Benzodiazepines can effectively treat anxiety, agitation, insomnia, and alcohol withdrawal, but their use in older adults has been linked to higher adverse event rates. These drugs can also become habit-forming, making it difficult to discontinue them after years of use. “Benzodiazepines are effective drugs for many ailments, but they may not be the best option for older adults,” says Erin M. Marra, MD. Recent studies of older adults show that these agents can increase risks for falls, hip fractures, memory problems, delirium, daytime drowsiness, and motor vehicle crashes when compared with younger people.
Despite these safety concerns, benzodiazepines are still commonly prescribed in older adults. Some studies estimate that 10% to 25% of people aged 65 and older are using benzodiazepines. Several guidelines, such as the Beers criteria and the Screening Tool of Older Persons’ Prescriptions criteria, have been issued to reduce prescribing of these drugs to older adults. Few studies, however, have examined benzodiazepine prescribing trends in in ambulatory clinics and EDs in the United States.
For a retrospective study published in the Journal of the American Geriatrics Society, Dr. Marra and colleagues assessed data on ambulatory clinics and EDs from 2001 to 2010 using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. The investigators analyzed encounters involving people aged 65 and older for whom a benzodiazepine might be prescribed and explored trends in benzodiazepine use in these visits. They hypothesized that benzodiazepine prescribing rates would be lower in both ambulatory clinics and EDs in light of recent guideline recommendations.
According to the results, benzodiazepines were used in 16.6 million of 133.3 million ambulatory clinic visits and 1.9 million of 18.1 million ED visits with the selected reasons for the visits from 2001 to 2010. “We observed no significant changes in benzodiazepine use in either setting over the study period,” Dr. Marra says. “In fact, use of these drugs increased in patients aged 85 and older in both ambulatory clinics and EDs.” The study also revealed that patients with anxiety who visited ambulatory clinics were five times more likely to receive benzodiazepines than other individuals. Anxious patients who visited EDs were twice as likely to receive benzodiazepines as others.
“These data are important because older adults are more susceptible to the negative consequences of benzodiazepines,” says Dr. Marra. “We must keep in mind that physiological changes are magnified with advancing age.” Although the overall rate was relatively low in these settings, the lack of prescription rate changes seen in the study suggests that recent initiatives to reduce prescribing of benzodiazepines in older adults should be reassessed.
Clinicians at ambulatory clinics and EDs have other first-line treatment options to treat many of the conditions for which benzodiazepines are used in older adults. “Other treatments have fewer side-effect profiles than benzodiazepines,” Dr. Marra says. “Our findings should be seen as a call to action to inform and educate physicians about the most appropriate use of these benzodiazepines and about other options that are available for older patients.”
Dr. Marra notes that the American College of Emergency Physicians, the Choosing Wisely campaign, and other respected groups are making efforts to address the problem by targeting educational programs to clinicians. “We need to better inform healthcare providers in all fields of medicine on the appropriate prescribing of benzodiazepines and alternative therapies,” she says.
Readings & Resources (click to view)
Marra EM, Mazer-Amirshahi M, Brooks G, van den Anker J, May L, Pines JM. Benzodiazepine prescribing in older adults in U.S. ambulatory clinics and emergency departments (2001-10). J Am Geriatr Soc. 2015;63:2074-2081. Available at: http://onlinelibrary.wiley.com/doi/10.1111/jgs.13666/abstract.
Fick D, Semla T, Belzer J et al. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60:616-631.
Kaur S, Mitchell G, Vitetta L et al. Interventions that can reduce inappropriate prescribing in the elderly: A systematic review. Drugs Aging. 2009;26:1013-1028.