Therapeutic dilemmas with benzodiazepines and Z-drugs: insomnia and anxiety disorders versus increased fall risk: a clinical review

Abstract

Purpose The aim of this clinical review was to summarise the existing knowledge on fall risk associated with benzodiazepines (BZDs) and Z-drugs in older people with focus on appropriate prescribing, including deprescribing. Methods We conducted a literature search in June 2021 in PubMed and Embase with citation and reference checking. Personal reference libraries and international websites were also used. Keywords for the searches included “benzodiazepines”, “Z-drugs”, “falls”, “deprescribing”, “fall-risk-increasing-drugs”, “inappropriate prescribing”, “older people” and matching synonyms. We discuss use of BZDs and Z-drugs, potential fall-related adverse reactions, alternatives for and deprescribing of BZDs and Z-drugs in older persons. Results BZDs and Z-drugs differ in fall-related adverse effect profile. They contribute to fall risk through orthostatic hypotension, dizziness and/or imbalance, sedation, muscular weakness, ataxia, etc. Fall incidents contribute significantly to mortality and morbidity. Therefore, there is a need for appropriate prescribing and use of BZDs and Z-drugs in older people. In practice, this means pertaining to a strict indication, strongly consider to non-pharmacological alternatives, limit use to the lowest dose and the shortest duration possible. Judicious deprescribing should be considered and encouraged as well. Practical resources, tools and algorithms are available to guide and assist clinicians in deprescribing BZDs and Z-drugs. Conclusions Prescribing BZDs and Z-drugs should be done in a well-considered way in fall-prone older people. A good overview and insight in the fall-related adverse effects of these drugs, as well as the availability of different strategies to increase the appropriate use, including deprescribing initiatives, can assist clinicians in clinical decision-making.

Insomnia in Postmenopausal Women: How to Approach and Treat It?

“…Common side effects of benzodiazepines and Z-class drugs include headache, dizziness, and daytime sleepiness and drowsiness, and in particular, the elderly are at increased risk of side effects such as cognitive function impairment, delirium, and falls and fractures due to the muscle relaxation effect, although Z-class drugs have relatively fewer side effects compared to benzodiazepines [73]. It is not clear to what extent these sedative hypnotics impact insomnia in postmenopausal women, but considering that older women are more vulnerable to fractures, more caution is needed when prescribing them to older women [74]. Indeed, meta-analyses showed that the use of benzodiazepines or Z-class drugs was associated with an increased risk of falls and fractures in older adults [75,76].…”

Hyperbaric oxygen therapy for poststroke insomnia: a systematic review and meta-analysis protocol

“…Consequently, the study ardently advocated the contemplation of non-pharmacological substitutes and proposed the imposition of stringent restrictions on the minimum prescribed dosages and the abbreviated temporal span of drug utilisation. 27 Concerning non-pharmacological interventions, cognitive behavioural therapy for insomnia (CBT-I) stands as one of the more prevalent modalities. 28 Cognitivebehavioural therapy represents a multifaceted therapeutic regimen encompassing sleep education, behavioural interventions, cognitive restructuring and relaxation therapies.…”

“…Importantly, these fall events directly contributed to an amplified mortality risk. Consequently, the study ardently advocated the contemplation of non-pharmacological substitutes and proposed the imposition of stringent restrictions on the minimum prescribed dosages and the abbreviated temporal span of drug utilisation 27…”

Association Between Hypnotics and Dementia: A Mini Narrative Review

“…In response to these sleep-related issues, the widespread use of hypnotics, especially benzodiazepines (BZDs), and Z-drug (ZD), has emerged as a common treatment [ 3 ]. Nevertheless, ongoing debates persist regarding the potential long-term consequences of prolonged hypnotics use on health [ 4 - 6 ].…”

“…3 Nevertheless, ongoing debates persist regarding the potential long-term consequences of prolonged hypnotics use on health. [4][5][6] In 2019, an approximate 57.4 million individuals across the globe were afflicted by dementia, and prognostications indicated that the incidence of such cases was poised to nearly triple within the ensuing three decades. 7 Modifying several risk factors, like hypertension, obesity, diabetes mellitus and smoking, could help prevent or delay up to 40% of dementias.…”