Benzodiazepine Use in Older Adults: Dangers, Management, and Alternative Therapies

doi:10.1016/j.mayocp.2016.07.024

Mayo Clinic Proceedings

Volume 91, Issue 11, November 2016, Pages 1632-1639

https://doi.org/10.1016/j.mayocp.2016.07.024 Get rights and content

Abstract

Several major medical and psychiatric organizations, including the American Geriatrics Society, advise against using benzodiazepines or nonbenzodiazepine hypnotics in older adults. Despite these recommendations, benzodiazepines continue to be massively prescribed to a group with the highest risk of serious adverse effects from these medications. This article summarizes legitimate reasons for prescribing benzodiazepines in the elderly, serious associated risks of prescribing them, particularly when not indicated, barriers physicians encounter in changing their prescription patterns, and evidence-based strategies on how to discontinue benzodiazepines in older patients. Although more research is needed, we propose several alternatives for treating insomnia and anxiety in older adults in primary care settings. These include nonpharmacological approaches such as sleep restriction–sleep compression therapy and cognitive behavioral therapy for anxiety or insomnia, and as well as alternative pharmacological agents.

Section snippets

AGS Guidelines and Clinical Practice

In 2015, the AGS published the fourth update of the so-called Beers criteria. These criteria are meant to be evidence-based recommendations by the AGS to guide decision making for prescribing to elderly patients by listing medications that have an unfavorable risk to benefit ratio. The criteria should be used to support clinical judgment and not to prohibit the use of the listed medications.¹ The AGS recommendations are intended for use in all clinical settings for people older than 65 years in

Dependence

“Red flags” for an elderly patient becoming dependent on benzodiazepines are long-term use; rebound anxiety and insomnia on withdrawal of the drug; strong desire to use benzodiazepines; driving while under the influence of benzodiazepines; use of benzodiazepines despite falls; use of benzodiazepines in addition to other hypnotics; and continuing use of benzodiazepines despite physicians’ recommendations to discontinue. Although these issues are often encountered in clinical practice, the

Education

Educating patients about the potential risks of long-term benzodiazepine use is the most effective first step in tapering. A common misperception among primary care physicians is that convincing a patient to begin tapering benzodiazepines takes too much time and is unlikely to succeed.⁵ However, studies have consistently found that minimal interventions are needed to initiate a successful tapering protocol in a large proportion of elderly long-term benzodiazepine users. Simply giving patients

Insomnia

For older patients with insomnia, 2 nonpharmacological approaches—sleep restriction–sleep compression therapy and CBT—have strong evidence of efficacy.²³ Sleep restriction–sleep compression therapy focuses on restricting time in bed to actual time sleeping. The patient first keeps a 2-week log of time spent in bed and overall estimated sleeping time.²³ According to Bloom et al,²³ if a patient sleeps 5½ hours but spends 8½ hours in bed, the time in bed should first be restricted to 5½ to 6

Conclusion

Physicians prescribing benzodiazepines to their elderly patients should educate these patients about the risks of their benzodiazepine use and when advisable, offer them tapering protocols. There is increasing evidence that a substantial proportion of long-term users can discontinue benzodiazepines via interventions that require minimal investment of the physician’s time. As long as benzodiazepines are tapered gradually, their discontinuation is safe and comfortable, and many patients can

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Concise review for cliniciansBenzodiazepine Use in Older Adults: Dangers, Management, and Alternative Therapies

Abstract

Section snippets

AGS Guidelines and Clinical Practice

Dependence

Education

Insomnia

Conclusion

Mayo Clin Proc

Arch Clin Neuropsychol

Eur Neuropsychopharmacol

Mayo Clin Proc

American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults

J Am Geriatr Soc

Benzodiazepine use in the United States

JAMA Psychiatry

Psychiatric treatment in primary care patients with anxiety disorders: a comparison of care received from primary care providers and psychiatrists

Am J Psychiatry

Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis

BMJ Open

Benzodiazepine prescribing in older adults in U.S. ambulatory clinics and emergency departments (2001-10)

J Am Geriatr Soc

Psychotropic drug-induced falls in older people: a review of interventions aimed at reducing the problem

Drugs Aging

Risk of hip fracture among older people using anxiolytic and hypnotic drugs: a nationwide prospective cohort study

Eur J Clin Pharmacol

Concise review for clinicians
Benzodiazepine Use in Older Adults: Dangers, Management, and Alternative Therapies