Benzodiazepine Use in Older Adults

Last Updated: June 30, 2019

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This tool is designed to help primary care providers assess and discuss with their patients 65 years of age or older, the potential risks and benefits of benzodiazepines. This tool also contains steps to support primary care providers in safely discontinuing, starting or continuing to prescribe benzodiazepines for their older patients.

Potential risks and benefits of benzodiazepines

Benzodiazepines are not the preferred treatment for anxiety disorders, insomnia or panic disorder among older adults.^1-4 As patients age, their bodies respond to medications differently, and some medications become less safe than others.

It is important to re-evaluate all medications as a patient approaches the age of 65. Re-evaluating the risks and benefits of concurrent medications is a routine part of medicine. It is particularly important to review the use of benzodiazepines, given the patient safety risks associated with the use of this medication in advanced age, as discussed in this tool.

Potential Risks

Older adults have an increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents
All benzodiazepines increase the risk of cognitive impairment, delirium, falls, fractures and motor vehicle accidents in older adults
Insomnia: NNH for any harm at 2 weeks = 6³

Potential Benefits

Anxiety disorders: NNT at 4-6 weeks = 7⁵
Insomnia: NNT at 2 weeks = 13³
- 34.2 additional minutes of sleep
- 0.60 less awakenings per night
Panic disorder: NNT (timeframe unknown) = 5⁶

Determine whether a benzodiazepine is appropriate or problematic⁷

Identify patients opportunistically, when the patient:^{8, 9}

Is 65 or over
Comes in for a preventative health exam
Comes in for a prescription renewal or refill
Has had a recent hospitalization
Has had a recent fall
Is admitted to long-term care
Presents with new cognitive concerns or early onset dementia
Reports driving difficulty or their family, caregivers or friends reports concerns
Demonstrates rapid escalation of medication use
Has an active substance use disorder that could trigger inappropriate or problematic use of benzodiazepines
Has a potential benzodiazepine use disorder¹³Possible indications of benzodiazepine use disorder:
• Deteriorating function despite increasing dose
• Dishonesty with respect to prescriptions (e.g. frequent reports of loss or theft of medications and/or routine early refill requests)
• Involvement with law-enforcement
• Non-oral route of administration
• Active misuse of another substance
• Diversion or other substance-dealing behaviour If patient presents with possible indications of a benzodiazepine use disorder, diagnose the patient using the DSM-5 criteria for Sedative, Hypnotic, or Anxiolytic Use Disorder.

Identify patients proactively:

Set EMR reminders or patient record flags as a reminder to review a patient’s benzodiazepine use during their next appointment.⁸
Encourage patients to bring up their use of benzodiazepines during their next appointment:
- mail or hand-out patient material to rostered patients ages 65 or over
- put waiting room patient posters up or provide screening questions while patients wait for their appointments. This type of patient material is available from the Centre for Effective Practice and the Canadian Deprescribing Network.

Consider benzodiazepine appropriateness

If the patient is taking/starting it for anxiety disorders / Insomnia / panic disorder:

Discontinuing Benzodiazepines
Alternatives to Benzodiazepines for Anxiety
Alternatives to Benzodiazepines for Insomnia
Alternatives to Benzodiazepines for Panic Disorders

If the patient is taking/starting it for seizure disorders / alcohol withdrawal / Short-term use (<4 weeks):

Starting Benzodiazepines
Continuing Benzodiazepines

Expand All

Discontinuing Benzodiazepines

Important information to collect before discontinuing benzodiazepines

Current dose and duration, including prn use of benzodiazepine

Discontinuation with no taper is possible if the benzodiazepine has been taken for <3 weeks ¹⁴
Individuals taking the equivalent of ≥60mg diazepam daily (see Benzodiazepines available in Ontario), or with a history of serious withdrawal reactions, should be hospitalized during acute withdrawal and tapering should be slower ¹⁴

All prescribed and over-the-counter medications that the patient is currently taking

Including supplements, vitamins, and naturopathic treatments

History of previous non-pharmacological and pharmacological alternatives tried for anxiety disorders, insomnia or panic disorder

Understand what the patient means by “tried” and consider if the duration “tried” is long enough to evaluate efficacy/side effects
An adequate trial of non- pharmacological and pharmacological alternatives is approximately 6-8 weeks

Substance use history

E.g. alcohol, cannabinoids, caffeine, nicotine

History of adverse events

E.g. delirium, dementia or cognitive impairment, falls, fractures or motor-vehicle accidents

Baseline assessment of anxiety disorders, insomnia or panic disorder

Use validated assessment tools such as, GAD-7 and PHQ (PHQ section 4 on panic disorder) ¹⁵, and the Insomnia Severity Index.¹⁶

Tapering Steps

If taking a benzodiazepine is no longer appropriate for a patient, then use the following steps to help them taper off of the
medication or to a lower dose.

Step 1: Plan the taper

Engage patients

In developing a clear plan for tapering, incorporating goals and preferences regarding benzodiazepine use.⁷
Discuss a goal of discontinuation versus lowest possible dose
- If a medication cannot be completely discontinued, a decrease in dose is still a win!
Ensure patients know what is required of them (e.g. schedule for primary care provider visits and schedule for picking up prescriptions at designated pharmacy).
Reassure patients that they have control in the taper; taper can go as slow as they need and can be paused and adjusted as needed.

Establish the formulation to be used for tapering

See Benzodiazepines available in Ontario if switching patient to another benzodiazepine before tapering
There is insufficient evidence to support the use of one particular benzodiazepine over another (or for long–acting benzodiazepines vs. short-acting benzodiazepines) for a tapering schedule.⁷
Switching to long-acting benzodiazepines may be done (e.g. diazepam, clonazepam), but this has not shown to reduce the incidence of withdrawal symptoms or improve cessation rates more than tapering shorter-acting benzodiazepines.⁷
- Long-acting benzodiazepines do however offer advantages when tapering, including fewer rebound symptoms, constant drug levels and ease of formulation.^{14, 19, 20}
- To reduce the severity of withdrawal symptoms, keep a patient on a long-acting benzodiazepine for at least 2 months following a switch (from a short-acting benzodiazepine) and before initiating a taper from the long-acting benzodiazepine.¹⁴

Establish the dosing interval

Scheduled doses are preferred over prn doses (to help with the withdrawal).
Keep the dosing interval constant (e.g. bid).

Establish the rate of the taper

Based on the patient’s health and preferences, as well as formulations available for the current benzodiazepine see Benzodiazepines available in Ontario.
For older adults, it is recommended to taper the benzodiazepine dose slowly: 25% reduction every 2 weeks and then a slower taper of 12.5% every 2 weeks near the end.⁷
For long-acting benzodiazepines taper by no more than diazepam 5mg or clonazepam 0.25mg equivalent/week.²¹

Contact the patient’s pharmacy to discuss the tapering plan

By phone and/or fax depending on what is feasible.
Discuss with the pharmacist any pill splitting or liquid formulations necessary to accommodate tapering doses as well as packaging options for older adults (e.g. dosette or blister pack).
For long-acting benzodiazepines instruct the pharmacist to dispense daily, weekly or every 2 weeks depending on the dose and patient reliability.²¹

Step 2: Consider adjunctive therapy

Consider cognitive behaviour therapy to improve tapering success rates

Cognitive behaviour therapy has the highest success rate for patients discontinuing benzodiazepines compared to usual care or other prescribing interventions (see Provider and Patients Resources)⁷.
The use of pharmacological adjunctive agents has limited evidence to support success.

Step 3. Initiate and monitor^7,12

Decrease patient’s dose

By 25% (or decided upon rate) every 2 weeks until dose is close to end goal (discontinuation or lowest possible dose), then slow the dose reduction to 12.5% (or decided upon rate) every 2 weeks until the end goal is reached.⁷
For long-acting benzodiazepinesslow the pace of the taper once the dose is below 20mg of diazepam equivalent (e.g. 1–2 mg/week); adjust rate of taper according to patient’s symptoms.²¹

Monitor for expected benefits and withdrawal symptoms^{7, 12}

Schedule follow-up appointments every 1-2 weeks (in-person or over the phone) to monitor for expected benefits as as well as adverse drug withdrawal symptoms and manage accordingly.⁷ If a patient is at high risk of withdrawal symptoms, refer to a supervised setting during taper initiation.
Use validated assessment tools to assess withdrawal symptoms: Clinical Institute Withdrawal Assessment-Benzodiazepines²³ and/or The Benzodiazepine Withdrawal Symptom Questionnaire.²⁴

Expected benefits:

Less daytime sedation
Improved cognition. Use validated assessment tools such as, the Montreal Cognitive Assessment^.²²
Fewer falls
Fewer fractures
Fewer motor vehicle accidents
Improved function
Fewer respiratory exacerbations

Common withdrawal symptoms:

Rebound anxiety disorders and/or panic disorder. Use validated assessment tools such as, the GAD-7 and PHQ (PHQ section 4 on panic disorder).¹⁵
Rebound insomnia. Use a validated assessment tool such as, the Insomnia Severity Index.¹⁶
Irritability
Sweating
Gastrointestinal symptoms (i.e. diarrhea, abdominal cramps, nausea and vomiting)
Chills
Tremors
Dizziness
Visual distortion (patient should be told to see their primary care provider if they are experiencing visual distortion)
Tinnitus

Severe withdrawal symptoms:*

Agitation
Confusion
Disorientation
Depersonalization
Delirium
Seizures
Unstable vital signs

*Severe withdrawal symptoms do not appear to occur with tapering but have been reported rarely in patients stopping very high doses without tapering or who have underlying seizure disorders⁷

Manage withdrawal symptom(s)

If withdrawal symptoms are bothersome for a patient or if the taper is not going well, consider maintaining the current dose for an additional 1-2 weeks before attempting the next dose reduction, then continue to taper at a slower rate if appropriate.⁷
Currently, no medications are recommended or approved for the management of benzodiazepine withdrawal after long-term use.²⁷

Oxybutynin* 2.5–5mg bid prn (short-term use)
Ensure patient is well-hydrated

* Appears in 2019 AGS Beers Criteria® – the Beers Criteria is published by the American Geriatrics Society and is a list of potentially inappropriate medications in older adults²⁸

Stop stool softeners and/or laxatives (e.g. sennosides, docusate sodium, lactulose), if applicable
Loperamide (if necessary) 4mg STAT, then 2mg after each unformed stool up to a maximum of 16mg per day

If BP >90/50 mmHg, may give clonidine* 0.1mg (check BP and HR 1 hour later and if BP <90/50, HR <50 or dizziness, do not prescribe further); may titrate up to qid prn, then taper

* Appears in 2019 AGS Beers Criteria® – the Beers Criteria is published by the American Geriatrics Society and is a list of potentially inappropriate medications in older adults²⁸

Dimenhydrinate* 25–50mg q4h prn •
Prochlorperazine* 5–10mg q6h prn
Haloperidol* 0.5–1mg q12h prn
Metoclopramide* 10mg q4–6h prn

* Appears in 2019 AGS Beers Criteria® – the Beers Criteria is published by the American Geriatrics Society and is a list of potentially inappropriate medications in older adults²⁸

For additional examples of tapering approaches see The Ashton Manual.

Starting Benzodiazepines

Important information to collect before starting benzodiazepines

All prescribed and over-the-counter medications that the patient is currently taking

Including supplements, vitamins, and naturopathic treatments

History of previous non-pharmacological and pharmacological alternatives tried

Understand what the patient means by “tried” and consider if the duration “tried” is long enough to evaluate efficacy/side effects
An adequate trial of non-pharmacological and pharmacological alternatives is approximately 6-8 weeks

Substance use history

E.g. alcohol, cannabinoids, caffeine, nicotine

History of adverse events

E.g. delirium, dementia or cognitive impairment, falls, fractures or motor-vehicle accidents

Baseline assessment of anxiety disorders, insomnia or panic disorder

Use validated assessment tools such as, GAD-7 and PHQ (PHQ section 4 on panic disorder) ¹⁵, and the Insomnia Severity Index.¹⁶

Safeguards for benzodiazepine prescribing

Avoid prescribing any combination of ≥3 central nervous system-active drugs (i.e. antidepressants, antipsychotics, antiepileptics, nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids).²⁸

Use limited dispensing⁹and intermittent therapy, if appropriate (e.g. limit to 3 nights/week).¹⁴

Collaborate with the patient’s pharmacist regarding packaging options for older adults (e.g. dosette or blister pack), pill counts, home visits as well as patient education on safe storage and proper disposal.

Set expectations and confirm an exit strategy with the patient. Implement treatment agreements – a sample benzodiazepine treatment agreement is available from the College of Physicians and Surgeons of Alberta. Educate the patient about side effects and risk of overdose. Educate the patient about avoiding use with alcohol and over-the-counter sedatives (e.g. acetaminophen, codeine).

Implement adjunctive non-pharmacological therapy (see Alternatives to benzodiazepines for anxiety, insomnia, or panic disorder).

Monitor the patient closely for adverse events, such as cognitive impairment, delirium, falls, fractures and motor vehicle accidents.²⁸Be alert to the development of dependence – tolerance to the effects of benzodiazepines can develop quickly after only 3-6 weeks (i.e. within weeks) and then more of the drug is needed to achieve the same effect.¹²Consider use of urine drug screening if misuse is suspected (note: urine drug screening does not detect all benzodiazepines).

Increased risk: Benzodiazepines and opioids

The concurrent use of benzodiazepines and opioids is associated with an increased risk of adverse reactions due to the depression of the central nervous system exerted by both types of drugs:

Increases the risk of cognitive effects, falls, motor vehicle accidents, overdoses and drug-related death ^{27, 28, 32}
Risks are increased further when benzodiazepines are taken concurrently with alcohol
The expert perspective is that opioids and benzodiazepines should rarely be prescribed together³²
For patients who may benefit from both an opioid taper and a benzodiazepine taper, consider completing the opioid taper first or taper the medication that the patient is most willing to taper first⁹

Benzodiazepine available in Ontario^{7, 21, 30, 31}

Scroll (left-right) for details

Long-acting
Chlordiazepoxide
Covered by Ontario Drug Benefit³⁰
Formulations
Capsule: 5 mg, 10 mg, 25 mg
Approximate equivalent to 5mg diazepam oral dose
10 mg
Half-life (hours)**
100
Long-acting
Clorazepate
Covered by Ontario Drug Benefit³⁰
Formulations
Capsule: 3.75 mg, 7.5 mg, 15 mg
Approximate equivalent to 5mg diazepam oral dose
7.5 mg
Half-life (hours)**
100
Long-acting
Diazepam
Covered by Ontario Drug Benefit³⁰
Formulations
- Tablet: 2 mg^, 5 mg^, 10 mg^
Approximate equivalent to 5mg diazepam oral dose
- 5 mg
Half-life (hours)**
- 100
Long-acting
Flurazepam
Covered by Ontario Drug Benefit³⁰
Formulations
- Capsule: 15 mg, 30 mg
Approximate equivalent to 5mg diazepam oral dose
- 15 mg
Half-life (hours)**
- 100
Intermediate-acting
Alprazolam
Only 0.25 mg, 0.5 mg covered by Ontario Drug Benefit³⁰
Formulations
- Tablet: 0.25 mg^, 0.5 mg^, 1 mg^, 2 mg
Approximate equivalent to 5mg diazepam oral dose
- 0.5 mg
Half-life (hours)**
- 12-15
Intermediate-acting
Bromazepam
Covered by Ontario Drug Benefit³⁰
Formulations
- Tablet: 1.5 mg^, 3mg^, 6 mg^
Approximate equivalent to 5mg diazepam oral dose
- 3 mg
Half-life (hours)**
- 8-30
Intermediate-acting
Clobazam
Covered by Ontario Drug Benefit³⁰
Formulations
- Tablet: 10 mg^
Approximate equivalent to 5mg diazepam oral dose
- 10 mg
Half-life (hours)**
- 10-46
Intermediate-acting
Clonzepam
Only 0.5 mg^, 2 mg^ covered by Ontario Drug Benefit
Formulations
- Tablet: 0.25 mg, 0.5 mg^, 1 mg, 2 mg^
Approximate equivalent to 5mg diazepam oral dose
- 0.25 mg
Half-life (hours)**
- 20-80
Intermediate-acting
Lorazapem
Covered by Ontario Drug Benefit³⁰
Formulations
- Tablet: 0.5 mg, 1 mg^, 2 mg^
Approximate equivalent to 5mg diazepam oral dose
- 1 mg
Half-life (hours)**
- 10-20
Intermediate-acting
Nitrazapem
Covered by Ontario Drug Benefit³⁰
Formulations
- Tablet: 5 mg^, 10 mg^
Approximate equivalent to 5mg diazepam oral dose
- 5 mg
Half-life (hours)**
- 16-55
Intermediate-acting
Oxazapem
Covered by Ontario Drug Benefit³⁰
Formulations
- Tablet: 10 mg^, 15 mg^, 30 mg^
Approximate equivalent to 5mg diazepam oral dose
- 15 mg
Half-life (hours)**
- 5-15
Intermediate-acting
Temazapem
Covered by Ontario Drug Benefit³⁰
Formulations
- Capsule: 15 mg, 30 mg
Approximate equivalent to 5mg diazepam oral dose
- 15 mg
Half-life (hours)**
- 10-20
Short-acting
Triazolam
Covered by Ontario Drug Benefit³⁰
Formulations
- Tablet: 0.125 mg^, 0.25 mg^
Approximate equivalent to 5mg diazepam oral dose
- 0.25 mg
Half-life (hours)**
- 1.5-5

^ Scored
** Parent compound and active metabolite

Continuing Benzodiazepines

For patients continuing on a benzodiazepine, ensure safeguards are put in place to reduce harms and revisit the tapering conversation if/when appropriate.

Safeguards for benzodiazepine prescribing

Use limited dispensing⁹and intermittent therapy, if appropriate (e.g. limit to 3 nights/week).¹⁴

Implement adjunctive non-pharmacological therapy (see Alternatives to benzodiazepines for anxiety, insomnia, or panic disorders).

Increased risk: Benzodiazepines and opioids

The concurrent use of benzodiazepines and opioids is associated with an increased risk of adverse reactions due to the depression of the central nervous system exerted by both types of drugs:

Increases the risk of cognitive effects, falls, motor vehicle accidents, overdoses and drug-related death ^{27, 28, 32}
Risks are increased further when benzodiazepines are taken concurrently with alcohol
The expert perspective is that opioids and benzodiazepines should rarely be prescribed together³²
For patients who may benefit from both an opioid taper and a benzodiazepine taper, consider completing the opioid taper first or taper the medication that the patient is most willing to taper first⁹

Benzodiazepine available in Ontario^{7, 21, 30, 31}

Scroll (left-right) for details

Long-acting
Chlordiazepoxide
Covered by Ontario Drug Benefit³⁰
Formulations
Capsule: 5 mg, 10 mg, 25 mg
Approximate equivalent to 5mg diazepam oral dose
10 mg
Half-life (hours)**
100
Long-acting
Clorazepate
Covered by Ontario Drug Benefit³⁰
Formulations
Capsule: 3.75 mg, 7.5 mg, 15 mg
Approximate equivalent to 5mg diazepam oral dose
7.5 mg
Half-life (hours)**
100
Long-acting
Diazepam
Covered by Ontario Drug Benefit³⁰
Formulations
- Tablet: 2 mg^, 5 mg^, 10 mg^
Approximate equivalent to 5mg diazepam oral dose
- 5 mg
Half-life (hours)**
- 100
Long-acting
Flurazepam
Covered by Ontario Drug Benefit³⁰
Formulations
- Capsule: 15 mg, 30 mg
Approximate equivalent to 5mg diazepam oral dose
- 15 mg
Half-life (hours)**
- 100
Intermediate-acting
Alprazolam
Only 0.25 mg, 0.5 mg covered by Ontario Drug Benefit³⁰
Formulations
- Tablet: 0.25 mg^, 0.5 mg^, 1 mg^, 2 mg
Approximate equivalent to 5mg diazepam oral dose
- 0.5 mg
Half-life (hours)**
- 12-15
Intermediate-acting
Bromazepam
Covered by Ontario Drug Benefit³⁰
Formulations
- Tablet: 1.5 mg^, 3mg^, 6 mg^
Approximate equivalent to 5mg diazepam oral dose
- 3 mg
Half-life (hours)**
- 8-30
Intermediate-acting
Clobazam
Covered by Ontario Drug Benefit³⁰
Formulations
- Tablet: 10 mg^
Approximate equivalent to 5mg diazepam oral dose
- 10 mg
Half-life (hours)**
- 10-46
Intermediate-acting
Clonzepam
Only 0.5 mg^, 2 mg^ covered by Ontario Drug Benefit
Formulations
- Tablet: 0.25 mg, 0.5 mg^, 1 mg, 2 mg^
Approximate equivalent to 5mg diazepam oral dose
- 0.25 mg
Half-life (hours)**
- 20-80
Intermediate-acting
Lorazapem
Covered by Ontario Drug Benefit³⁰
Formulations
- Tablet: 0.5 mg, 1 mg^, 2 mg^
Approximate equivalent to 5mg diazepam oral dose
- 1 mg
Half-life (hours)**
- 10-20
Intermediate-acting
Nitrazapem
Covered by Ontario Drug Benefit³⁰
Formulations
- Tablet: 5 mg^, 10 mg^
Approximate equivalent to 5mg diazepam oral dose
- 5 mg
Half-life (hours)**
- 16-55
Intermediate-acting
Oxazapem
Covered by Ontario Drug Benefit³⁰
Formulations
- Tablet: 10 mg^, 15 mg^, 30 mg^
Approximate equivalent to 5mg diazepam oral dose
- 15 mg
Half-life (hours)**
- 5-15
Intermediate-acting
Temazapem
Covered by Ontario Drug Benefit³⁰
Formulations
- Capsule: 15 mg, 30 mg
Approximate equivalent to 5mg diazepam oral dose
- 15 mg
Half-life (hours)**
- 10-20
Short-acting
Triazolam
Covered by Ontario Drug Benefit³⁰
Formulations
- Tablet: 0.125 mg^, 0.25 mg^
Approximate equivalent to 5mg diazepam oral dose
- 0.25 mg
Half-life (hours)**
- 1.5-5

^ Scored
** Parent compound and active metabolite

Alternatives to Benzodiazepines for Anxiety

The following outline many of the non-pharmacological and pharmacological alternative therapy options to benzodiazepines for older adults, along with the level of evidence and adverse effects associated with each therapy.

Non-pharmacological options^1,2

Non-pharmacological alternatives are the preferred treatment for anxiety disorders, insomnia or panic disorder among older adults.

Scroll (left-right) for details

Cognitive behavioural therapy
Level of evidence • • •
Efficacy of psychological treatment is similar to that of pharmacotherapy for the treatment of anxiety disorders in older patients
Progressive muscle relaxation
Level of evidence • • •
Efficacy of psychological treatment is similar to that of pharmacotherapy for the treatment of anxiety disorders in older patients
Psychological therapy (supportive psychotherapy)
Level of evidence • •
Efficacy of psychological treatment is similar to that of pharmacotherapy for the treatment of anxiety disorders in older patients
Physical activity
Level of evidence •
Physical activity: 2.5 hours of moderate to higher intensity aerobic activity/week in bouts of 10minutes or more³³

Level of evidence:
· · · = meta-analysis or at least 2 randomized controlled trials that included a placebo condition,
· · = at least 1 randomized controlled trial with placebo or active comparison condition,
· = uncontrolled trial with at least 10 subjects

See Patient Resources for more information.

Pharmacological options

As patients age, their bodies respond to medications differently, making them more susceptible to adverse events and drug-drug interactions. If using pharmacological alternatives in older patients, consider patient factors and use the “start low, go slow” approach.

Scroll (left-right) for details

First-line treatment (SSRIs)
Escitalopram and Sertraline
Level of evidence • • •
Adverse effects
- Insomnia
- Somnolence
- Sedation
- Nausea
- GI
- Sexual Dysfunction
- Qt prolongation
- Dizziness
- Dry mouth
- Hyponatremia
Additional information
- SSRI appears as a class in 2019 AGS Beers Criteria®*
First-line treatment (SNRIs)
Duloxetine and Venlafaxine ER
Level of evidence • • •
Adverse effects
- Insomnia
- Sleep disturbances
- Sedation
- Nausea
- GI
- Decreased appetite
- Increased BP
- Dizziness
- Hyponatremia
Additional information
- SNRI appears as a class in 2019 AGS Beers Criteria®*
First-line treatment
Pregabalin
Level of evidence • • •
Adverse effects
- Sedation
- Nausea
- GI
- Increased appetite and weight
- Dizziness
- Dry mouth
Additional information
- Pregabalin has the most robust data in older patients that demonstrates significant improvements and good tolerability
Second-line treatment
Bupropion SR/XL
Level of evidence • •
Adverse effects
- Insomnia
- GI
- Decreased appetite
- Increased seizure activity
Third-line treatment (SSRIs)
Citalopram
Level of evidence •
Adverse effects
- Insomnia
- Sleep disturbances
- Somnolence
- Sedation
- Nausea
- GI
- Sexual dysfunction
- Qt prolongation
- Dizziness
- Dry mouth
- Hyponatremia
Additional information
- May increase QT (doses >40mg/day)
- SSRI appears as a class in 2019 AGS Beers Criteria®*
Third-line treatment
Trazodone
Level of evidence • •
Adverse effects
- Nausea
- Priapism in men (rare)
- Orthostatic hypotension
Third-line treatment (tetracyclic antidepressant)
Mirtazapine
Level of evidence •
Adverse effects
- Sedation
- Increased appetite & weight
- Dizziness
- Dry mouth
Third-line treatment (SNRI)
Fluoxetine
Level of evidence •
Adverse effects
- Insomnia
- Sleep disturbances
- Somnolence
- Sedation
- Nausea
- GI
- Anorexic & stimulating
- Sexual dysfunction
- Qt prolongation
- Dizziness
- Dry mouth
- Hyponatremia
Additional information
- SNRI appears as a class in 2019 AGS Beers Criteria®*
- Long half-life (5-week washout)

Notes: BP= blood pressure, ER= extended release, CR= controlled release, GI= gastrointestinal, SNRIs= serotonin and norepinephrine reuptake inhibitors, SR= sustained release, SSRIs= selective serotonin reuptake inhibitors, XL= extra-long /large

* The Beers Criteria is published by the American Geriatrics Society and is a list of potentially inappropriate medications in older adults. ²⁸

Alternatives to Benzodiazepines for Insomnia

The following outlines many of the non-pharmacological and pharmacological alternative therapy options to benzodiazepines for older adults, along with the level of evidence and adverse effects associated with each therapy.

Non-pharmacological options

Non-pharmacological alternatives are the preferred treatment for anxiety disorders, insomnia or panic disorder among older adults.

Scroll (left-right) for details

Cognitive behavioural therapy
Level of evidence • • to • • •
Notes
- Cognitive behavioural therapy for insomnia is more effective than pharmacological therapy for the short- and long-term management of insomnia in older adults.¹⁷
- Restructures maladaptive beliefs regarding health and daytime consequences of insomnia
Good sleep hygiene
Level of evidence • •
Notes
- Reduces behaviours that interfere with sleep drive or increased arousal
Sleep restriction
Level of evidence • to • •
Notes
- Increases sleep drive and stabilizes circadian rhythm
Stimulus control
Level of evidence • to • •
Notes
- Reduces arousal in sleep environment and promotes the association between bed and sleep
Progressive muscle relaxation
Level of evidence • to • •
Notes
- Reduces physical and psychological arousal in sleep environment

See Patient Resources for more information.

Nonbenzodiazepine benzodiazepine receptor agonist hypnotics (Z-drugs)

Z-drugs have adverse events similar to those of benzodiazepines in older adults (e.g. delirium, falls, fractures, daytime sedation, increased emergency room visits/hospitalizations, motor vehicle crashes and minimal improvement in sleep latency and duration). Z-drugs should be avoided in older adults or those with a history of these adverse events.^{28, 35, 36}

Increased risk: Z-drugs and complex sleep disorders⁴¹

Serious injuries and death from complex sleep behaviors have occurred in patients who have taken Z-drugs with and without a history of such behaviors, even at the lowest recommended doses, and the behaviors can occur after just 1 dose
Health care professionals should not prescribe Z-drugs to patients who have previously experienced complex sleep behaviors after taking these medications

Discontinuing Z-drugs¹⁴

Tapering is recommended when discontinuing after use for more than 4 weeks. To help lessen the more common withdrawal symptom of rebound insomnia:

Gradually reduce the dose by 50% every week until lowest available dose is being used, then reduce use to every other day, then use only as needed and then discontinue use completely OR
Gradually reduce the dose by 25% every 2 weeks and then slow the taper to 12.5% every 2 weeks near the end⁷

Educate the patient that some sleep difficulty should be expected but that it should resolve within a week.

Pharmacological options

There are no medications for primary or chronic insomnia in older adults that are proven to be safe and effective.⁷

Scroll (left-right) for details

Z-drug
Zopiclone
Level of evidence • to • •
Covered by Exceptional Access Program³⁹
Formulations
- 3.75mg, 5mg, 7.5mg ^
- Older patient max: 5mg/day
Notes
- Indicated for insomnia but avoid in older adults²⁸
- Improves sleep onset latency (~19 min), total sleep time (~45 min), wake after sleep onset (~11 min)
- Risk of physical tolerance and dependence
Z-drug
Zolpidem
Level of evidence • to • •
Possibly covered by Exceptional Access Program⁴⁰
Formulations
- 5mg, 10mg
- Older patient max: 5mg/day
Notes
- Indicated for insomnia but avoid in older adults²⁸
- Improves sleep onset latency (~15 min), total sleep time (~23 min)
- Oral disintegrating tablet – cannot be split
- Less chance of morning hang-over effect than zopiclone
- Risk of physical tolerance and dependence
Tricyclic antidepressant
Doxepin
Level of evidence • to • •
Adverse effects
- Anticholinergic side effects with higher dose
Notes
- Appears in 2019 AGS Beers Criteria®* (for doses greater than 6mg)
- 3mg: improves total sleep time (~12 min), wake after sleep onset (~10 min)
- 6mg: improves total sleep time (~17 min), wake after sleep onset (~14 min)
- Not to be taken within 3 hours of a meal due to delayed absorption and the potential for next day drowsiness
- Minimal risk of physical tolerance/dependence; consider doxepin if substance abuse or dependence is a concern
Trazodone
Level of evidence • to • •
Adverse effects
- Orthostatic hypotension
- Priapism in men (rare)
Notes
- Trazodone is indicated for depression; limited evidence for insomnia
- Lower risk of morning hangover effect due to a short half-life
- Minimal risk of tolerance/dependence
- Low anticholinergic activity
Melatonin
Level of evidence • to • •
Adverse effects
- Fatigue
- Headache
- Dizziness
- Irritability
- Abdominal cramps
Notes
- Modest effect on sleep (may decrease sleep onset latency [~7 min]; increases total sleep time [~8 min], and improves sleep quality)
- No apparent physical tolerance and dependence
- Purity concerns
Valerian root
Level of evidence • to • •
Adverse effects
- Headache
- Dizziness
- Nausea
- Upset stomach
- Hepatotoxicity (rare)
Notes
- Limited evidence for insomnia
- Purity concerns

Notes: TCA= tricyclic antidepressant, Z-drugs= non-benzodiazepine benzodiazepine receptor agonist hypnotics

• the Beers Criteria is published by the American Geriatrics Society and is a list of potentially inappropriate medications in older adults²⁸
^ Scored

Medications not recommended for the sole management of insomnia:^{21, 29}

Adverse effects

Anticholinergic
Sedation
Somnolence
GI
Headache

Notes

Relative lack of evidence
Significant adverse effects

Adverse effects

Anticholinergic
Cognitive Impairment
Extrapyramidal reactions
Hypotension

Notes

Lack of evidence or excessive risk of daytime sedation, psychomotor impairment and anticholinergic activity

Adverse effects

Anticholinergic
Sedation
Somnolence
Cognitive Impairment

Notes

Lack of evidence or excessive risk of daytime sedation, psychomotor impairment and anticholinergic activity

Adverse effects

Anticholinergic
Sedation
Extrapyramidal reactions
Weight gain

Notes

Lack of evidence
Risk of anticholinergic and neurological toxicity (conventional)and metabolic toxicity (atypicals)
Possible increased risk of stroke/mortality in patients with behavioural and psychological symptoms of dementia (NNH = 100 in 12 weeks)

Adverse effects

Somnolence
Impaired function
Falls
Dependence

Notes

Lack of evidence and risk of central nervous system effects

Adverse effects

Somnolence
GI
Weight gain
Edema

Notes

Lack of evidence

Alternatives to Benzodiazepines for Panic Disorders New

Non-pharmacological options

Non-pharmacological alternatives are the preferred treatment for anxiety disorders, insomnia or panic disorder among older adults.

Scroll (left-right) for details

Cognitive behavioural therapy
Level of evidence • • •
Notes
- Cognitive behavioural therapy as the initial treatment for panic disorder is strongly supported by demonstrated efficacy in numerous randomized controlled trials ⁴
Daily diary
Level of evidence • • •
Notes
- Allows for monitoring of panic symptoms to gather information about the association between internal stimuli (e.g. emotions) and external stimuli (e.g. substances, particular situations or settings)
Patient education
Level of evidence • • •
Notes
- To reassure the patient that their symptoms are not life-threatening and that panic disorders are common (i.e. they are not alone)
- Should include general promotion of healthy behaviours (e.g. good nutrition, exercise, good sleep hygiene) as well as decreased used of caffeine, tobacco, alcohol and other potentially deleterious substances

See Patient Resources for more information.

Pharmacological options

If pharmacotherapy is used, use lower starting and therapeutic doses and a slower dose titration of medication than those used for younger patients.⁴

Scroll (left-right) for details

First-line treatment
Citalopram, escitalopram, fluoxetine, fluvoxamine and sertraline (SSRIs)
Level of evidence • • •
Adverse effects
- Insomnia
- Somnolence
- Nausea
- GI
- Weight gain
- Sexual dysfunction
- Qt prolongation
- Hyponatremia
- Dry mouth
- Dizziness
Notes
- SSRI appears as a class in 2019 AGS Beers Criteria®*
- Few drug interactions
Second-line treament
Mirtazapine
Level of evidence • •
Adverse effects
- Sedation
- Increased appetite
- Weight gain
- Dry mouth
- Dizziness
- Edema
Notes
- SSRI appears as a class in 2019 AGS Beers Criteria®*
Second-line treatment
Clomipramine and imipramine (TCAs)
Level of evidence • • •
Adverse effects
- Somnolence
- Increased appetite
- Weight gain
- Suicidal Ideation
- Confusion
- Qt prolongation
- Agitation
- Dry mouth
Notes
- Appears in 2019 AGS Beers Criteria®*
- Caution due to anticholinergic and cardiovascular side effects
Third-line treatment
Duloxetine (SNRI)
Level of evidence •
Adverse effects
- Sleep disturbances
- Nausea
- GI
- Decreased appetite
- Dry mouth
- Dizziness
- Increased BP
Third-line treatment
Bupropion SR
Level of evidence •
Adverse effects
- Insomnia
- GI
- Decreased appetite
- Increased seizure activity
Third-line treatment
Gabapentin
Level of evidence • •
Adverse effects
- Somnolence
- Sedation
- GI
- Dizziness
- Edema
Notes
- Appears in 2019 AGS Beers Criteria®*

Notes: BP= blood pressure, GI= gastrointestinal, SNRIs= serotonin and norepinephrine reuptake inhibitors, SR= sustained release, SSRIs= selective serotonin reuptake inhibitors, TCAs= tricyclic antidepressants

* The Beers Criteria is published by the American Geriatrics Society and is a list of potentially inappropriate medications in older adults. ²⁸

Provider and Patient Resources

For providers

Decision support tools and resources

Centre for Effective Practice increased risk patient postcard
Canadian Deprescribing Network (CaDeN) useful patient resources
The Ashton Manual benzodiazepines tapering approaches
College of Physicians and Surgeons of Alberta benzodiazepine treatment agreement
GeriMedRisk telemedicine (telephone and eConsult) consultation service for questions regarding medication use in older adult patients from a team of geriatric specialists and pharmacists
Centre for Effective Practice Management of chronic insomnia tool
iAM Medical Guidelines deprescribing.org app
Ontario Drug Benefit formulary search
2019 AGS Beers Criteria® list of potentially inappropriate medications in older adults published by the by the American Geriatrics Society

For patients

Patient resources handout

Benzo-Patient-Resource.pdf

Download

For patients with anxiety disorders and/or panic disorders

Independent cognitive behavioural therapy (book, online, and mobile app)

Mind Over Mood: A cognitive behavioural therapy hard copy workbook that provides instruction for how to manage anxiety disorders, panic disorder and other mood problems. Cost is $29.64 USD.
BounceBack Ontario: Guided self-help program grounded in cognitive behavioural therapy designed to help adults manage symptoms of anxiety (and depression). Involves 6 telephone sessions with trained coaches who lead the patient through a series of workbooks. Cost is free. Patient is contacted within 5 business days of referral to schedule first appointment. Referral or patient self-referral is required.
FearFighter — CCBT: A 9-week cognitive behavioural therapy for anxiety and panic disorders mobile app. Provided by Magellan Health Services Inc. Cost is free.
Moodgym: A 5-session online cognitive behavioural therapy program for anxiety (and depression). Cost is $39 AUD for 12 month access.
Centre for Mindfulness Studies: Provides mindfulness-based cognitive therapy, mindfulness-based stressed reduction, mindful self-compas- sion and specialized mindfulness training to the general public, healthcare providers and social service professionals.

Progressive muscle relaxation for anxiety

Progressive muscle relaxation instructions: Free online/printable instructions for patients on how to conduct progressive muscle relaxation.

Daily Diary

Worry diary: Free online/printable template for patients to use to keep track of their panic symptoms.

For patients with insomnia

Independent cognitive behavioural therapy (book, online, and mobile app)

Sink into Sleep: A 6-step cognitive behavioural therapy hard copy workbook that provides instruction for how to manage insomnia. Cost is $23.58 CAD.
CBT-i Coach: Cognitive behavioural therapy for insomnia mobile app. Provided by the US Department of Veterans Affairs. Cost is free.
Restore CBT-I: A 6-week cognitive behavioural therapy for insomnia mobile app. Provided by Magellan Health Services Inc. Cost is free.Re
Go! To Sleep: A 6-week cognitive behavioural therapy for insomnia online and mobile app program. Provided by the Cleveland Clinic of Well- ness. Cost is $3.99 USD for app or $40 USD for online.
CBT for Insomnia: A 5-session online cognitive behavioural therapy program for insomnia. Cost ranges from $24.95 USD to $49.95 USD.
Sleep Training System: A 6-week online cognitive behavioural therapy for insomnia program with money-back guarantee and personalized feedback. Cost is $29.95 USD.
Sleepio: Cognitive behavioural therapy for insomnia online and mobile app program. Cost is $300 USD for a 12-month subscription.

Good Sleep Hygiene, sleep Restrictions, Stimulus Control and Progressive Muscle Relaxation

Sleepwell: Free online supports for sleep, including sleep hygiene checklist, instructions for sleep restriction instructions, stimulus control and progressive muscle relaxation as well as sleep diaries and sleep calculators.

Daily Diary

Sleep Diary: Free online/printable template for patients to use to keep track of their daily sleep patterns.

For patients: general psychological therapy

In-person cognitive behavioural therapy

Canadian Association of Cognitive and Behavioural Therapy — Find a certified therapist webpage: Online search tool to find a certified therapist who provides cognitive behavioural therapy in Canada.

Other psychological therapy

Big White Wall: Online mental health and wellbeing service offering online peer support and self-management tool. This anonymous service is funded by the government, is available 24 hours a day and has no wait times. Cost is free. No referral needed; valid Ontario postal code required.
Ontario Psychological Association — Find a psychologist search webpage: Online search tool to find a psychologist or psychological associate in Ontario.
PsychologyToday—Find a therapist webpage: Online search tool to find a therapist.

For patients: physical activity

Physical activity

Exercise prescription: Free online/printable patient take-home prescription for aerobic activity or strength training.
Tips to get active: Free online/printable physical activity tips for older adults.
Seniors Active Living Centres: Seniors Active Living Centres locations
YMCA: List of in-person YMCA locations across Ontario (senior membership approximately $50/month for individuals or $77/month for couples).

References

[1]
National Institute for Health and Care Excellence (NICE). Generalized anxiety disorder and panic disorder in adults: management. London: NICE; 2011 Jan. 41 p. Report No.:CG113
[2]
Katzman MA, Bleau P, Blier P, Chokka P, Kjernisted K, Van Ameringen M. Canadian Anxiety Guidelines Initiative Group. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;14(Suppl 1):S1.
[3]
Glass J, Lanctôt KL, Herrmann N, Sproule BA, Busto UE. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ. 2005 Nov;331:1169.
[4]
American Psychiatric Association (APA). Practice guideline for the treatment of patients with panic disorder [Internet]. 2010 [cited 2019 Jun 5].
[5]
Alberta College of Family Physicians (ACFP). Benzodiazepines in generalized anxiety disorder: calm your nerves [Internet]. 2015 Apr 27 [cited 2019 Jun 5].
[6]
Australian government: Department of Health. Effective treatments for panic disorder [Internet]. 2005 Jun [cited 2019 Jun 5].
[7]
Pottie K, Thompson W, Davies S, Grenier J, Sadowski CA, Welch V et al. Deprescribing benzodiazepine receptor agonists: evidence-based clinical practice guideline. Can Fam Physician. 2018 May;64(5):339-51(Eng), e209-24 (Fr).
[8]
Choosing Wisely Canada. Drowsy without feeling lousy [Internet]. 2017 [updated 2017 Jul; cited 2019 May 28].
[9]
Expert opinion
[10]
Sirdfield C, Chipchase SY, Owen S, Siriwardena AN. A systematic review and meta-synthesis of patients’ experiences and perceptions of seeking and using benzodiazepines and z-drugs: towards safer prescribing. Patient. 2017;10(1):1-15.
[11]
Tannenbaum C. You may be at risk [Internet]. 2014 [cited 2019 May 31].
[12]
College of Physicians and Surgeons of Alberta (CPSA). Benzodiazepines: use and taper [Internet]. 2016 [cited 2019 May 28].
[13]
American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: APA; 2013.
[14]
RxFiles. Geri-RxFiles: assessing medications in older adults. 3rd ed. Saskatoon: Saskatoon City Hospital; 2019.
[15]
Pfizer ND. Welcome to the Patient Health Questionnaire (PHQ) screeners [Internet]. 2019 [cited 2019 May 31].
[16]
Morin CM, Belleville G, Bélanger L, Ivers H. The Insomnia Severity Index: Psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep. 2011 Jun;34(5):601–608.
[17]
Siversten B, Omvik S, Pallesen S, Bjorvatn B, Havik OE, Kvale G et al. Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial. JAMA. 2006 Jun;295(24):2851-2858.
[18]
Page AT, Clifford RM, Potter K, Schwartz D, Etherton-Beer CD. The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta- analysis. Br J Clin Pharmacol. 2016;82(3):583-623.
[19]
Vissers FHJA, Knipschild PG, Crebolder HFJM. Is melatonin helpful in stopping the long-term use of hypnotics? A discontinuation trial. Pharm Word Sci. 2007 Dec;29(6):641-646.
[20]
Voshaar RCO, Gorgels WJMJ, Mol AJJ, Van Balkom AJLM, Van de Lisdonk EH, Breteler MHM et al. Tapering off long-term benzodiazepine use with or without group cognitive-behavioural therapy: three-condition randomised controlled trial. Br J Psychiatry. 2003 Jun;182(6):498-504.
[21]
Centre for Effective Practice (CEP). Management of chronic insomnia [Internet]. 2017 Jan 16 [cited 2019 May 31].
[22]
Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005 Mar;53(4):695-9.
[23]
Busto UE, Sykora K, Sellers EM. A clinical scale to assess benzodiazepine withdrawal. J Clin Psychopharmacol. 1989 Dec;9(6):412-6.
[24]
Tyrer P, Murphy S, Riley P. The Benzodiazepine Withdrawal Symptom Questionnaire. J Affect Disord. 1990;19(1):53-61.
[25]
World Health Organization (WHO). Clinical guidelines for withdrawal management and treatment of drug dependence in closed setting [Internet]. 2009 [cited 2019 Jun 5].
[26]
Centre for Effective Practice (CEP). Opioid tapering template [Internet]. 2018 Feb [2019 Jun 5].
[27]
Baandrup L, Ebdrup BH, Rasmussen JØ, Lindschou J, Gluud C, Glenthøj BY. Pharmacological interventions for benzodiazepine discontinuation in chronic benzodiazepine users. Cochrane Database Syst Rev. 2018 Mar 15;3:CD011481.
[28]
2019 American Geriatrics Society (AGS) Beers Criteria Update Expert Panel. American Geriatrics Society 2019 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019;67:674-694.
[29]
Toward Optimized Practice (TOP). Diagnosis to management guideline for adult primary insomnia. 2015 [cited 2019 Jun 14].
[30]
Ontario Ministry of Health and Long-Term Care (MOHLTC). Formulary search [Internet]. 2018 Nov 8 [cited 2019 May 31].
[31]
Canadian Pharmacists Association (CPhA). Compendium of pharmaceuticals and specialties: Benzodiazepine. 2015 [cited 2019 Jun 14].
[32]
Busse, J. The 2017 Canadian guideline for opioids for chronic non-cancer pain [Internet]. 2017 [cited 2019 May 31].
[33]
Participaction. Benefits and guidelines: older adults 65+ [Internet]. 2019 [cited 2019 Jun 5].
[34]
Qaseem A, Kansagara D, Forciea M, Cooke M, Denberg T. Management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of Physicians. Ann Intern Med. 2016;165(2):125-133.
[35]
O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015 Mar;44(2):213-8.
[36]
Canadian Pharmacists Association (CPhA). Compendium of pharmaceuticals and specialties: Zopiclone CPhA monograph. 2019 Feb [cited 2019 Jun 14].
[37]
Sanofi-Aventis Canada Inc. Product monograph: IvadalTM [Internet]. 2011 [cited 2019 Jun 5].
[38]
Sanofi-Aventis Canada Inc. Product monograph: Imovane® [Internet]. 2018 [cited 2019 Jun 14].
[39]
MOHLTC. Exceptional Access Program (EAP) reimbursement criteria for frequently requested drugs [Internet]. 2019 [updated 2019 Mar 1; cited 2019 Jun 5].
[40]
MOHLTC. Applying to the EAP [Internet]. 2016 [updated 2019 Apr 30; cited 2019 Jun 5].
[41]
United States Food and Drug Administration. Taking Z-drugs for insomnia? Know the risks [Internet]. 2019 Apr 30 [cited 2019 Jun 5].

Acknowledgement and legal

This Tool was developed as part of the Knowledge Translation in Primary Care Initiative, led by the Centre for Effective Practice in collaboration with the Ontario College of Family Physicians and the Nurse Practitioners’ Association of Ontario. Clinical leadership for the development of the Tool was provided by Dr. Mark Silverman CCFP and was subject to external review by health care providers and other relevant stakeholders. This Tool was funded by the Government of Ontario as part of the Knowledge Translation in Primary Care Initiative.

This Tool was developed for licensed health care professionals in Ontario as a guide only and does not constitute medical or other professional advice. Health care professionals are required to exercise their own clinical judgement in using this Tool. Neither the Centre for Effective Practice (“CEP”), Ontario College of Family Physicians, Nurse Practitioners’ Association of Ontario, Government of Ontario, nor any of their respective agents, appointees, directors, officers, employees, contractors, members or volunteers: (i) are providing medical, diagnostic or treatment services through this Tool; (ii) to the extent permitted by applicable law, accept any responsibility for the use or misuse of this Tool by any individual including, but not limited to, primary care providers or entity, including for any loss, damage or injury (including death) arising from or in connection with the use of this Tool, in whole or in part; or (iii) give or make any representation, warranty or endorsement of any external sources referenced in this Tool (whether specifically named or not) that are owned or operated by their parties, including any information or advice contained therein.

The Managing Benzodiazepine Use in Older Adults tool is a product of the Centre for Effective Practice. Permission to use, copy, and distribute this material is for all non-commercial and research purposes is granted, provided the above disclaimer, this paragraph and the following paragraphs, and appropriate citations appear in all copies, modifications, and distributions. Use of the Managing Benzodiazepine Use in Older Adults Tool for commercial purposes or any modifications of the Tool are subject to charge and must be negotiated with the Centre for Effective Practice (Email: info@cep.health).

Developed by:

In collaboration with:

Benzodiazepine Use in Older Adults

Potential risks and benefits of benzodiazepines

Potential Risks

Potential Benefits

Determine whether a benzodiazepine is appropriate or problematic7

Identify patients opportunistically, when the patient:8, 9

Identify patients proactively:

Discuss their use of benzodiazepines

Discuss their use of benzodiazepines

Ask patients what they take the benzodiazepine for:

Highlight the benefits versus risks of benzodiazepine use for older adults:

Consider benzodiazepine appropriateness

If the patient is taking/starting it for anxiety disorders / Insomnia / panic disorder:

If the patient is taking/starting it for seizure disorders / alcohol withdrawal / Short-term use (<4 weeks):

Discontinuing Benzodiazepines

Important information to collect before discontinuing benzodiazepines

Current dose and duration, including prn use of benzodiazepine

All prescribed and over-the-counter medications that the patient is currently taking

History of previous non-pharmacological and pharmacological alternatives tried for anxiety disorders, insomnia or panic disorder

Substance use history

History of adverse events

Baseline assessment of anxiety disorders, insomnia or panic disorder

Tapering Steps

Step 1: Plan the taper

Engage patients

Establish the formulation to be used for tapering

Establish the dosing interval

Establish the rate of the taper

Alternative rates for tapering

Alternative rates for tapering

Contact the patient’s pharmacy to discuss the tapering plan

Step 2: Consider adjunctive therapy

Consider cognitive behaviour therapy to improve tapering success rates

Step 3. Initiate and monitor7,12

Decrease patient’s dose

Talking tips

Talking tips

Monitor for expected benefits and withdrawal symptoms7, 12

Manage withdrawal symptom(s)

For additional examples of tapering approaches see The Ashton Manual.

Starting Benzodiazepines

Important information to collect before starting benzodiazepines

All prescribed and over-the-counter medications that the patient is currently taking

History of previous non-pharmacological and pharmacological alternatives tried

Substance use history

History of adverse events

Baseline assessment of anxiety disorders, insomnia or panic disorder

Tips for safe benzodiazepine prescribing

Tips for safe benzodiazepine prescribing

Safeguards for benzodiazepine prescribing

Increased risk: Benzodiazepines and opioids

Benzodiazepine available in Ontario7, 21, 30, 31

Scroll (left-right) for details

Chlordiazepoxide

Clorazepate

Diazepam

Flurazepam

Alprazolam

Bromazepam

Clobazam

Clonzepam

Lorazapem

Nitrazapem

Oxazapem

Temazapem

Triazolam

Continuing Benzodiazepines

Safeguards for benzodiazepine prescribing

Increased risk: Benzodiazepines and opioids

Benzodiazepine available in Ontario7, 21, 30, 31

Scroll (left-right) for details

Chlordiazepoxide

Clorazepate

Diazepam

Flurazepam

Alprazolam

Bromazepam

Clobazam

Clonzepam

Lorazapem

Determine whether a benzodiazepine is appropriate or problematic⁷

Identify patients opportunistically, when the patient:^{8, 9}

Step 3. Initiate and monitor^7,12

Monitor for expected benefits and withdrawal symptoms^{7, 12}

Benzodiazepine available in Ontario^{7, 21, 30, 31}

Benzodiazepine available in Ontario^{7, 21, 30, 31}

Non-pharmacological options^1,2

Increased risk: Z-drugs and complex sleep disorders⁴¹

Discontinuing Z-drugs¹⁴

Medications not recommended for the sole management of insomnia:^{21, 29}