Benzodiazepines for insomnia in older adults carry significant risks that generally outweigh their benefits, and their use should be limited to very short-term, acute situations only. Pharmacological treatment with benzodiazepines is not recommended for long-term management of insomnia in older adults due to risks including dependency, cognitive impairment, increased falls, and adverse effects on mobility and daytime functioning NICE CKS.
When benzodiazepines are considered, they should be prescribed at the lowest effective dose for the shortest possible duration, ideally less than one week and not exceeding two weeks, to minimise risks of tolerance, dependence, and withdrawal symptoms NICE CKS. Older adults are particularly vulnerable to these adverse effects due to altered pharmacokinetics and pharmacodynamics, increased sensitivity to sedative effects, and higher likelihood of comorbidities and polypharmacy NICE CKS,NICE CG185.
Alternatives such as cognitive behavioural therapy for insomnia (CBTi) are recommended as first-line treatment for chronic insomnia in older adults, with pharmacological options like prolonged-release melatonin preferred if medication is necessary NICE CKS. Benzodiazepines may be considered only as a temporary adjunct in severe acute exacerbations of insomnia when non-pharmacological measures have failed, but even then, caution is advised NICE CKS.
Risks specific to benzodiazepines in older adults include increased risk of falls and fractures, cognitive decline, daytime sedation leading to impaired driving ability, and potential for misuse and dependence NICE CKS,NICE CKS. Withdrawal from benzodiazepines should be gradual to avoid severe withdrawal symptoms such as confusion, seizures, or delirium NICE CKS.
Recent literature supports these guideline recommendations, emphasising that benzodiazepines should be avoided or used with extreme caution in elderly patients due to their side effect profile and the availability of safer alternatives Abad & Guilleminault 2018. The literature also highlights the importance of non-pharmacological interventions and careful patient education about the risks of benzodiazepines Lader 1999.
Key References
- CKS - Insomnia
- CG78 - Borderline personality disorder: recognition and management
- CKS - Benzodiazepine and z-drug withdrawal
- CG115 - Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence
- CG192 - Antenatal and postnatal mental health: clinical management and service guidance
- CG185 - Bipolar disorder: assessment and management
- (Lader, 1999): Limitations on the use of benzodiazepines in anxiety and insomnia: are they justified?
- (Abad and Guilleminault, 2018): Insomnia in Elderly Patients: Recommendations for Pharmacological Management.