What are the potential risks and benefits of prescribing benzodiazepines for insomnia in older adults?

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 ¹.

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 ¹. 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 ¹,⁶.

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 ¹. 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 ¹.

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 ¹,³. Withdrawal from benzodiazepines should be gradual to avoid severe withdrawal symptoms such as confusion, seizures, or delirium ³.

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 and Guilleminault, 2018). The literature also highlights the importance of non-pharmacological interventions and careful patient education about the risks of benzodiazepines (Lader, 1999).