If you’re feeling anxious or sleeping poorly, it’s tempting to turn to pills to solve the problem. However, prescription sedative drugs known as benzodiazepines carry significant risks, particularly for older adults.
Many people in their 60s, 70s and 80s take antianxiety medications — such as Xanax, Valium and Ativan — sometimes indefinitely. Sleeping pills — such as Halcion and Restoril — meant for short-term use can turn into long-term habits.
Sedation, dizziness and weakness are among the most common benzodiazepine side effects. Depressed mood, headaches, memory problems and irritability can also occur.
Disorientation, balance problems, daytime drowsiness and increased risk of injuries — like falls — are also benzodiazepine side effects. The very problems older adults hope to avoid, such as mental confusion or hip fractures, become more likely.
Even so, physicians keep writing and refilling these prescriptions for their older patients. A new study finds that many patients take benzodiazepine drugs for months on end.
When the generic name of a drug ends with “pam” or “lam,” that indicates it’s a benzodiazepine.
Valium (diazepam), Ativan (lorazepam) and Xanax (alprazolam) are common medications for treating anxiety disorders. Klonopin (clonazepam), used to control and prevent seizures, is also prescribed for panic attacks. For sleep problems, benzodiazepines approved by the Food and Drug Administration are flurazepam (Dalmane), quazepam (Doral), temazepam (Restoril), triazolam (Halcion) and Estazolam (estazolam).
Benzodiazepines are thought to work by affecting chemicals in the brain called neurotransmitters, which communicate with nerves in the body. These drugs appear to enhance the calming effects on the nerves.
Overprescribing to Older Adults
A new review published in the September/October 2018 Harvard Review of Psychiatry looked at evidence of effectiveness and tolerability among older adults with three conditions for which benzodiazepines are commonly prescribed: insomnia, anxiety disorders and dementia symptoms.
For insomnia treatment, 21 of 25 studies showed improved sleep outcomes with use of benzodiazepines. For anxiety, the single related study found a benefit with benzodiazepines when compared to placebos. For behavioral disturbances in dementia, only one of five studies showed improvement compared to placebos.
Overall, the review found that “benzodiazepine prescribing in older adults is significantly in excess of what the available evidence suggests is appropriate,” according to research led by Dr. Lauren Gerlach, an assistant professor with the University of Michigan’s department of psychiatry.
Staying on Drugs Too Long
Taking benzodiazepines over a long period is problematic, but it’s common among older adults, according to another study, also led by Gerlach. Released in September in JAMA Internal Medicine, it focused on nearly 600 adults with an average age of 78 who were newly prescribed benzodiazepines or sedatives.
“We looked at folks who were started on medications by non-psychiatric providers and followed them over the next year.” Gerlach says. “We found nearly one in four stayed on these medications long-term. Most of these medications for older adults are really recommended for short-term, if any, use.”
Short-term use varies with the patient’s condition and symptoms, Gerlach notes. For most people, she says, you would expect roughly one to three months for these medications. However, she says, “Most of the people who were staying on these medications long-term were receiving at least eight months of medication over the following year.”
Among study participants, those who received more pills with their first benzodiazepine prescription were more likely to become extended users. “For only 10 additional days of supplied medicine, that almost doubled the patient’s risk of continuing into long-term use over the next year,” Gerlach says.
Age Amplifies Risks
Benzodiazepines carry “a host of side effects” for anyone who takes them, Gerlach says. However, risks are amplified for older adults, she says, given changes in how their bodies metabolize, or break down, medications.
Using benzodiazepines to treat people with dementia is not particularly helpful. “Despite benzodiazepines being widely prescribed to patients with behavioral disturbances in dementia, there is little evidence to show that these medications provide any benefit other than sedation,” Gerlach says.
If anything, with this class of drugs, “There’s been some evidence to show that they can worsen our thinking or cause confusion,” Gerlach says. “They may even be linked to an increased risk of developing dementia.”
Deaths involving benzodiazepines have been rising, with an eightfold increase from 2002 to 2016, according to the National Institute on Drug Abuse.
While the opioid epidemic draws the spotlight, benzodiazepines come second in terms of dependence and overdose risk. Benzodiazepines are involved in more than 30 percent of opioid-related overdoses, according to the NIDA. Because both types of drugs suppress breathing, taking them together is dangerous.
There are signs of increasing awareness. A study encompassing adults ages 65 and older in the U.S., Australia and Ontario, Canada, found significant decreases in use of benzodiazepines for U.S. and Canada between 2010 and 2016. The prevalence of usage among older U.S. adults dropped from 9.2 percent to 7.3 percent during that period, according to the study published February in the Journal of the American Geriatrics Society. However, use remains “inappropriately high,” authors noted, particularly among adults ages 85 and older.
According to the most recent Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, an authoritative set of guidelines from the American Geriatrics Society, benzodiazepines are among the medications to be avoided if possible, although they may be appropriate in some cases.
Along with memory impairment, falls, fractures and motor vehicle accidents, these drugs are responsible for a significant number of avoidable hospital admissions and emergency department visits, as noted in a May 2015 study in the Journal of Psychiatry and Neuroscience that focused primarily on the use of benzodiazepines to treat insomnia.
Many misconceptions surround sleep, says study author Dr. Cara Tannenbaum, a professor in the faculties of medicine and pharmacy at the University of Montreal. In her work as a geriatrician and consultant, sleep concerns frequently come up in discussions with older patients.
“A lot of people would like to sleep 12 hours a night,” Tannenbaum says. “But after the age of 65, your sleep architecture changes and that’s not a realistic expectation.” It doesn’t make sense to medicate patients for perfectly normal sleep patterns, she says. Sleeping only six or seven hours a night, maybe waking up once or twice during that time, is typical for many older adults.
Signs of a Problem
How can you tell if benzodiazepines (or other sedatives like Ambien) are becoming a problem for a family member? Tannenbaum points out possible clues:
— Repeating the same question twice in a short period of time
— Being off the current date by a day or two and mixing up times for appointments
— Forgetting where they parked the car, or misplacing keys, and then being unable to locate them fairly quickly
— Driving and missing the street
— Stumbling a bit while getting up from a chair
“If somebody told you that they fell, but, ‘Don’t worry; I was fine,'” that could be a sign, Tannenbaum says. “Maybe the next time they won’t be fine.”
Medication from a nighttime sleeping pill can linger in the bloodstream until noon or 1 p.m. the next day, Tannenbaum warns. The effect is much worse for women, she adds, as pills remain in the body longer for physiological reasons. Frail, older women face the highest risk of all.
Coming Off Benzodiazepines
Older adults may need help to gradually come off benzodiazepines. For everyone, safer treatments and more effective methods exist to reduce anxiety and improve sleep.
Deprescribing involves stopping or decreasing medications that aren’t helping patients and may be hurting them. “We always try to deprescribe benzodiazepines,” says Tannenbaum, who is the director of the Canadian Deprescribing Network. It’s not safe to quit these drugs abruptly, she adds: “It really has to go slowly because you could have withdrawal symptoms.”
The deprescribing process must be done with help from your doctor, nurse or pharmacist, the CDN website emphasizes. The site provides a tapering-off schedule to be followed under the supervision of a health care professional.
If you’re having serious trouble falling asleep, a form of counseling called cognitive behavioral therapy could help you get a good night’s sleep without medication. With CBT, you learn techniques such as setting a consistent bedtime and wake time, avoiding naps and using your bed for sleep and sex only. Relaxation training and biofeedback also help, as well as tweaking your sleep environment — such as keeping it quiet and cool, and avoiding bedroom clutter.
Anxiety can also be treated more safely. A combination of an antidepressant drug and cognitive behavioral therapy would be recommended as a first-line treatment before the use of a benzodiazepine medication, Gerlach says.
When it comes to benzodiazepines, Gerlach says, it’s important for health care providers to be cautious with the initial prescription. Prescribers should focus on short-term use of the medications, she says, and immediately begin the discussion with patients about when to re-evaluate their symptoms, start reducing the medications and eventually come off these drugs.
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