Rational use of benzodiazepines in the elderly

In the 40 years since the introduction of benzodiazepines into clinical practice, considerable controversy has surrounded their use. While there is little evidence to suggest widespread abuse or long term use in most age groups, benzodiazepines continue to be widely prescribed to older adults in both community and long term care settings. Several studies have described an increased sensitivity to the clinical effects and toxicity of benzodiazepines in older adults. However, it is unclear whether these observations are attributable to age-related changes in benzodiazepine pharmacokinetics or pharmacodynamics. Benzodiazepines are the safest and most effective agents available for the pharmacological management of symptoms of anxiety and insomnia. However, the acute administration of benzodiazepines is associated with impairments in cognition, memory, coordination and balance, and long term use, even at therapeutic dosages, has been associated with symptoms of withdrawal upon abrupt discontinuation. Therefore, it is essential that the practitioner develop a treatment plan when utilising these agents to treat older patients. This plan may also involved the implementation of psychotherapy or other nonpharmacological modalities in the management of anxiety or insomnia. Although we recommend initiating benzodiazepines using the lowest available dosage, older patients should be treated with enough drug to produce a therapeutic response. For most clinical situations of anxiety or insomnia, we recommend prescribing limited quantities (e.g. a 2-week supply with a return visit for re-evaluation of effectiveness and adverse effects) of a drug with a short elimination half-life. Persistent anxiety or insomnia in the elderly may require a medical and possibly psychiatric evaluation. If benzodiazepines are used continuously for 6 weeks or longer, we recommend a gradual taper over 2 to 12 weeks with frequent follow-up to evaluate for signs of withdrawal or the return of symptoms.