Best-practice use of benzodiazepines

Benzodiazepines have limited use and should be used with caution in older people, writes Natalie Soulsby.

A key focus area for the royal commission is the use of medications including their role in being prescribed as a chemical restraint.

Benzodiazepines, such as example temazepam (Temaze) or diazepam (Valium) which are  commonly used for treating insomnia or anxiety, can be placed in this category as we see them prescribed to aged care residents with dementia to treat aggression or agitation.

Benzodiazepines have a limited role in treating older people and they should only be used short term and reviewed regularly. This is because tolerance to the sedating effects of this group of medicines can occur within two weeks of regular use.

Despite their limited role, last financial year over 7 million prescriptions were dispensed for benzodiazepines. It is estimated that more than 15 per cent of Australians over 65 years are currently or have at some point in their life since reaching this age been prescribed a benzodiazepine.

Like all medications, if used as recommended, they can be effective. Since their role is limited they should only be used in the following circumstances and only after the necessary steps have been taken to ensure all other non-pharmacological interventions have been tried and documented.

Insomnia

It’s important to identify and manage possible underlying causes of insomnia such as pain, hunger, toileting needs, reflux or dyspnoea.

Non-pharmacological therapies should be considered in the first instance, for example offering residents a warm milk drink and a carbohydrate snack at bedtime and avoiding caffeine-based drinks after 4pm. Maximising daytime exercise and sunlight exposure may also assist. Many patients find paracetamol at bedtime can help with settling.

Alternative options to consider include:

• the use of relaxation techniques
• sleep hygiene, such as ensuring a similar routine is followed before going to sleep each evening, the room is at the correct temperature and the bed and bedding are comfortable
• avoiding day time napsr Healthcare Australia
• stimulus control
• cognitive therapy.

If a benzodiazepine is considered, ensure the patient is aware of potential risks and benefits, including tolerance with long term use and risk of dependence.

Anxiety

Cognitive behavioural therapy and self-help strategies should be first line for mild to moderate anxiety. Short term benzodiazepine use can be considered if:

• the resident is not able to participate in psychological therapy
• the resident is unwilling to trial non-pharmacological therapies
• a trial of psychological therapy has not been effective
• an antidepressant has been started and still awaiting benefit

Agitation in dementia

Benzodiazepines have a limited role in providing symptom relief for moderate to severe agitation in advanced dementia. If used for agitation, therapy should be reviewed at least every two weeks as risk of morbidity and adverse effects is higher in older people.

Side effects include:

• confusion
• increased risk of falls
• sedation
• memory impairment
• respiratory depression.

There is also an increased risk of pneumonia when benzodiazepines are co-prescribed with opioids.

This combination should be avoided where possible because the interaction between these two groups of medications can lead to an increase in concentration of the opioids and their metabolites, increasing the risk of respiratory depression.

It is important to start with a low dose to reduce the risk of side effects and use a short acting agent like oxazepam, lorazepam or temazepam. Using benzodiazepines for more than four weeks can lead to dependency and tolerance. To cease benzodiazepines, it is best to gradually reduce the dose.

Reducing the dose of benzodiazepine is likely to improve memory, alertness and quality of life and reduce risk of falls, fractures and accidents and injuries.

Natalie Soulsby is a clinical pharmacist, specialist in geriatric medicine and head of clinical development at Ward Medication Management. She won the AACP 2017 Consultant Pharmacist of the Year and the 2016 South Australian Pharmacist of the Year awards.

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