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Benzodiazepine use in older adults has been a highlighted topic of discussion ever since benzodiazepines made an appearance on the Beers Criteria list as potentially inappropriate medications (PIMs). Concern for older adults who take benzodiazepines is substantiated by the potential increased risk of adverse events (eg, falls, fractures, cognitive impairment, and sedation).1,2 Though the levels of benzodiazepine use have decreased over the years, their continued use in older adults is a likely indication of their usefulness in the older adult population.3,4 A study was conducted by Egger et al to determine whether geriatric physicians might prescribe fewer PIMs for their patients than general medical physicians based on the assumption that geriatric physicians are more likely to be aware of the risks involved with prescribing PIMs to older adults. The results showed no difference in the number of PIMs prescribed by geriatric physicians and general physicians.5 These results suggest that providers find that the benefits of benzodiazepines outweigh the risks in many of their patients, despite the number of warnings in the media against benzodiazepine use in older adults.
The risks and warnings that persistently appear in the media can be categorized as true risks or ambiguous risks. True risks would include established benzodiazepine-related adverse events that are associated with increased dose and duration of exposure (eg, sedation, falls, and fractures).1,2,5 Some studies show, though, that exposure to short-acting benzodiazepines is not associated with lower risk of adverse events compared to exposure to long-acting benzodiazepines in the older adult patient population.6,7 Benzodiazepine dependency, which can be physiological and/or psychological, however, has been shown to be associated more with continuous administration of long-acting benzodiazepines than with intermittent administration.8
Ambiguous risks refer to adverse events reported to be associated with benzodiazepine exposure, yet cannot be easily separated from confounding factors, including a disease or condition. Recently, a case-control study published in the British Medical Journal raised concerns about the increased risk of Alzheimer’s disease in older adult patients exposed to benzodiazepines.9 Such a warning could be an example of an ambiguous risk. Alzheimer’s disease is difficult to diagnose, and early symptoms (prodromal symptoms) may include anxiety, agitation, and insomnia.9 Without an established diagnosis of Alzheimer’s disease, older adults who complain of anxiety, agitation, and/or insomnia may be prescribed a benzodiazepine. Thus, a study that finds a positive association between use of benzodiazepines and Alzheimer’s disease is more than likely when there is temporal ambiguity (ie, did benzodiazepine use cause Alzheimer’s disease or did the onset of Alzheimer’s cause a need for benzodiazepine use prior to diagnosis).
Certainly, clinicians are taught to use sound professional judgment in caring for all patients, and they are trusted to be aware of the benefits and risks associated with benzodiazepine use in older adults. Thus, providers who decide to prescribe a benzodiazepine to an older adult may have determined that a benzodiazepine is the most reasonable drug therapy option available at that point in a patient’s care. Benzodiazepine therapy is commonly used in older adults to treat anxiety and insomnia, but there are other valid medical conditions in older adults that may warrant benzodiazepine therapy, including seizure, alcohol or central nervous system depressant withdrawal, periprocedural anesthesia, palliative care, and agitation.2,8 Despite due diligence from prescribers, issues of duplication and/or inappropriate medication therapy are bound to occur when patients have multiple prescribers and multiple pharmacies. Older adult patients deemed eligible for benzodiazepine therapy should be regularly monitored by pharmacists for frequency of use, inappropriate use, and need for continued use. Physicians have been shown to place great value in the vital role of pharmacists in reviewing patients’ medications and alerting physicians of medication issues.10
It is unlikely that reports about the dangers of benzodiazepine use in older adults will diminish. Providers should be encouraged to continue using professional clinical judgment that weighs all true risks and benefits; reassess the use of benzodiazepines every 6 months based on indication, drug use pattern, and side-effect profile; prescribe the lowest therapeutic dose with the least frequent dosing schedule tolerated; and educate patients/caregivers of the risks of adverse events.8,11 Pharmacists should also continue to educate patients and providers on the true risks of benzodiazepine use, evaluate the various ambiguous risk claims made in literature and media, and monitor medications for duplicate and/or inappropriate therapy.