How to Wean Geriatric Patients Off Benzodiazepines

Yale School of Medicine

A recent study found that benzodiazepine prescriptions and overdose mortality involving benzodiazepines increased considerably in the United States over the last two decades [1]. Between 1996 and 2013, the percentage of adults filling a benzodiazepine prescription increased from 4.1 percent to 5.6 percent. At the same time, the rate of overdose deaths involving benzodiazepines increased from 0.58 to 3.07 per 100,000 adults. Given this alarming statistic, it is prudent that we regulate the prescription of these drugs and minimize their adverse effects.

Despite growing evidence that benzodiazepines use can lead to adverse outcomes in elderly patients [2-5], current data indicate that approximately 8.5 percent to 45 percent of elderly patients are still prescribed these medications [6-7].

In October 2015, the American Geriatrics Society (AGS) published an updated version of the Beers Criteria, which lists benzodiazepines as a potentially inappropriate medication that should be avoided in older adults [8]. One reason the group recommends that clinicians avoid prescribing benzodiazepines to older adults is because evidence suggests that benzodiazepines may increase the risk of cognitive impairment including dementia in older adults—though some studies dispute this association [9-12].

In a systematic review, Billiotti de Gage and colleagues assessed data from 10 studies that evaluated the association between benzodiazepine use and dementia [13]. The investigators included six case-control and four cohort studies of fairly good quality in their review.

Eight of the 10 studies included in this review showed an increased risk of dementia in benzodiazepine users by a factor of 1.24 to 2.30. The investigators found that the risk appears unlikely for short duration of use (less than three months). A dose-effect relationship was found by several studies, with one study concluding that there was a stronger effect for medications or metabolites with a long half-life. In another study, the excess risk disappeared after one-year discontinuation in light users (less than 90 defined daily doses) but remained unchanged after a three-year discontinuation in heavy users (360 or more defined daily doses).

The investigators concluded that although a causality of dementia cannot be established among older individuals using benzodiazepines, there is a statistically increased risk for dementia among long-term users of these medications.

One way to decrease the use of benzodiazepines in older adults is to educate them about possible adverse effects of taking the medications [14]. One study found that short conversations between a patient and clinician regarding the discontinuation of benzodiazepines can lead to a reduction in the use of these drugs by almost 50 percent at the end of one year [15].

Multiple protocols also exist for tapering benzodiazepines in older adults [16]. Reducing the drug by 25 percent every one to two weeks until the individual is drug free is a safe and accepted method of tapering the drugs. For those individuals who have difficulties with tapering the medication, supportive measures including cognitive-behavioral therapy (CBT) and taper with medication substitution may improve outcomes.

For those individuals who develop dementias, careful monitoring of their medication regimen is important [17]. Medications that worsen cognition should be minimized or avoided.

Acetylcholinesterase inhibitors (donepezil, galantamine, and rivastigmine) are approved by the U.S. Food and Drug Administration (FDA) for the treatment of dementia due to Alzheimer’s disease [18]. Memantine is indicated for individuals with moderate to severe dementia due to Alzheimer’s disease [19]. Although these medications are approved for use in individuals with dementia due to Alzheimer’s disease, available data indicate that they don’t enhance cognition or modify the disease process [18, 19].

For Lewy body dementia, the use of acetylcholinesterase inhibitors particularly rivastigmine and donepezil are recommended [20]. Memantine may also benefit individuals with Lewy body dementia. Drugs with substantial anticholinergic properties should be avoided given the risk for cognitive decline and delirium.

Although there are no FDA-approved medications for the treatment of frontotemporal dementia, available data indicate that SSRIs, trazodone, and amphetamines may reduce behavioral symptoms in these individuals [21]. However, none of these medications has been shown to have an impact on cognition.

There are no FDA-approved treatments for vascular dementia, but identifying and managing comorbidities and ensuring that vascular risk factors are optimally managed have been shown to improve the quality of life of these individuals [22].

In conclusion, available evidence indicates that benzodiazepines can be safely tapered off and discontinued in the elderly. Effective discontinuation strategies include patient education, a gradual taper schedule, use of CBT for support, and medication substitution. For those individuals who develop dementia, avoidance of medications that worsen cognition and the use of FDA-approved medications like acetylcholinesterase inhibitors and memantine may help. ■