, 2, 3

From the Research

Significant Concerns with Benzodiazepine Prescription in Elderly Patients

• Impaired renal function and other comorbidities can increase the risk of adverse reactions to benzodiazepines in elderly patients 4, 5, 6, 7, 8
• Benzodiazepines can accumulate in the body with regular administration, particularly in elderly patients with impaired renal function, leading to increased risk of falls, fractures, cognitive impairment, and other adverse effects 6, 7
• The use of benzodiazepines in elderly patients with comorbidities, such as cardiovascular or rheumatological problems, can exacerbate these conditions and increase the risk of adverse reactions 6, 7
• Elderly patients are more prone to adverse reactions to benzodiazepines, including manifestations of central nervous system depression, due to changes in pharmacodynamics and pharmacokinetics 7
• The incidence of benzodiazepine dependence and withdrawal symptoms in elderly patients is unknown, but may be underestimated due to the complexity of multimorbid patients 7, 8

Considerations for Prescribing Benzodiazepines in Elderly Patients

• It is essential to start therapy at lower doses and titrate dosages individually to minimize the risk of adverse reactions 7
• The use of benzodiazepines with a short half-life, such as lorazepam or temazepam, may be preferred in elderly patients to reduce the risk of accumulation and adverse effects 6
• Alternative therapeutic strategies, such as nonpharmacological approaches or alternative pharmacological agents, should be considered to treat anxiety and insomnia in elderly patients 5, 8
• Regular monitoring and assessment of the patient's response to benzodiazepines is crucial to minimize the risk of adverse reactions and dependence 4, 8