How do you counsel an older patient about the risks of benzodiazepines?  

Mr. Davis is a 75-year-old man with a history of hypertension, type 2 diabetes (A1c 6.8), and insomnia. He recently moved to be closer to his grandchildren and is establishing primary care with you. His medications are amlodipine 10 mg daily, metformin 500 mg twice daily, semaglutide 1 mg weekly, atorvastatin 40 mg daily, and temazepam 30 mg at bedtime. He has been on this regimen for at least 15 years (except the semaglutide – that one is new and effective!). Mr. Davis has been exploring his new neighborhood on foot and unfortunately fell on the sidewalk and broke his wrist 3 days ago. 

Mr. Davis wants to continue to be active and available for his son and grandchildren. He asks you if there is anything he can do to reduce his risk for falling in the future. Considering his lifestyle, medical history, support structures, and current medications, you decide to focus on his insomnia and temazepam usage.

Mr. Davis was prescribed temazepam by his PCP 15 years ago, when he first had difficulty falling asleep. His PCP quickly increased the dosage to 30 mg at night, which has been effective in helping him fall and stay asleep. He has never felt the need to increase the dose of the medication or use more than prescribed. He has occasionally felt groggy the next morning, but otherwise has not experienced negative side effects of the medication. 

Benzodiazepine use is ~3x more common in older adults than younger adults. Of the older adults treated with benzodiazepines, 1/3 have been prescribed benzodiazepines long term, with less than 10% receiving prescriptions from a psychiatrist (Olfson, 2015).

What are the actual risks of benzodiazepines? Benzodiazepines are associated with increased falls and fractures in the elderly. A 2009 meta-analysis on 9 different drug classes, found a Bayesian adjusted odds ratio of 1.41 of falls in elderly persons for benzodiazepines, which was higher than the adjusted OR estimates for diuretics, antipsychotics, and antidepressants (Woolcott, 2009). Studies looking at large databases of administrative and healthcare utilization also demonstrate an association between benzodiazepines and increased incidence of fracture (Bolton 2008, Wang 2001, Wagner 2004). While Wagner et al. controlled for many variables, confounding bias by factors not measured in Medicare claims data may account for some of the risks observed in these research studies (Schneewiess, 2005). Yet, even after correcting for bias due to these previously unavailable factors, the relative risk of hip fracture among elderly patients on benzodiazepines remains elevated (changing from 1.46 to 1.38) (Schneewiess, 2005).

Benzodiazepines have also been associated with reduced cognitive functioning and impaired driving skills in patients who are actively taking benzodiazepines. A series of studies looked at the changes in cognition before and after an adult takes a benzodiazepine, using detailed neuropsychological testing. In a 2012 systematic review of these randomized, double-blind, placebo-controlled trials, the benzodiazepines consistently produced cognitive impairments, with a dose-response relationship (Tannenbaum, 2012). Data on 2105 elderly respondents in the Longitudinal Aging Study Amsterdam demonstrated a small negative effect of benzodiazepine use on cognitive performance as well (Bierman, 2007). 

An association between benzodiazepine use and dementia has been explored through multiple case-control and cohort studies. A 2018 meta-analysis and systematic review found that the studies supporting this relationship were of low quality (Lucchetta, 2018), though two more recent international meta-analyses support an association between benzodiazepine use and dementia, despite high heterogeneity between the studies included (Ferreira 2022, He 2019).

The newly updated 2023 American Geriatric Society’s Beers Criteria makes a strong recommendation to avoid benzodiazepines, based on moderate quality of evidence (AGS, 2023). 

You summarize the research for Mr. Davis – temazepam 30mg at night is a benzodiazepine that may help people fall asleep and stay asleep. Unfortunately, benzodiazepines are associated with multiple negative outcomes in older adults, most strongly – falling, fractures, and cognitive problems. For a patient like Mr. Davis, who has insomnia treated with benzodiazepines, there are alternative treatments that have fewer side effects and may even be more effective long term. You recommend tapering temazepam, with the long-term goal of stopping this medication. For patients who are motivated and have their withdrawal carefully managed with adequate psychological support available, the success rate of stopping benzodiazepines is 70-80% (Ashton, 2005). People who are unable to stop benzodiazepines completely but reduce their dose also reduce their risk of adverse effects like falling.  

Before outlining the taper plan, you address Mr. Davis’s worries. It makes sense that people are worried about medication changes. You ask Mr. Davis, “Is there something in particular that you are worried about? Have you ever tried to stop or reduce the medication before? What happened?” 

Mr. Davis has never tried to stop the medication. He almost never misses a dose; when he does, he struggles to fall asleep. While Mr. Davis is interested in tapering the medication given his recent fall and fracture, he is worried about worsening insomnia.

You acknowledge the challenges of this change and recommend starting CBT-I as an alternative treatment for insomnia while you taper temazepam (see recent PsychSnaps on insomnia treatment options and benefits of CBT-I). You also tell Mr. Davis that you are going to taper the temazepam slowly to try to avoid both benzodiazepine withdrawal syndrome and rebound insomnia. You explain that temazepam is one of many medications in the benzodiazepine class. When our brains are exposed to benzodiazepines over a long period of time, some parts of our brains change and get used to having the medication present. If the medication is then stopped suddenly, people can experience symptoms of benzodiazepine withdrawal.  Benzodiazepine withdrawal most commonly includes anxiety, irritability, and trouble sleeping, but can also include tremors, changes in blood pressure and heart rate, and seizures. Some people may experience rebound insomnia after stopping a benzodiazepine – insomnia that is worse than the initial insomnia disorder. By gradually reducing the dosage of the benzodiazepine in a series of small steps over months, we give the brain a chance to gradually reverse the prior neuroadaption that occurred and minimize the risk of withdrawal symptoms or rebound insomnia.

Look for Part 2 of this PsychSnap on November 3 focused on the mechanics of tapering benzodiazepines.


Key Points

1) Long term benzodiazepine use by elderly patients is common.
2) Benzodiazepines are associated with falls, fractures, impaired cognitive functioning, and dementia; the American Geriatric Society strongly recommends avoiding their use in the elderly.
3) Patients who are motivated to stop benzodiazepines and are supported in tapering them are successful 70-80% of the time. 


References:
2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J American Geriatrics Society. 2023;71(7):2052-2081. doi:10.1111/jgs.18372

Ashton, Heather. The diagnosis and management of benzodiazepine dependence. Current Opinion in Psychiatry 18(3):p 249-255, May 2005. | DOI: 10.1097/01.yco.0000165594.60434.84

Bierman EJ, Comijs HC, Gundy CM, Sonnenberg C, Jonker C, Beekman AT. The effect of chronic benzodiazepine use on cognitive functioning in older persons: good, bad or indifferent? Int J Geriatr Psychiatry. 2007;22(12):1194-1200.

Bolton JM, Metge C,Lix L, Prior H, Sareen J, Leslie WD. Fracture risk from psychotropic medications: a population-based analysis. J Clin Psychopharmacol. 2008;28(4):384-391.

Ferreira P, Ferreira AR, Barreto B, Fernandes L. Is there a link between the use of benzodiazepines and related drugs and dementia? A systematic review of reviews. Eur Geriatr Med. 2022 Feb;13(1):19-32. doi: 10.1007/s41999-021-00553-w. Epub 2021 Aug 17.

He Q, Chen X, Wu T, Li L, Fei X. Risk of Dementia in Long-Term Benzodiazepine Users: Evidence from a Meta-Analysis of Observational Studies. J Clin Neurol. 2019;15(1):9. doi:10.3988/jcn.2019.15.1.9

Lucchetta RC, Da Mata BPM, Mastroianni PDC. Association between Development of Dementia and Use of Benzodiazepines: A Systematic Review and Meta‐Analysis. Pharmacotherapy. 2018;38(10):1010-1020. doi:10.1002/phar.2170

Olfson M, King M, Schoenbaum M. Benzodiazepine Use in the United States. JAMA Psychiatry. 2015;72(2):136. doi:10.1001/jamapsychiatry.2014.1763

Schneeweiss S, Wang PS. Claims data studies of sedative-hypnotics and hip fractures in older people: exploring residual confounding using survey information. J Am Geriatr Soc. 2005; 53:948– 54.

Tannenbaum C, Paquette A, Hilmer S, Holroyd-Leduc J, Carnahan R. A systematic review of amnestic and non-amnestic mild cognitive impairment induced by anticholinergic, antihistamine, GABAergic and opioid drugs. Drugs Aging. 2012; 29:639–58.

Wagner AK, Zhang F, Soumerai SB, et al. Benzodiazepine use and hip fractures in the elderly: who is at greatest risk? Arch Intern Med. 2004;164 (14):1567-1572.

Wang PS, Bohn RL, Glynn RJ, Mogun H, Avorn J. Hazardous benzodiazepine regimens in the elderly: effects of half-life, dosage, and duration on risk of hip fracture. Am J Psychiatry. 2001;158(6): 892-898.

Woolcott JC, Richardson KJ, Wiens MO, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med. 2009; 169(21):1952-1960.