Data: Seniors prescribed benzodiazepines most often
While prescription rates for benzodiazepines have dipped a few tenths of a percentage point across all age groups in a sample of 3 million patients seeing primary care providers between 2013 and 2017, prescriptions continue to rise as patients age, peaking after the age of 65. Female patients over 65 are prescribed benzodiazepines at nearly twice the rate as male patients in the same age group.
That's in line with research published in the American Journal of Public Health, which showed that between 1996 and 2013, the percentage of adults filling a benzodiazepine prescription increased from 4.1 percent to 5.6 percent, an annual change of 2.5 percent.
Benzodiazepines, which include Ativan, Klonopin, and Xanax, are highly addictive at any age and infrequently recommended for long-term use — and the risks of extended use compound for the elderly. “We're seeing all benzodiazepines have a problem in terms of fall risk, cognitive function, psychomotor retardation, increase in car accidents," says Nicole Brandt, doctor of pharmacy and executive director of the Peter Lamy Center on Drug Therapy and Aging.
Brandt helped design the American Geriatric Society's Beers Criteria for Potentially Inappropriate Use of Medications in Older Adults. While the report recommends caution with some drugs, it labels benzodiazepines with a flat-out “Avoid." One reason: a fall that might leave a bruise on a younger person could fracture a hip in an elder, setting them on a downward spiral of loss of independence, inpatient stays, and high healthcare costs.
Once begun, benzodiazepines are difficult to stop, says Brandt, even when a patient is not yet physically dependent. With temporary relief from anxiety, depression, and insomnia, elderly patients can be fearful of life without the medication — and so deprescribing becomes challenging for both patient and the provider.
"I had one woman I cared for in a nursing home. For five years we tried to stop her benzodiazepine," says Brandt. "And we couldn't, because she was so physically and emotionally dependent on it. So we got her to the lowest effective dose. "
Brandt points providers to deprescribing.org, which offers evidence-based protocols for weaning patients off medications.
Behavioral health 101
As with opioids, however, tapering patients off benzodiazepines takes time – of which providers have very little, says Balu Gadhe, M.D. and chief of specialty services at CareMore Health. "Physicians are overwhelmed when they are expected to see a patient in the primary care setting every 15 minutes," he says. When "this patient with multiple comorbidities comes in, along with anxiety – they just don't have the time to address all these issues."
Dangling a "quick fix," benzodiazepines may seem a faster and more efficient solution than the exploration and adjustments needed for long-term behavioral health.
Managing anxiety and other behavioral health issues, however, is at the core of primary care, says Gadhe. “[At CareMore] we are training our clinicians on behavioral health 101, teaching them how to manage depression, anxiety, and other behavioral health diagnoses in conjunction with our psychiatrists." That investment in supportive resources for physicians, he says, may reduce prescription rates, hospital stays, and healthcare costs.
Gadhe also advises education for families and caretakers of elderly patients on the dangers of benzodiazepines. “If they become smart consumers, they will challenge the clinicians about medications with these known harmful effects." An informed family member may feel empowered to speak up even in a stressful environment, such as the emergency department.
And if benzodiazepines are prescribed, providers can ensure the story doesn't end there. "Ideally," says Gadhe, "you should be having a very clear-cut discussion with patients and family members on what the plan is" – and the plan should be deprescribing.