Individuals aged 65 and older face the highest risk of experiencing harmful effects from benzodiazepine drugs such as Ativan (lorazepam), Xanax (alprazolam), Klonopin (clonazepam), Valium (diazepam), Librium (chlordiazepoxide), and Tranxene (clorazepate dipotassium). Despite this elevated risk, this age group ranks as the second-highest in benzodiazepine prescriptions, with 8.9% of seniors receiving these medications, and 31% of these prescriptions being long-term.
Considering the availability of less harmful alternatives, benzodiazepines should seldom be the primary choice for treating individuals aged 65 and above. Prescribers should, at the very least, ensure informed consent, elucidating these risks to patients or their caregivers in cases where the patients are unable to make decisions independently.
Inappropriate Treatment for Older Adults
The Screening Tool of Older Person’s Prescriptions (STOPP) and Beers Criteria for Potentially Inappropriate Medication Use in Older Adults say that benzodiazepines are not a good choice for treating older people. Beers mentions that older adults are more sensitive to benzodiazepines, and their bodies don’t break down long-acting ones as quickly. They also say that using these drugs might raise the chances of older adults having problems like trouble thinking, confusion, falling, and accidents while driving.
Different metabolism
These benzodiazepines are preferred for patients with kidney failure and for older adult patients due to their metabolism:
Lorazepam
Oxazepam
Temazepam
This can be easily remembered with the acronym LOT. As these are short half-life benzodiazepines, they are even more challenging to taper due to interdose withdrawal should physical dependence develop.
Insomnia Treatment
Benzodiazepines aren’t very effective for long-term treatment of insomnia, but they’re often given to older people for this purpose. Studies on using benzodiazepines for insomnia over a long time reveal that their helpful effects usually decrease after about a month and sometimes even sooner.
Cognitive Decline, Delirium, Alzheimer’s and Dementia in Older Adults
The greater harm to those over the age of 65 who are otherwise living independently is also related to the increased risks to impaired cognition. Benzodiazepines are linked to noticeable negative effects on cognitive abilities like memory, thinking speed, attention, drawing things, recent memory, and talking, which might not get better even after stopping the medication.
A team of researchers in France and Canada published findings that people over the age of 65 who take benzodiazepines longer than 2-4 weeks may have an increased risk for Alzheimer’s disease. Taking the drug for three to six months raised the risk of developing Alzheimer’s by 32%, and taking it for more than six months boosted the risk by 84%. In the study, the greater people’s cumulative dose of benzodiazepines, the higher their risk. Another recent meta-analysis found benzodiazepines significantly increases the risk of dementia in the older adult population. The risk is higher in patients taking benzodiazepines with a longer half-life (>20 hours) and for a longer duration (>3 years).
A University of Washington study contradicts earlier results. According to this study, only those on moderate or lower doses developed Alzheimer’s. Another found the risk of dementia is slightly higher in people with minimal exposure to benzodiazepines but not with the highest level of exposure. However, despite this, the overall evidence suggests a higher risk of dementia in patients taking benzodiazepines. A 2023 umbrella review found that all meta-analyses found significant relationships between benzodiazepine use and dementia risk, but the strength of the evidence was weak due to the low methodological quality of the included studies.
A cross-sectional 2024 study found that the consumption of benzodiazepines may be associated with possible dementia, as well as increased drowsiness and functional dependence compared to non-users. Additionally, a direct relationship was found between the equivalent dose of benzodiazepines and the potential onset of dementia. Another 2024 study found that benzodiazepine use is not associated with dementia, but prolonged benzodiazepine use is “significantly associated with lower total brain volume.”
Accidents in Older Adults
Accidents in older adults are also a concern to consider before prescribing or taking a benzodiazepine. The usage increases the likelihood of a hip fracture from a fall by 50%-80%. Hip fractures are associated with significant morbidity, mortality, loss of independence, and financial burden. Car accidents are also a concern, with the use of benzodiazepines increasing car accidents in older adults.
A new study, led by Dr. David Carr of the Department of Medicine at Washington University, has discovered that there is an increased risk of participants failing the road test when they take sedatives, antidepressants, serotonin and norepinephrine reuptake inhibitors, or non-steroidal anti-inflammatory drugs. The study focused on participants over the age of 65 who possessed a valid driver’s license and had a Clinical Dementia Rating Score of 0. It revealed that out of 198 adults, 70 (35%) received a marginal or failing rating on the road test.
Violent Behavior in Older Adults
The risk of suicide in persons over the age of 65 is 4x greater for those on benzodiazepines. Benzodiazepines had the highest impact of suicidality, beating SSRIs, antipsychotics, and other medicines with an FDA suicide risk black box warning.
Benzodiazepines can also trigger aggressive behavior, especially in the older adult population. This in combination with the increased risks for drug interactions, suicide, cognitive impairment, accident, and death has caused researchers to consider benzodiazepine use in older patients a major public health concern.
A Warning About Physical Dependence and Cessation in the older adult population
Older adults, like all benzodiazepine patients, are vulnerable to developing physical dependence (not addiction) through long-term prescriptions. Long-term use is considered daily use lasting more than 2 to 4 weeks. Physical dependence, according to the FDA, is a state that develops as a result of physiological adaptation in response to repeated drug use, manifested by withdrawal signs and symptoms after abrupt discontinuation or a significant dose reduction of a drug.
While physical dependence can be mitigated for some patients with slow, patient-led tapering, this is not true for all patients. According to the late Heather Ashton, leading benzodiazepine expert and author of the Ashton Manual, benzodiazepine cessation was associated with better sleep, improvement in physical and psychological health, and fewer doctor visits. On the other hand, for some patients, cessation is extremely risky. At a safe reduction rate of 5-10% of the current dose per month or less, cessation can take many months to years to complete. Many patients find even slow, lengthy taper intolerable and many even report that after cessation their body doesn’t recover from the taper, leaving them in a long-term state of benzodiazepine cessation. This results in disability, living with constant symptoms, pain, and, for some, leaving them completely bedridden. When this protracted state occurs, it can take many years to resolve. Because of the risk of cessation and withdrawal effects that could last longer than the patient’s lifespan, patients should be informed of the potential benefits and risks before cessation is attempted.
Older adults metabolize benzodiazepines less efficiently, and they may be unable to tolerate longer half-life medications. Ashton states that benzodiazepines without active metabolites are tolerated better in older adults than slowly eliminated metabolites. As diazepam (generic Valium) has active metabolites, it may be risky to follow the Ashton Manual with older patients, as the Ashton Manual relies upon diazepam conversion to taper. Patients already on a benzodiazepine without metabolites may be better off with a dry microtaper as described in our Benzodiazepine Tapering Strategies and Solutions and The Maudsley Deprescribing Guidelines.
For More Information
Benzodiazepine Tapering Strategies and Solutions
Elderly Former NASA Analysts Protracted Lorazepam Injury
The New York Times: A Quiet Drug Problem Among the Elderly