Benzodiazepine Use Among Seniors
Benzodiazepines are a commonly prescribed drug, especially for older adults. The drug is often used as a therapy for anxiety or sleep problems. It can also be used a muscle relaxant, and to help people who are withdrawing from alcohol use. (1) These drugs, which are intended for short term use, can be relatively effective and safe when prescribed and taken in an appropriate manner. However, some older adults are prescribed the drug for much longer than therapeutically recommended, and at levels that may be unsafe for them. In some cases, older adults have been prescribed benzodiazepines for anxiety symptoms, but the underlyin reason that they are feeling this way is because they are depressed.
The use of high daily doses of benzodiazepines by seniors, in particular, is associated with increased risk of hip fractures, motor vehicle accidents, accidental falls, accidental poisonings, hospitalization for depression and other psychiatric problems, as well as attempted and completed suicides. (2)
Adverse Effects of Benzodiazepines in Older Adults
Benzodiazepines work on the central nervous system (brain and spinal cord, and the spinal cord in turn conducts messages from the brain to skeletal muscles, heart and smooth muscles).
Older people are more sensitive than younger people to the central nervous system depressant effects of benzodiazepines. Benzodiazepines can cause confusion, night wandering, amnesia, loss of balance, hangover effects and "pseudodementia" (sometimes wrongly attributed to Alzheimer’s disease) in older adults.
As people grow older, they become more sensitive to the effects of benzodiazepines in older people is partly because their bodies metabolize drugs less efficiently than younger people: the drug effects last longer and the drug readily accumulates in the body with regular use.
For these reasons, it is generally advised that, if benzodiazepines are used by older adults, the physician should only prescribe half the dose recommended for younger adults, and the drug's use should be short-term (2 weeks) only. (1)
Some benzodiazepines (those without active metabolites (e.g. oxazepam [Serax], temazepam [Restoril])) are tolerated better by older adults than those with slowly eliminated metabolites (e.g. chlordiazepoxide [Librium], nitrazepam [Mogadon]). (1)
Even at lower doses, benzodiazepines can cause problems for some seniors.
Benzodiazepines are commonly divided into two types: short acting and long acting.
How Common Is Benzodiapine Use Among Seniors in Canada.
The figures vary according to region, type of study, and whether we are looking at seniors' living in community or institutional settings. A 2002 New Brunswick survey found that 9.4% of the seniors reporting they were prescribed medication for anxiety. (3) A smaller study conducted on the North Shore in British Columbia in the mid 1990s found that one quarter of seniors aged 75 and over were prescribed benzodiazepines.(4) Similarly, in Nova Scotia in 1995/96, approximately 25% of seniors were prescribed a benzodiazepine during the year. (6)
An Ontario study looked at over one million residents of Ontario aged 65 and older who were covered by the provincial universal drug benefit program. (5)
Who is Prescribed Benzodiazepines?
In general, older women tend to be prescribed benzodiazepines more often than older men. When the researchers in the Ontario study looked at
the overall prevalence of older adults being prescribed benzodiazepines, and
whether there were any differences in prevalence with respect to age and gender
they also found the older the person, the more likely the person was being prescribed a benzodiazepine. (5)
The rate ranged from approximately 20% of those aged 65 to 69 to approximately 30% of those age 85. Older women were more likely to receive benzodiazepines than older men (relative risk = 1.50).
It has been suggested that some seniors are being prescribed benzodiazepines at unsafe levels. A 2001 Quebec study found that in a one year period, 7.9% of the seniors on benzodiazepines were receiving high daily doses. This was more common for younger seniors and those who had reported anxiety during the previous year. Patients without cognitive impairment were more likely to receive high dose prescriptions from general practitioners, while people with cognitive impairment were more likely to receive high dose prescriptions from specialists. (2)
Are Physicians Changing Their Prescribing Practices?
The Ontario researchers were interested any changes in prescribing practices of Ontario physicians in dispensing benzodiazepines to older people during the study period of 1993 to 1998. (6) They also looked at the annual rates of physicians switching older people to other psychotropic agents when they discontinued filling benzodiazepine prescriptions.
They found annual prevalence of benzodiazepine prescriptions dispensed was decreasing consistently over time (25.1% in 1993 to 22.5% in 1998), and that the ratio of short- to long-acting benzodiazepine prescriptions being filled increased over time (3.6 in 1993 to 5.8 in 1998), in line with guideline recommendations.
They found that some physicians switched from benzodiazepines to antidepressants and this trend among physicians increased over time (8.5% in 1993 to 10.2% in 1998). Very few switched their patients to barbiturates.
[SSRIs antidepressants came out in the 1980s and these can be prescribed for depression and anxiety]
Withdrawal from Benzodiazepines
If a person has been on benzodiazepines an extended period of time (over six months), the drug may be doing more harm than good. Some people have been taking benzodiazepines prescribed by their doctors for many years, sometimes over 20 years. The long term use of the drug can cause a number of physical and mental symptoms, including depression and/or anxiety; "irritable bowel", cardiac or neurological problems.(1)
A person who has been on benzodiazepines a long time should never stop "cold turkey". [Professionals, see Alcohol and Substance Use Withdrawal ] Instead it is better to discuss with their doctor how to slowly and very gradually reduce the amount of the drug they are taking. Depending on the type, amount of daily dose, and how long they have been taking the drug, this process may take several months.
If older adults who are long time users stop the use of the benzodiazepine too quickly, they may experience severe post-withdrawal anxiety ("rebound anxiety"). Slowing tapering (reducing) the amount of the drug helps avoid this problem. Some benzodiazepine users may never be able to completely stop all use of the prescription drug. However, most are able to reduce the use to a level where it helps and does not interfere with their daily functioning. [Professionals, see Alcohol and Substance Use Withdrawal ]
All of these anti-anxiety medications are benzodiazepines, except buspirone.
buspirone (BuSpar )
chlordiazepoxide (Librax, Libritabs, Librium)
clorazepate (Azene, Tranxene)
There are major differences in potency between different benzodiazepines, so that equivalent doses vary as much as 20-fold. For example, 0.5 milligrams (mg) of alprazolam (Xanax) is approximately equivalent to 10mg of diazepam (Valium). (1)
Why Are Older Adults Prescribed These Drugs So Often?
There are many likely reasons. In some cases the drugs are prescribed in response to acute stress such as after the loss of a spouse. (Older women are more likely to become widowed than older men).
Many older adults have difficulty with sleep and the drugs are used for people with insomnia. In some cases, physicians may find it easier simply to prescribe a medication instead of looking at the underlying reasons for the distress the older person is feeling and helping the person find ways of addressing the problem. Or, alternatively, some older persons come to expect a prescription from their doctor.
It has been suggested that in institutional settings (nursing homes), the drugs are sometimes prescribed to "keep cognitively impaired residents quiet or passive", particularly where the staff levels are not adequate or staff have not had proper training in positive ways of addressing difficult behaviours. (7, 8) These psychoactive drugs can adversely interact with other medications the older person requires.
In many cases in the community and institutional setting, there may be other ways of addressing the underlying problem without the use of benzodiazepines or other drug alternatives. (9)
(1) Ashton, M. (August, 2002). Benzodiazepines: How They Work and How to Withdraw. Online: www.benzo.org.uk/
(2) Egan, M. Y., Wolfson, C. Moride, Y. & Monette, J. (2001). High daily doses of benzodiazepines among Quebec seniors: prevalence and correlates. BMC Geriatrics, 1:4. Online at : www.biomedcentral.com/1471-2318/1/4
(3) 2002 Seniors Survey – Prevalence of Substance Use and Gambling Among New Brunswick Adults Aged 55+. Online at: www.gnb.ca/0378/pdf/SeniorsFinalReport2002ENG.pdf
(4) Barbone, F., McMahon A.D., Davey, P.G., Morris, A.D., Reid, I.C., McDevitt, D.G., & MacDonald, T.M. (1998) Association of road-traffic accidents with benzodiazepine use. Lancet, 352(9137), 1331-6.
(5) As mentioned in Tu, K. Mamdani, M., Hux, J. & Tu, J. (October, 2001). Progressive Trends in the Prevalence of Benzodiazepine Prescribing in Older People in Ontario, Canada. Journal of the American Geriatric Society, 49 (10), 1341-1345.
(6) Rojas- Fernandez, C.H., Carver, D. & Tonks, R. (Autumn, 1999). Population trends in the prevalence of benzodiazepine use in the older population of Nova Scotia: A cause for concern? Canadian Journal of Clinical Pharmacology, 6 (3):149-56.
(7) Office of Inspector General, Department of Health and Human Services. Prescription Drug Use in Nursing Homes.
(8) University of Massachusetts Medical School (August 9, 2000) Adverse Drug Events in Nursing Homes: Common and Preventable. Online at: www.umassmed.edu/pap/news/2000/08-09-00.cfm
(9) Office of the Inspector General. (November, 2001). Psychotropic Drug Use in Nursing Homes Supplemental Information - 10 Case Studies
Resources and Links
Benzodiazepine, Addiction, Withdrawal and Recovery. Online at : www.benzo.org.uk/
Alcohol and Substance Use Withdrawal
Page last updated Sunday October 31, 2004
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