Benzodiazepines & Older People
Professor C Heather Ashton, DM, FRCP
March, 2002
School of Neurosciences
Division of Psychiatry
The Royal Victoria Infirmary
Queen Victoria Road
Newcastle upon Tyne NE1 4LP
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Older people are more sensitive than younger people to the central nervous system depressant effects of benzodiazepines, and indeed to all central nervous system depressant drugs in general.
Benzodiazepines can cause confusion, night wandering, amnesia, ataxia, hangover effects and pseudodementia in the elderly, and should be avoided wherever possible.
Increased sensitivity to benzodiazepines in older people is partly because they metabolise drugs less efficiently than younger people, so that drug effects last longer, and drug accumulation may occur with regular use.
However, even at the same blood concentration, the depressant effects of benzodiazepines are greater in the elderly, possibly because they have fewer brain cells and less cortical reserve than younger people.
For these reasons, it is generally advised that, if benzodiazepines are used in the elderly, dosage should be half that recommended for adults, and use (as for adults) should be short-term (2 weeks) only.
In addition, benzodiazepines without active metabolites (e.g. oxazepam [Serax], temazepam [Restoril]) are tolerated better than those with slowly eliminated metabolites (e.g. chlordiazepoxide [Librium], nitrazepam [Mogadon]).
Equivalent potencies (See Equivalence Table) of different benzodiazepines are approximately the same in older as in younger patients. Thus 5mg diazepam (Valium) is approximately equal to 10mg temazepam (Restoril) or 0.25mg clonazepam (Klonopin) in the elderly, just as 10mg diazepam is equivalent to 20mg temazepam or 0.5mg clonazepam in younger people (although the effects of diazepam may be more prolonged in the elderly). However, exact equivalency between different benzodiazepines is always an individual matter in both young and elderly patients, and in both cases may have to be found by clinical experience.
Older people can withdraw from benzodiazepines as successfully as younger people, even if they have taken the drugs for years. Our recent experience with an elderly population of 273 general practice patients on long-term (mean=15 years) benzodiazepines, showed that dosage reduction and total withdrawal of benzodiazepines was accompanied by better sleep, improvement in psychological and physical health and fewer visits to doctors. These findings have been repeated in several other studies of elderly patients taking benzodiazepines long-term.
There are particularly compelling reasons why older patients should withdraw from benzodiazepines since, as age advances, they become more prone to ataxia (leading to falls and fractures), confusion, memory loss and psychiatric problems (sometimes leading to a false diagnosis of dementia or Alzheimer's disease). A slow tapering regimen, in our experience, is easily tolerated, even by people in their 80s who have taken benzodiazepines for 20 or more years.
Methods of benzodiazepine withdrawal in older people are similar to those recommended for youger adults. Such methods include slow tapering of the benzodiazepine in current use, sometimes with liquid preparations if available, and also judicious stepwise substitution with diazepam (Valium), especially for those using short-acting benzodiazepines such as alprazolam (Xanax) or lorazepam (Ativan). There is, of course, a great deal of variation in the age at which individuals become "older".
Heather Ashton
March 2002
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