Despite many clinical guidelines and studies warning of the risks associated with benzodiazepines, agents such as lorazepam (Ativan®) and alprazolam (Xanax®), remain commonly-prescribed drugs for older adults. With uses ranging from anxiety to insomnia to behavioral disorders, benzodiazepines (BZDs) find their way onto many medication lists and put patients in harm’s way. It is important to recognize the risks that BZDs pose to older adults and find alternative methods of treatment whenever possible.
BZDs are particularly risky in older adults for a few fundamental reasons. First, like numerous other medications, sensitivity to BZDs is increased in older adults. Second, as liver and kidney function declines, so does the ability to metabolize and excrete BZDs, especially long-acting agents (e.g., diazepam). The inability to clear BZDs can lead to a longer duration of action or accumulation of drug in the body. Finally, the side effect profile of BZDs mirrors some physiological effects of aging. Namely, BZDs increase the risk of cognitive impairment, gait instability, and psychomotor impairment. Put simply, giving a benzodiazepine to an individual who is already at a high risk of falling means walking the tightrope between treating a condition and risking serious injury.
Insomnia is a common reason BZDs are prescribed, particularly among older adults who often suffer from difficulty sleeping. While the sedative properties of BZDs are useful for falling asleep, problems can arise if users don’t stay asleep. Waking up feeling excessively groggy can lead to confusion and impaired coordination, which add up to a high risk of falling in older adults. For sleep aids, trazodone* or melatonin* are likely to be safer options than BZDs. However, the safest and most effective treatments for insomnia are non-pharmacologic practices such as avoiding use of electronics before bedtime and only using the bed for sleep (not reading or watching TV). Consider addressing these potential “sleep hygiene” issues before turning to sedatives for insomnia.
Anxiety is another issue that BZDs are prescribed to treat, again via the blunt instrument of sedation. This is problematic for older adults because it means BZDs will be taken during daytime when we are most active and risk of falling is high. BZD use has been associated with increased risk of falls and fractures, which can lead to chronic pain, loss of independence, and even death. Anxiety is a significant challenge for many people and should be treated whenever possible. However, there are numerous non-sedating options that are likely to be safer for older adults, such as selective serotonin reuptake inhibitors (SSRIs), as well as non-pharmacologic measures such as cognitive behavioral therapy and avoiding stressors.
Finally, BZDs are frequently used to treat neuropsychiatric symptoms that arise in some patients with Alzheimer’s dementia (AD). BZDs are even riskier for this population, as their use has been associated with higher risk of hip fracture, pneumonia, and stroke in AD patients compared to older adults without AD. A recent study from Finland found that BZD use in community-dwelling persons with AD was associated with a significantly higher chance of death within 6 months. Non-pharmacologic measures are first-line therapy for behavioral and psychiatric symptoms of dementia (BPSD) and should be attempted prior to reaching for potentially harmful pharmacologic options.
Benzodiazepines have well-established risks but are still frequently prescribed to older adults. This is not to say that benzodiazepines are always inappropriate, but they should be used only when necessary and ideally after other options have been evaluated. When BZDs are used, it should be at the lowest effective dose and frequency, as well as for the shortest possible duration. Furthermore, the concomitant use of other sedating drugs like opioids and gabapentin adds to the patient’s fall risk and should be limited while the patient is taking BZDs. As with any sedating medication, it is always important to monitor how a benzodiazepine affects the patient while taking every measure possible to prevent falls and keep our older adults upright.
*Always get evaluated by your doctor before trying any new medication for sleep or any other condition*