There has been a steady campaign to convince primary care physicians to stop prescribing long term benzodiazepine treatment to elderly patients. The intense declaratory nature of these admonitions suggests an almost emotional commitment to these recommendations. The argument against their use includes a loss of effect after as brief a period as 4 weeks, an increase in the risk of falls, cognitive impairment, and a greater risk of automobile accidents. These arguments are summed up in this article – Deprescribing Benzodiazepines: Changing Attitudes. Yet these drugs are still widely prescribed, especially in elderly patients.
If their use in the elderly is so fraught with peril, either doctors are stubbornly ignorant of their ill effects or there are reasons that might justify their continued use. They are widely used as a sleep aid. If they lose their effect after a month or so why would patients continue to use them? They are not addicting in the strict pharmacological sense that I have previously used here. Doctors love to make plenary recommendations devoid of nuance. So let’s examine one facet of benzodiazepine therapy in detail – as a sleep aid.
Consider this patient. An 80 year old woman developed chronic neck pain in her mid 30s. The pain was associated with the prone position during sleep. Sleeping supine eased the pain until she was about 60. She then required 200 mg daily of celecoxib to control her neck pain, but increasingly she found that the NSAID did not give sufficient pain relief to allow her to sleep recumbent. She could sleep in a chair, but not in a bed. She was then prescribed temazepam, first 30 mg at bedtime, then 60 mg. She has been on this regimen for almost 20 years and is symptom free. This is her only health problem. Though retired from her teaching job, she is engaged in numerous community projects, has a normal gait, and an accident free driving record. Her mental status exam shows her to be as alert and engaged as she ever was. She has tried several times to forgo both the NSAID and the benzodiazepine, but each attempt has been thwarted by the return of neck pain.
The purpose of medicine is to prevent premature death and pain and suffering. The former is no longer possible in our 80 year old women. The goal of her treatment is to relieve the pain that is her only complaint. Why should her temazepam treatment be discontinued because of risk factors associated with their use that do not apply to her?
Here are a few papers that reflect current thinking about the use or abuse of benzodiazepines, usually by doctors who do not routinely provide general medical care to elderly patients. They tend to be written by physicians who see the problems associated with such therapy, but who do not see the patients who benefit from long term benzodiazepine therapy. First a paper in JAMA Psychiatry – Benzodiazepine Use in the United States. It gives all the reasons why long term treatment may cause problems. It mentions that “primary care physicians rather than psychiatrists write most of the benzodiazepine prescriptions.” One might wonder why this is? Are primary care doctors seeing the use of this class of drugs through a different lens from those advising against their long term use? The same issue of JAMA Psychiatry presents an admonitory piece Why Are Benzodiazepines Not Yet Controlled Substances? This is from a French Pharmacology Department which, not surprisingly, sees government intervention as the solution to a problem they deem serious.
Doctors are taught, virtually from their first day in medical school, that patients should be treated as individuals. Making sweeping recommendations like those described above fail to consider the conditions that apply to individual patients. Thus, while it might be a good idea to carefully examine the wisdom of prescribing benzodiazepines to elderly patients in general, there may be individual elderly patients in whom such treatment is indicated. Patients, regardless of age, who are mobile, alert, and sharp of mind and who have a good indication for such therapy should not be denied it because there are other classes of patients in whom it should be withheld.
Our patient above who has been on a temazepam for 20 years without an adverse effect will likely induce a therapeutic gasp from the pharmacologists and psychiatrists who argue strongly against such use. But the patient has been under the watchful gaze of an excellent primary care doctor who is well aware of the potential harm of benzodiazepine therapy. The patient who has been taking this drug does not consider herself the victim of tachyphylaxis. As always in clinical practice, guidelines should be tempered by good judgement.
Physicians who write about elderly subjects are sometimes the victims of selection bias. They may not see or write about the vigorous elderly population with minor, or even no, problems. Such subjects do not exhibit the frailty that is typically the subject of the medical literature that examines the hazards of aging.
