Deprescribing Benzodiazepines in Elderly Patients - #73
Take Quiz(A) The incidence of benzodiazepine use reaches 8.7 % in those patients 65 to 80 years old (1). Benzodiazepines are included in the Beers’ List of Potentially Inappropriate Medications in Elderly Patients, as older adults are more sensitive to their effects and side effects (e.g., delirium, neurocognitive impairment, daytime sedation, functional impairment, falls with injury including fractures, motor vehicle accidents) ultimately leading to increased morbidity and mortality.
(B) Drugs in this class include: alprazolam, diazepam, lorazepam, temazepam, and oxazepam.
- Benzodiazepines can act synergistically with opiates on receptor organs (e.g., including depressed respirations through the pulmonary system).
- Tapering and discontinuing benzodiazepines in older adults should be thoughtfully considered and attempted when at all possible.
(C) Why is the patient taking a benzodiazepine?
(e.g.,anxiety, past psychiatrist consult, started in hospital for sleep, for grief)
1. If for sleeping disorders (e.g. restless legs), unmanaged anxiety, depression, or a physical or mental condition that may be causing/aggravating insomnia, or alcohol withdrawal
- Continue benzodiazepine
- Minimize use of drugs that worsen insomnia (caffeine, alcohol)
- Treat underlying condition
- Consider psychology, psychiatry or sleep specialist consultation
2. If for insomnia on its own or insomnia with managed underlying comorbidities
- Engage patients (see GFF #68 Deprescribing Medications in Elderly Patients), discussing potential risks, benefits, withdrawal plan, symptoms and duration
- Recommend deprescribing
(D) If deprescribing is recommended:
1. Offer behavioral sleeping advice; consider cognitive behavioral therapy if available
2. Taper and then stop the benzodiazepine
- Decrease dose by 25% every two weeks, and if possible, 12.5% reductions near the end of the taper prior to discontinuation
3. Monitor every 1-2 weeks for duration of tapering
- Expected benefits: May improve alertness, cognition, daytime sedation and reduce falls
- Withdrawal symptoms: Insomnia, anxiety, irritability, sweating, GI symptoms (all usually mild and last for days to a few weeks)
4. If symptoms relapse:
- Consider: Maintaining current benzodiazepine dose for 1-2 weeks, then continue to taper at a slower rate
- Alternate drugs: Other medications have been used to manage insomnia and could be considered for appropriateness (see GFF #40, Treating Insomnia)
Geriatric patients in clinic and long-term care outpatient settings.
Elderly patients taking benzodiazepines presenting to a clinic or long term care setting.
Benzodiazepines are common anxiolytic and sedative medications whose primary pharmacologic properties and side effects carry increased risk in older patients.
5.2% of 18 to 80 year old adults in the US use benzodiazepines, with the prevalence increasing with age. By the age range of 65 to 80 years, the incidence reaches 8.7 %.(1).
- Identify unnecessary or inappropriate benzodiazepine medication use in elderly patients.
- Describe a strategy to partner with patients and develop options for decreasing and possibly deprescribing benzodiazepines.
- Olfson M, King M Schoenbaum M. Benzodiazepine use in the United States. JAMA Psychiatry. 2015 Feb; 72(2):1)36-42.
- Campanelli, C. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medications Use in Older Adults: The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. JAGS 2012: Apr 60(4); 616-631.
- Pottie K, Thompson W, Davies S, Grenier J, Sadowski C, Welch V, Holbrook A, Boyd C, Swenson JR, Ma A, Farrell B (2016). Evidence-based clinical practice guideline for deprescribing benzodiazepine receptor agonists. Unpublished manuscript deprescribing.org Benzodiazepine & Z-Drug (BZRA) Deprescribing Notes.