Persons over the age of 65 are at the greatest risk for adverse effects from benzodiazepine drugs like Ativan (lorazepam) or Xanax (alprazolam), Klonopin (clonazepam), Valium (diazepam), Librium (chlordiazepoxide) and Tranxene (clorazepate dipotassium). Despite heightened risks, this age group remains the second highest prescribed group of benzodiazepines, with 8.9% of the elderly population prescribed them and 31% of these prescriptions considered long term.
Given the availability of options that are far less harmful, benzodiazepines should rarely be considered a first option when it comes to treating people over the age of 65. It is, at minimum, important for prescribers to provide informed consent, explaining these risks to the patients (or their caregivers) if they are not able to make the decision on their own.
Inappropriate Treatment for the Elderly
The Screening Tool of Older Person’s Prescriptions (STOPP) and Beers Criteria for Potentially Inappropriate Medication Use in Older Adults classify benzodiazepines as inappropriate treatment for the elderly. Beers warns that older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents. They also warn that they may increase the risk of cognitive impairment, delirium, falls, and motor vehicle crashes in older adults.
These benzodiazepines are preferred for patients with kidney failure and for elderly patients due to their metabolism:
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 in the Elderly
Benzodiazepines are not particularly effective long term for insomnia, but are frequently prescribed to the elderly for this reason. Long term studies of benzodiazepines for insomnia show that the beneficial effects of benzodiazepines for insomnia generally wane beyond a month and often before.
Cognitive Decline, Delirium, Alzheimer’s and Dementia in the Elderly
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 associated with statistically significant, negative effects for the cognitive domains of working memory, processing speed, divided attention, visuoconstruction, recent memory, and expressive language that may not resolve after cessation.
A team of researchers in France and Canada published findings that 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.
Findings after this study are mixed. A second study from the University of Washington with conflicting outcomes came out refuting the risk, stating that only those on moderate or lower doses developed Alzheimer’s. A more recently published meta-analysis found no association between benzodiazepines and dementia. Despite this, the analysis found that the pooled evidence shows that risk of dementia is high in patients taking benzodiazepines. More research is needed to determine if there is a clear association.
Accidents in the Elderly
Accidents in the elderly 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 the elderly.
Violent Behavior in the Elderly
The risk of suicide in persons over the age of 65 is 4xs 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 elderly. This in combination with the increased risks for drug interactions, suicide, cognitive impairment, accident and death have caused researchers to consider benzodiazepine use in elderly patients a major public health concern.
A Warning About Physical Dependence and Cessation in the Elderly
The elderly, like all benzodiazepine patients, are vulnerable to developing physical dependence in 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 potentially last longer than the patient’s lifespan patients should be informed of both the potential benefits and risks before cessation is attempted.
The elderly 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 the elderly than slowly eliminated metabolites. As diazepam (generic Valium) has active metabolites it may be risky to follow the Ashton Manual with elderly patients, as the Ashton Manual relies 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.