Benzos in the elderly

Armin Moradi

2021-11-12

Hi there!
Becky
The Past
Med Trail
Med Trail 2.0
Benzo
Benzo - short
Benzo - intermediate
Benzo - long
Benzo in the elderly
Why?
It's bad
Really bad
Going back
Discussion
Thank you

Hi there!

Benzos in elderly

Becky

The Past

Family Physician
Depression
Venlafaxine

Med Trail

Venlafaxine
Fluoxetine
Paroxetine
Bupropion
Sertraline

Med Trail 2.0

Alprazolam 0.5 bid
Then tid

Somewhere along the way, she was started on Alprazolam 0.5mg bid. She has reportedly been on it for more than a year, so we can presume the anxiety symptoms have been present for at least that long and gotten unmanageable by then.

Around the time her sertraline was being titrated and was at 75mg, she presented to hospital with worsening anxiety. She was discharged home with reduction in sertraline to 50 and increasing alprazolam to 0.5 tid.

Note that I'm intentionally presenting the case vaguely. I don't intend to focus on this case as an isolated event and so I'm doing a lot of hand-wavy descriptions of what happened with loose timelines. My intention to consider this scenario as something that can generalized to a fair number of cases we see regarding how benzos are used, and be alert to when and how we can intervene.

With that said, that's pretty much the end of the case presentation. Let's discuss the key points and a bit of background that helps us better analyze this scenario.

Benzo

short
medium
long

Benzo - short

Midaz and Triaz

Benzo - intermediate

LOAT
TALO
OTLA

Benzo - long

Everything else

Benzo in the elderly

Avoid

What about the elderly specifically. This lady is 75 years old, does that make a difference in terms of how we go about her management?

We'll refer to AGS's Beers Criteria which is intended for people 65+ and not in palliative or hospice situation. On page 7 of the 2019 publication, Beers criteria states Avoid use of benzos with strong recommendation with moderate quality of evidence. It mentions increased risk of cognitive impairment, delirium, falls, fractures, and MVAs. The recommendation applies to short and intermediate acting benzos. There are two situations that Beers criteria strongly recommends to avoid benzos with "high" quality evidence: history of falls or 2 or more drugs acting on CNS.

Beers criteria also notes continued use of benzos in elderly despite evidence of harms.

So why are they bad?

Why?

increased sensitivity
decreased metabolism

It's bad

dependence
falls and fractures
cognitive decline

Long-term use is a red flag for dependence. There is also rebound anxiety, insomnia, strong desire to use benzos, use despite falls, in addition to other hypnotics, and use despite physician's recommendation. These are all things that needs to be considered as tingling spidey senses when a patient is on benzos as cues for dependence.

Falls happens through a number of mechanisms, including increased reaction time, disrupted balance and gait, and sedation. The risk of falls is dose-dependent as all the factors I mentioned are also dose-dependent. In some studies it has been estimated that risk of fall increases by 50%. They are also strongly associated with hip fractures, which then relates to studies demonstrating that 1/3 of patients with hip fractures die within one year. Most importantly, decreasing the dose appears to reduce the risk of falls.

Benzodiazepine use has also been associated with short-term cognitive deficits including memory, learning, attention, and visuospatial ability. Interestingly, in two studies, one RCT and a meta-analysis, it has been shown that in long-term users cognitive deficits remain and can potentially be irreversible. Although they didn't make any definitive conclusions and there was a lot of vague-ness in their conclusion. But it's something to keep in mind.