What is the safety comparison between Lorazepam (Ativan) and Temazepam (Restoril) in an 83-year-old patient with potential impaired renal function?

From the Guidelines

For an 83-year-old patient, lorazepam is not recommended due to its higher potency and slower clearance, making temazepam a safer alternative. When considering the safety of lorazepam vs temazepam in an elderly patient, it's crucial to prioritize the potential risks associated with benzodiazepine use, such as respiratory depression, systemic hypotension, and increased sensitivity to sedative effects 1.

Key Considerations

• Elderly patients are significantly more sensitive to the sedative effects of benzodiazepines, with lorazepam being more potent than other options 1.
• The elimination half-life and duration of clinical effect of lorazepam are increased in patients with renal failure, which is a common comorbidity in the elderly population 1.
• Benzodiazepine clearance decreases with age, leading to a higher risk of accumulation and prolonged sedation 1.

Recommendations

• Temazepam (7.5-15mg at bedtime) is preferred for elderly patients needing short-term insomnia treatment due to its shorter half-life and lower risk of daytime sedation and falls.
• Lorazepam (0.25-0.5mg) should be used cautiously if needed for anxiety, and only when the benefits outweigh the risks.
• Both medications should be used at the lowest effective dose for the shortest duration possible, typically not exceeding 2-4 weeks.
• Non-pharmacological approaches, such as sleep hygiene practices, cognitive behavioral therapy for insomnia, and addressing underlying conditions like pain or depression, should be tried first.
• Regular medication reviews are essential, and any benzodiazepine should be tapered gradually when discontinuing to prevent withdrawal symptoms.

From the FDA Drug Label

Geriatric Use Clinical studies of lorazepam generally were not adequate to determine whether subjects aged 65 and over respond differently than younger subjects; however, the incidence of sedation and unsteadiness was observed to increase with age In general, dose selection for an elderly patient should be cautious, and lower doses may be sufficient in these patients Geriatric Use Clinical studies of Temazepam did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy commonly observed in this population.

Safety Comparison:

• Both lorazepam and temazepam require cautious dose selection in elderly patients due to increased sensitivity and potential for adverse effects such as sedation, unsteadiness, and falls.
• Lorazepam's incidence of sedation and unsteadiness increases with age, while temazepam's risk of oversedation, dizziness, confusion, ataxia, and/or falls increases substantially with larger doses in elderly and debilitated patients.
• There is no direct comparison of the safety of lorazepam and temazepam in elderly patients, but both drugs require careful consideration of the patient's overall health and potential for adverse effects. 2 3

From the Research

Safety of Lorazepam vs Temazepam in an 83-year-old

• The safety of lorazepam and temazepam in elderly patients is a concern due to altered pharmacokinetics 4.
• Benzodiazepines with a relatively short half-life, such as temazepam and lorazepam, are considered better hypnotics for the elderly than those with a long half-life 4.
• Lorazepam is also considered an appropriate anxiolytic for elderly patients 4.
• There is no direct comparison of the safety of lorazepam and temazepam in the provided studies, but the studies suggest that both medications can be used in elderly patients with caution.
• The choice between lorazepam and temazepam should be based on the individual patient's needs and medical history.

Considerations for Elderly Patients

• Elderly patients are more susceptible to the adverse effects of psychotropic medications, including benzodiazepines 4.
• The use of benzodiazepines in elderly patients should be carefully monitored, and the dosage should be adjusted accordingly 4.
• Alternative treatments, such as cognitive behavioral therapy, may be considered for elderly patients with insomnia or anxiety 5, 6, 7, 8.