In the Journals

Consider risks when prescribing benzodiazepines for insomnia in elderly

Data published in Psychiatric Annals revealed that although benzodiazepines are FDA-indicated for short-term use in insomnia, long-term use in older adults should be avoided due to possible risks for serious adverse events.

Discontinuing use in patients who have been on benzodiazepines for months or years can result in withdrawal symptoms such as seizures, insomnia, nightmares and psychosis; therefore, slower tapers may be the best course of action, according to the results.

“Physiologic changes that occur with aging affect drug pharmacokinetics and pharmacodynamics,” Rashona Thomas, PharmD, BCGP, geriatric pharmacy program manager, VA North Texas Healthcare System, and Edid Ramos-Rivas, MD, geriatrics and internal medicine physician, wrote in the study. “[Benzodiazepines] are still widely prescribed and frequently used, particularly in institutionalized older populations.”

Meta-analyses of studies that compared benzodiazepines and placebo have shown benzodiazepine use resulted in significant improvement in sleep quality and a decrease in nighttime awakenings, according to the authors. Many trials of temazepam in older adults have also shown improvements in sleep onset latency, but none in total sleep time. However, evidence for these trials was insufficient or low strength, demonstrating that overall, there is not enough evidence to support long-term benzodiazepine use.

“Older adults are disproportionately affected by adverse drug effects and nearly seven times more likely to be subsequently hospitalized than younger people,” Thomas and Ramos-Rivas wrote. “Adverse effects with [benzodiazepines] can be seen at therapeutic doses but are often dose-related. Confusion, impaired psychomotor performance (including slower reaction time), and decreased ability to perform simple tasks have been noted.”

Other benzodiazepine-associated adverse effects include loss of memory — most frequently with triazolam and lorazepam — possible cognitive impairment, complex sleep-related behaviors and falls, the authors explained. However, cognitive functioning often improves once benzodiazepine use is tapered or discontinued.

Benzodiazepine use can also result in acute excitement, anxiety, hyperactivity, disinhibition, hostility, aggressive impulses, assault and rage; however, these effects are mediated by BZD dose, concurrent alcohol use and patient personality factors, according to the authors.

In addition, falls are an underrecognized, but constantly growing, health concern in the elderly population. The authors wrote that benzodiazepines raise the risk of falling by 50%, with a 1-year mortality rate thereafter of 20%.

Insomnia is not often a nightly experience, therefore routine benzodiazepine administration may not be necessary and intermittent dosing — 3 to 4 nights each week — presents an alternative to minimize the risk of abuse, according to the authors.

“Before considering a pharmacologic agent to treat insomnia, a clinician should first encourage good sleep hygiene and consider nonpharmacologic therapies,” Thomas and Ramos-Rivas wrote. “Next, a thorough review of current medications should be done to screen for potential drug-drug interactions and agents that may be contributing to insomnia. It is important to specifically ask about over-the-counter and herbal products because some patients do not consider them ‘medicines.’” – by Savannah Demko

Disclosure: The authors report no relevant financial disclosures.

Data published in Psychiatric Annals revealed that although benzodiazepines are FDA-indicated for short-term use in insomnia, long-term use in older adults should be avoided due to possible risks for serious adverse events.

Discontinuing use in patients who have been on benzodiazepines for months or years can result in withdrawal symptoms such as seizures, insomnia, nightmares and psychosis; therefore, slower tapers may be the best course of action, according to the results.

“Physiologic changes that occur with aging affect drug pharmacokinetics and pharmacodynamics,” Rashona Thomas, PharmD, BCGP, geriatric pharmacy program manager, VA North Texas Healthcare System, and Edid Ramos-Rivas, MD, geriatrics and internal medicine physician, wrote in the study. “[Benzodiazepines] are still widely prescribed and frequently used, particularly in institutionalized older populations.”

Meta-analyses of studies that compared benzodiazepines and placebo have shown benzodiazepine use resulted in significant improvement in sleep quality and a decrease in nighttime awakenings, according to the authors. Many trials of temazepam in older adults have also shown improvements in sleep onset latency, but none in total sleep time. However, evidence for these trials was insufficient or low strength, demonstrating that overall, there is not enough evidence to support long-term benzodiazepine use.

“Older adults are disproportionately affected by adverse drug effects and nearly seven times more likely to be subsequently hospitalized than younger people,” Thomas and Ramos-Rivas wrote. “Adverse effects with [benzodiazepines] can be seen at therapeutic doses but are often dose-related. Confusion, impaired psychomotor performance (including slower reaction time), and decreased ability to perform simple tasks have been noted.”

Other benzodiazepine-associated adverse effects include loss of memory — most frequently with triazolam and lorazepam — possible cognitive impairment, complex sleep-related behaviors and falls, the authors explained. However, cognitive functioning often improves once benzodiazepine use is tapered or discontinued.

Benzodiazepine use can also result in acute excitement, anxiety, hyperactivity, disinhibition, hostility, aggressive impulses, assault and rage; however, these effects are mediated by BZD dose, concurrent alcohol use and patient personality factors, according to the authors.

In addition, falls are an underrecognized, but constantly growing, health concern in the elderly population. The authors wrote that benzodiazepines raise the risk of falling by 50%, with a 1-year mortality rate thereafter of 20%.

Insomnia is not often a nightly experience, therefore routine benzodiazepine administration may not be necessary and intermittent dosing — 3 to 4 nights each week — presents an alternative to minimize the risk of abuse, according to the authors.

“Before considering a pharmacologic agent to treat insomnia, a clinician should first encourage good sleep hygiene and consider nonpharmacologic therapies,” Thomas and Ramos-Rivas wrote. “Next, a thorough review of current medications should be done to screen for potential drug-drug interactions and agents that may be contributing to insomnia. It is important to specifically ask about over-the-counter and herbal products because some patients do not consider them ‘medicines.’” – by Savannah Demko

Disclosure: The authors report no relevant financial disclosures.