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Drugs such as Valium (diazepam), Xanax (alprazolam), and Ativan (lorazepam) belong to a class of compounds called benzodiazepines. These drugs are commonly prescribed to treat anxiety disorders and insomnia. Although these medications are used by adults of all ages, a recent study published in JAMA Psychiatry by Mark Olfson and colleagues demonstrates that older individuals are prescribed this class of drugs more often than middle-aged or younger adults.
Olfson’s group analyzed prescription records from a database that includes approximately 60% of US retail pharmacies. They found that over 5% of adults between the ages of 18 and 80 had filled at least 1 prescription for a benzodiazepine during 2008. In addition, they found that use of benzodiazepines increased with age: less than 3% of persons 18 to 35 years of age and about 5.5% of those 36 to 50 had been prescribed this class of drugs compared to about 7.5% of those 51 to 64 and almost 9% of people 65 and older. Moreover, the use of these drugs continued to increase even in those older than 65; i.e., a higher percentage of 75- to 80-year-olds were taking these drugs than 65- to 70-year-olds.
Olfson and colleagues also examined whether benzodiazepines were prescribed for short-term use or extended periods of time (longer than 4 months). Over 30% of 65- to 80-year-old individuals who were prescribed benzodiazepines were taking the drugs for extended periods. This was a higher percentage than seen in younger adults: fewer than 20% of people between18 and 50 years old who were prescribed benzodiazepines were taking them for extended periods of time.
Benzodiazepines can be helpful in treating anxiety. SSRI antidepressants such as fluoxetine (Prozac) also are effective in treating anxiety. These two classes of medications have different mechanisms of action involving specific brain neurotransmitters, which are related to practical differences in their use. Effects of benzodiazepines can be felt following a single dose. A person does not need to take benzodiazepines chronically in order to feel less anxious. This is in contrast to SSRI medications: the anxiety-reducing effects of the SSRIs require continuous treatment for a month or more. SSRIs are helpful in treating chronic anxiety states, but they aren’t useful on an “as needed” basis. For example, if a person has marked anxiety when flying on an airplane, taking a benzodiazepine before the flight may be quite helpful. This would not be the case when taking a single dose of an SSRI. Benzodiazepines also are used for chronic anxiety, although there are limited data about how effective they are over longer periods.
Benzodiazepines also can be beneficial in helping a person fall asleep or stay asleep when used for short periods of time. If a person is in the midst of short-term stress and is having difficulty sleeping, a brief course of a benzodiazepine may help with both the anxiety and insomnia. SSRIs are not indicated for the treatment of insomnia.
Benzodiazepines can have significant side effects. When they are used for extended periods of time, a person may have difficulty avoiding withdrawal effects upon discontinuing the drugs; in other words, this category of medications can have addictive properties. Also, these medications can lead to falls, cognitive slowing, inattentiveness, and difficulty driving. These side effects can occur in individuals of any age, but they are much more pronounced in the elderly. Older individuals are more prone to falls than younger people and are more likely to break a bone if they do fall. Cognitive dulling may be pronounced in an older person and may be additive with other age-related cognitive changes, including cognitive changes associated with dementias such as Alzheimer’s disease. In addition to these side effects, some older individuals can have a paradoxical response to benzodiazepines in that they may become more irritable.
There are reasons why a physician may feel that benzodiazepines are indicated for particular patients. There may be a need to treat acute anxiety or short-term insomnia. Anxiety disorders are common in the elderly and are potentially dangerous. Anxiety, with or without depression, should be recognized and treated. Treatment with benzodiazepines can be helpful especially if the treatment is brief and the dose carefully adjusted. The risk/benefit ratio of using these drugs should be carefully considered. An elderly person on a brief course of a benzodiazepine should be monitored closely by the health care team.
Some individuals may be treated for anxiety for extended periods of time on low doses of benzodiazepines. When attempts are made to decrease the dose, some of these individuals will experience an increase in nervousness. Both the patient and the doctor may think that the underlying anxiety has returned. However, it can be very hard to determine if such symptoms are due to a return of the original anxiety disorder or to withdrawal from the drug.
If a person has been on a benzodiazepine for an extended period of time and a decision is made to discontinue the medication, it is very important not to discontinue the medication abruptly. Doses should be reduced very gradually. It may take many months of very slow tapering to comfortably stop the medication. With this group of medications, changes in dose should be done in close consultation with one’s doctor.
The data from Olfson and colleagues’ study is eye-opening regarding the frequency of benzodiazepine use in the elderly. A related issue of major public health concern is the prevalence of anxiety and anxiety disorders among the elderly. Identifying effective and safer treatments for this problem, including non-pharmacological strategies, is imperative. Anxiety has a significantly adverse effect on quality of life for many older individuals.
This column was written by Eugene Rubin MD, PhD and Charles Zorumski MD.
