Patients over 60 years of age have the most significant risk of harm with benzodiazepine use (particularly if the patient has additional risk factors for cognitive or psychomotor adverse events) relating to falls, fractures and cognitive decline.50,167
Benzodiazepines are used by approximately 15% of people over 65 years of age in Australia.168 Use of benzodiazepines in this age group is often chronic, despite the combination of harms associated with long-term, physiological changes with ageing (eg hepatic metabolism impairment) and the potential for multiple coexisting pathologies and drug interactions.
Older patients are more sensitive to the CNS depressant effects of psychotropic medications including benzodiazepines. This may result in confusion, night wandering, amnesia, pseudo-dementia38 (refer to 18.104.22.168 Cognitive impairment ), ataxia, falls and fractures.
In older patients, all psychotropic medications have been associated with an increased risk of fractures. The risk increase is moderate and similar across all psychotropic medications. One meta-analysis demonstrated that the relative risk of fractures was 1.34 (95% CI=1.24–1.45) for benzodiazepines, 1.60 (95% CI=1.38–1.86) for antidepressants, 1.59 (95% CI=1.27–1.98) for antipsychotics and 1.38 (95% CI=1.15–1.66) for opioids.169
Older people presenting with anxiety symptoms should be treated initially with antidepressants and psychological therapies, rather than benzodiazepines.170
Sedative use for insomnia has shown statistically significant improvements in sleep, but the magnitude of effect is small and the benefits of these drugs may not justify the increased risk.167 Clinical judgement is required.
Zolpidem and other Z drugs have become preferred drugs to manage insomnia. They are widely used among older adults because of perceived improved safety profiles compared with traditional benzodiazepines. However, accumulating data in recent years in patients over 65 years of age suggest possible safety concerns of these medications (zolpidem specifically) including effects on balance and memory and increased fracture risk. Until better studies or pharmacovigilance data become available to guide patient selection for prescribing zolpidem and other Z drugs, judicious use of these hypnotic agents in older adults is warranted.171
Reduction in the use of benzodiazepines in the elderly is a worthwhile goal if this can be achieved without psychotropic substitution. Older patients require planned interventions including CBT and stepped-dose reduction to reduce long-term benzodiazepine prescription.
Patients living in residential aged care facilities
Prescribing for patients living in residential aged care facilities (RACFs) (and other residential facilities) carries all of the risks associated with benzodiazepine use in older patients and presents further special difficulties.
Accreditation of RACFs has resulted in a heightened awareness of the facility’s responsibilities for quality use of medicines.
Medication may occasionally be required to control anxiety, agitation or other disturbed behaviours. Staff should be knowledgeable in the appropriate management of challenging behaviours. Where staff have received education in geriatric care, and where the organisational culture is supportive, there is less use of benzodiazepines.170
In a study of sleep quality in patients using benzodiazepines in RACFs, patients who were long-term users slept more poorly than those who were non-users. The effects were worse in patients taking long-acting benzodiazepines.172 Although patients, doctors, nursing staff and families often fear the consequences of benzodiazepine withdrawal in older patients, there is no evidence that patients experience an ‘unmasking’ of depression or anxiety.173
Successful reduction in the rates of benzodiazepine use in RACF patients results in benefits (eg increased mobility and alertness, reduced incontinence and improved wellbeing).174 Discontinuation of benzodiazepines can often be achieved gradually in RACFs, providing patient, family and nursing staff are cooperative.175
Benzodiazepines have been associated with increased fracture risk in patients living in RACFs. However, a reduction in benzodiazepine use may not lead to a decrease in fracture risk if substitution medications are used.176 Reduction in benzodiazepine use for RACF patients is worthwhile if it can be achieved without psychotropic drug substitution.