Last week, we discussed how benzodiazepines effect families and how they came into use. So let’s do a quick review on benzodiazepines, how use continues to be high among older adults and why women are prescribed more of these drugs than men. We will then delve into this week's topic, the other effects of benzodiazepines on our seniors.
A recent Athena Health report continues to show that those over the age of 65 are prescribed benzodiazepines more than any other age group. Ten percent of women over the age of 65 are prescribed one of these drugs compared to just six percent of men, nearly twice the rate.
Why the disparity?
According to Dr. Robert Roca, the chair of the American Psychiatric Association's Council of Geriatric Psychiatry, “women are more likely to express distress” while men tend to hold their feelings. The problem with this, as we discussed before, men tend to use alcohol to deal with anxiety, which is a problem to be discussed in the future.
So now let’s look at the dangers of combining these drugs with other medications. When it comes to overdose risk, the combination of benzodiazepines and opioids are indeed the most dangerous, a concern that prompted a Black Box warning by the Food and Drug Administration regarding the use of these two classes of medications together.
A 2017 study shows that the combination of opioids with benzodiazepines is especially risky in the first 90 days of concurrent use. These include the following benzodiazepines - alprazolam (Xanax), diazepam (Valium), and clonazepam (Klonopin), which are most frequently prescribed to seniors in order to alleviate anxiety.
The study examined data from more than 71,000 Medicare Part D beneficiaries to find out how simultaneous use of opioids and benzos influence overdose risk over time. Patients were divided based on whether they had only taken opioids prior to overdose or had a supply of both opioids and a benzo drug. For those in the group with a supply of both, the researchers subdivided by the cumulative number of days the patients had taken an opioid with a benzo.
The analysis showed that overdose risk was five times higher for patients taking both drugs during the first 90 days compared to those only taking just an opioid. Risk was doubled for those taking both drugs during the next 90 days. After 180 days, risk of overdose was roughly the same as taking only opioids. There are a number of reasons for given for this, including the patient's understanding of the side-effects and when to report them as well as how the patient takes them. In any case, it is important to know that based on this study, if an overdose is to occur, it will be in the first three to six months, something care takers should be aware of.
But opioids are not the only drug when taken together with benzodiazepines that can cause serious side-effects. Let's look at three classes of medication that need to be monitored.
Known as “Z-drugs” and prescribed to help battle insomnia, many medical
providers are unaware that they have a similar mechanism of action as benzodiazepines. These drugs include Ambien , Lunesta and Sonata. When these medications are used in combination with benzodiazpines, they can cause blackout spells. In another 2017 study of emergency room visits for adverse events involving benzodiazepines or “Z-drugs”, it found a 4-fold increase risk for serious events when the two medications were combined.
Known as proton pump inhibitors (PPIs) used to treat acid reflux, medications such as Prilosec,
Nexium, Prevacid and Protonix have been shown to increase the blood levels of benzodiazepines by interfering with the way the liver clears them from the body. As a result, the side effects of benzodiazepines are magnified causing increased confusion, sedation, dizziness, falls and driving mishaps. The most common PPIs that associated with these side effects are Priolsec and Nexium.
Fluoroquinolones are antibiotics that are commonly used to treat a variety of
illnesses such as respiratory and urinary tract infections. These medications include Cipro, Levaquin and Avelox. Since they compete for the same binding site as benzos, the antibiotics actually block the benzos leading to acute withdrawal symptoms in those who have been taking them long term. Benzo withdrawal can be life threatening resulting in seizures, high fevers and psychosis.
At the end of this blog is a printable announcement from the FDA regarding their issuance of the Black Box Warning for benzodiazepines and the medications that can cause serious or even deadly side effects when used together. These include cough medications containing opioids, muscle relaxers, anti-psychotics and tranquilizers.
Please watch this video from the Mayo Clinic discussing the dangers of benzodiazepine use in older adults.
Here are some other issues associated with benzodiazepine use.
In the majority of studies, benzodiazepines have been shown to block a persons ability to learn new information. Research seems to indicate that this results from the brains inability to transfer short term memory to long term memory. Elderly patients are more sensitive than younger ones to the effects of benzodiazepines and memory problems. As a result, family and friend may be willing to chalk this up to aging issues or even the onset of dementia rather than looking at benzodiazepines as the cause.
Cognitive and Psychomotor Effects
Both short term and long term use of benzodiazepines have been shown to have an effect on cognitive and psychomotor functioning. These include sedation, drowsiness, coordination issues, vertigo and dizziness.
Benzodiazepines use has been shown to affect driving skills, especially in seniors. Even some of the less strong benzodiazepines have been associated with increased falls resulting in hip fractures.
Anxiety and Depression
In many users, anxiety did not decrease with the use of benzodiazepines while depression seemed to appear during the use of the medication.
But the problems don’t stop there.
In articles published in late 2017 and earlier this year, benzodiazepines and related drug use was associated with a 40 percent increase in mortality among persons with Alzheimer's disease, according to a study released from the University of Eastern Finland. The findings were published in the International Journal of Geriatric Psychiatry.
The study found that the risk of death was increased right from the initiation
of benzodiazepines and related drug use. The increased risk of death may result from the adverse events of these drugs, including fall-related injuries, such as hip fractures, as well as pneumonia and stroke.
One theory put forward by the researchers, based at several institutions across Finland, is that the sedative effects of benzodiazepines may increase the risk of pneumonia by boosting the likelihood of aspiration of saliva or food into the lungs.
This theory correlates with the study’s finding that pneumonia risk is highest at the start of benzodiazepine use, as the sedative effect is more pronounced initially before tolerance is built up, according to researchers.
When it comes to stroke risk, the researchers found that the use of benzodiazepines was associated with a 20 per cent increased risk of stroke among persons with Alzheimer's disease. The findings encourage a careful consideration of the use of benzodiazepines and benzodiazepine-like drugs among persons with Alzheimer's disease, as stroke is one of the leading causes of death in this group.
As mentioned earlier, benzodiazepine use while using alcohol can be a deadly combination. A recent study shows that seniors who go to hospital emergency rooms because of a drug interaction is usually the result of combining these two powerful sedatives which results in a synergistic effect, meaning that each drug amplifies the effect of the other, causing exaggerated side effects. Again, this results in falls, car accidents and respiratory issues.
So how do you know if someone you love is taking these drugs? Check the bottles. Below is a list of some of the most commonly prescribed benzodiazepines:
Be especially concerned if this person is exhibiting some of the symptoms we mentioned earlier. And above all else, if visiting a medical professional about odd behaviors or symptoms that may indicate the presence of dementia, provide them with the list of medications they are taking.
Also keep in mind that these drugs are designed for short-term use. If someone has been using them regularly for more than a few weeks, know that withdrawal symptoms can be powerful and potentially deadly. More importantly, never suggest stopping any medication without consulting the prescribing physician. It could be that the benefits of benzodiazepines may very well outweigh the possible side effects.
As you can see, there are many parallels between the so-called opioid epidemic and the continued prescribing of benzodiazepines for long term use among seniors. Unfortunately, despite the documented dangers, little has been done to educate the public on their dangers. And medical professionals, who have access to the literature regarding the dangers of benzodiazepines, continue to prescribe these drugs at alarmingly high rates.
So what can we do?
Be aware of what medications an elderly loved one is taking. Stay involved in their treatment and care, don't chalk up new behaviors as "conditions of aging" and don't be afraid to ask questions.
Below is the Black Box Warning literature issued by the Food and Drug Administration. It contains a list of medications that can have serious or even deadly side-effects when used with benzodiazepines. Click on the photo and download the information.
Don Drake is the behavioral health presenter for Connelly Law Offices, Ltd.'s Community Education Series. He is a retired licensed clinician in the Commonwealth of Massachusetts and has over thirty years providing staff and community training in human services and correctional issues, licensing preparation, program and organizational development and curriculum development. He has served as Program Director, Administrator and clinical trainer at facilities in Boston, Hartford, Providence, and Philadelphia where he supervised and trained staff in providing behavioral and addictions treatments to adolescent, adult, and senior clients, including those with HIV/AIDS. He has worked as a trainer for the Massachusetts Department of Public Health presenting the Question, Persuade and Refer (QPR) Suicide Prevention training, the Massachusetts Council on Compulsive Gambling, a non-profit health agency dedicated to reducing the social, financial and emotional costs of a gambling disorder and as a certified trainer for the Crisis Prevention Institute, an international training organization that specializes in the safe management of disruptive and assaultive behaviors and was also a Certified Hepatitis C Educator with the Commonwealth of Massachusetts. His email address is firstname.lastname@example.org.