Most major medical associations, including the American Geriatric Society (AGS), caution against the prescribing of benzodiazepines and nonbenzodiazepines in the elderly. And yet, this age group consumes these drugs at a higher rate than any other.
The numbers are staggering. Over four million senior citizens in the U.S. alone were prescribed a benzodiazepine over the course of a single year. And 25% of all elderly who start taking a benzodiazepine — even if prescribed for short-term only — become dependent.
Those are the numbers. Now, let’s look at the toll these drugs can take. There are five primary areas where complications — sometimes unique to the elderly population — arise when taking benzodiazepines.
1) Motor Vehicle Accidents
One of the most difficult struggles for a person as they age is the loss of freedom. For many, this happens when they lose the ability to drive. While some of the deterioration in skills and response time is normal with aging, there may be other factors at play, and evaluating those factors can be complicated.
One of the difficulties in measuring the effect of anti-anxiety drugs in the elderly may be due to the difference in effects between short and long half-life benzodiazepines. Many studies have not taken that variable into consideration.
A study published in the Journal of the American Medical Association (JAMA) back in 1997 did consider that factor in a cohort of 224,734 drivers in the Canadian province of Quebec. It found that drivers between the ages of 67 and 84 years-of-age who were on continuous use of a long half-life benzodiazepine showed a 26% increase in crash involvement. In the first week of use, crash involvement increased to 45%. For short half-life benzodiazepines, the news was much better. The study found no such elevated risk for these types of benzos.
2) Accidents and Falls
Psychiatric drug use causes thousands of trips to emergency each year. From 2009 through 2011, there were 89,094 U.S. visits to the emergency department (ED) caused by an adverse drug event (ADE) to psychiatric medication. This was based on a study published in JAMA Psychiatry in 2014. The number of these visits which was related to sedatives and anxiolytics (anxiety medication) was 30,707, or 34.4%.
…benzodiazepine use is associated with a statistically and clinically significant increase in risk of falls and fractures. — “BENZODIAZEPINE USE IN OLDER ADULTS: DANGERS, MANAGEMENT, AND ALTERNATIVE THERAPIES,” MAYO CLINIC PROCEEDINGS, 2016
According to a 2016 study in Mayo Clinic Proceedings, “Observational studies consistently report that benzodiazepine use is associated with a statistically and clinically significant increase in risk of falls and fractures.” The study states that the risk of fractures is dose-dependent and that, “exposure to benzodiazepines increases the risk of falling by 50%.”
This risk is strongly tied to hip fractures. Risk of hip fracture is greatest in the first two weeks after a person starts taking the drugs and when increasing dosage. This type of injury can lead to major life changes for the patient, including death. One-third of patients with a hip fracture die within a year.
3) Dementia and Cognitive Dysfunction
Several studies over the years have linked long-term benzo use to dementia and cognitive dysfunction. Unfortunately, these results have alarmed an already anxiety-prone audience — chronic benzodiazepine users.
In a 2002 study in the Journal of Clinical Psychopharmacology, the lead author, Sabrina Paterniti, stated, “Chronic users of benzodiazepines had a significantly higher risk of cognitive decline in the global cognitive test and the two attention tests than nonusers.” Paterniti also said that “episodic and recurrent users had lower cognitive scores than nonusers, but differences were not statistically significant.”
Side effects during benzo use can be a significant hurdle to functioning for this age group. A 2012 study published in Drugs & Aging stated, “In studies of short-, intermediate- and long-acting benzodiazepine drugs…these drugs consistently induced both amnestic and non-amnestic cognitive impairments, with evidence of a dose-response relationship.”
…these drugs consistently induced both amnestic and non-amnestic cognitive impairments… — “A SYSTEMATIC REVIEW OF AMNESTIC AND NON-AMNESTIC MILD COGNITIVE IMPAIRMENT INDUCED BY ANTICHOLINERGIC, ANTIHISTAMINE, GABAERGIC AND OPIOID DRUGS,” DRUGS AND AGING, 2012
Increased risk of dementia and Alzheimer’s disease in later life is another serious concern for all patients, regardless of age. According to a 2014 study published in the British Medical Journal, there was no associated increase in risk of developing Alzheimer’s disease for those who had taken the drugs less than 91 days. Unfortunately, the numbers for longer-term users was less favorable. Those who had taken the drugs for 91-180 days showed a 32% increase of risk — 180 days or longer, an 84% increase.
Caution needs to be used when analyzing such studies which may not indicate a causal correlation. Still, the author of this study said the following, “The stronger association observed for long term exposures reinforces the suspicion of a possible direct association, even if benzodiazepine use might also be an early marker of a condition associated with an increased risk of dementia.”
4) Dependence and Withdrawal
Dependence on a drug can be a concern for any age group. When a patient becomes dependent on a prescription drug, tolerance often follows, requiring dosage increases to maintain the same benefit. Considering the dangers of benzo use in the elderly, withdrawal is often a favorable option.
A slow, tapered withdrawal can be a very effective alternative for older adults. In fact, some studies have shown that withdrawal in the elderly is no more difficult than in younger populations. Unfortunately, many doctors are still resistant to believe the damages caused by these drugs.
Mark Olfson, M.D., led the study, “Benzodiazepine Use in the United States,” published in JAMA Psychiatry in 2015. In that study, he concluded, “Although many primary care physicians are aware of practice guidelines that caution against long-term benzodiazepine use in the elderly population, few believe that this practice poses a serious clinical threat and many physicians feel unprepared to address the issue with their patients.”
…an effective intervention involves gradual supervised benzodiazepine withdrawal combined with psychotherapy focused on coping with dependency symptoms and underlying psychiatric symptoms. — “BENZODIAZEPINE USE IN THE UNITED STATES,” JAMA PSYCHIATRY, 2015
In the study, Olfson also stated, “For withdrawing older individuals from benzodiazepines, an effective intervention involves gradual supervised benzodiazepine withdrawal combined with psychotherapy focused on coping with dependency symptoms and underlying psychiatric symptoms.”
Olfson also cautions doctors of the legal liability risk tied with prescribing benzodiazepines. A factor which may affect a physician’s prescribing practices.
Unfortunately, older patients who take benzos regularly, don’t live as long.
According to research in France and the U.K. published in European Neuropsychopharmacology, the following conclusion was reached: “Using two nationally representative databases, we found a significant while moderate increase in all-cause mortality in relation to benzodiazepines…” The study identified a 1.2 to 3.7 times higher rate of mortality, regardless of cause, in patients who had been exposed to benzodiazepines.
What Can Be Done?
Educating the doctor is first and foremost. Far too many doctors are still uneducated — or resistant to being educated — on the addictive potential of these drugs and the toll they take on elderly patients each and every day. And that risk extends beyond the patient themselves, with increased risk from motor vehicle accidents. We need to educate doctors. And we need doctors who have been reluctant to hear our message, to listen.
Direct-to-consumer education effectively elicits shared decision making around the overuse of medications that increase the risk of harm in older adults. — “REDUCTION OF INAPPROPRIATE BENZODIAZEPINE PRESCRIPTIONS AMONG OLDER ADULTS THROUGH DIRECT PATIENT EDUCATION: THE EMPOWER CLUSTER RANDOMIZED TRIAL,” JAMA INTERNAL MEDICINE, 2014
Educating the patient is another step in the right direction. A study in JAMA Internal Med from 2014 stated, “Direct-to-consumer education effectively elicits shared decision making around the overuse of medications that increase the risk of harm in older adults.”
Much like benzodiazepine use in the rest of the population, slow withdrawal from benzodiazepine use in the elderly appears to provide many benefits to the patients. No patient should be forced to withdraw from benzos, but with proper patient education and educated medical support, withdrawal may be the best choice and can reap many benefits.
The real trick is getting the message to the patient— and even more so — to their doctors.
American Geriatrics Society (AGS). “American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.” Beers Criteria Update Expert Panel (2015). Accessed April 9, 2018. http://www.sigot.org/allegato_docs/1057_Beers-Criteria.pdf.
Billioti de Gage, Sophie, Yola Moride, Thierry Ducruet, Tobias Kurth, Hélène Verdoux, Marie Tournier, Antoine Pariente and Bernard Bégaud. “Benzodiazepine Use and Risk of Alzheimer’s Disease: Case-Control Study.” BMJ 349(g5205)(2014). Accessed January 30, 2017. doi:10.1136/bmj.g5205.
Foster, D E Benzo Free: The World of Anti-Anxiety Drugs and the Reality of Withdrawal. Erie, Colorado: Denim Mountain Press, 2018. https://easinganxiety.com/book.
Hampton, Lee M., Matthew Daubresse, Hsien-Yen Chang, G. Caleb Alexander, and Daniel S. Budnitz. “Emergency Department Visits by Adults for Psychiatric Medication Adverse Events.” JAMA Psychiatry 71(9)(September 2014):1006-14. Accessed April 25, 2019. doi:10.1001/jamapsychiatry.2014.436.
Hemmelgarn, Brenda, Samy Suissa, and Allen Huang. “Benzodiazepine Use and the Risk of Motor Vehicle Crash in the Elderly.” JAMA 278(1)(1997):27-31. Accessed April 26, 2019. doi:10.1001/jama.1997.03550010041037.
Markota, Matej, Teresa A. Rummans, John M. Bostwick, and Maria I. Lapid. “Benzodiazepine Use in Older Adults: Dangers, Management, and Alternative Therapies.” Mayo Clinic Proceedings 91(11)(November 2016):1632-9. Accessed April 25, 2019. doi:10.1016/j.mayocp.2016.07.024.
Maust, Donovan T., Helen C. Kales, Ilse R. Wiechers, Frederic C. Blow, Mark Olfson. “No End in Sight: Benzodiazepine Use in Older Adults in the United States.” Journal of the American Geriatrics Society 64(12)(December 2016):2546-53. Accessed February 17, 2017. doi:10.1111/jgs.14379.
Olfson, M., M. King and M. Schoenbaum. “Benzodiazepine Use in the United States.” JAMA Psychiatry 72(2)(February 2015):136-42. Accessed March 7, 2017. doi:10.1001/jamapsychiatry.2014.1763.
Palmaro, A., J. Dupouy, and M. Lapeyre-Mestre. “Benzodiazepines and risk of death: Results from two large cohort studies in France and UK.” European Neuropsychopharmacology 25(10)(October 2015):1566-77. Accessed April 27, 2019. doi:10.1016/j.euroneuro.2015.07.006
Paterniti, Sabrina, Carole Dufouil, and Annick Alperovitch. “Long-Term Benzodiazepine Use and Cognitive Decline in the Elderly: The Epidemiology of Vascular Aging Study.” Journal of Clinical Psychopharmacology 22(3)(June 2002):285-93. Accessed April 26, 2019. https://journals.lww.com/psychopharmacology/Abstract/2002/06000/Long_Term_Benzodiazepine_Use_and_Cognitive_Decline.9.aspx
Tannenbaum, Cara. “Inappropriate benzodiazepine use in elderly patients and its reduction.” Journal of Psychiatry & Neuroscience 40(3)(May 2015):E27-8. Accessed April 26, 2019. doi:10.1503/jpn.140355.
Tannenbaum, C., A. Paguette, S. Hilmer, J. Holroyd-Leduc, and R. Carnahan. “A systematic review of amnestic and non-amnestic mild cognitive impairment induced by anticholinergic, antihistamine, GABAergic and opioid drugs.” Drugs & Aging 29(8)(August 1, 2012):639-58. Accessed on April 27, 2019. doi: 10.2165/11633250-000000000-00000.
Tannenbaum, C., P. Martin, R. Tamblyn, A. Benedetti, S. Ahmed. “Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial.” JAMA Internal Med 4(6)(June 2014):890-8. Accessed April 27, 2019. doi:10.1001/jamainternmed.2014.949.