All it Takes is a Conversation: Deprescribing Benzodiazepines in Older Adults
Benzodiazepines have proven effective in managing anxiety and insomnia, but they heighten risk of falls, cognitive impairment, functional decline, and mortality among older adults.
Prescribing medications and intensifying therapeutic regimens are often at the forefront of optimizing patient care. However, patients can accumulate a plethora of medications and such polypharmacy can cause adverse effects and even, potentially, the development of new conditions and diseases.
Benzodiazepines have proven effective in managing anxiety and insomnia, but they heighten risk of falls, cognitive impairment, functional decline, and mortality among older adults, as well as avoidable hospitalizations. Regardless of their risks and the availability of safer first-line treatments for anxiety and insomnia, benzodiazepines are still one of the most commonly prescribed medication classes in the United States, being given to almost 10% of Medicare beneficiaries.
At a large academic primary care clinic in Massachusetts, a team of researchers conducted a prospective single-center quality improvement project between February and April 2022, examining benzodiazepine deprescribing. A study evaluation published in the Journal of the American Geriatrics Society indicates that simple conversations and education are enough to facilitate benzodiazepine deprescribing. Health care professionals such as pharmacists and providers can overcome clinical inertia by actively promoting and facilitating shared decision-making. This involves fostering effective patient education and communication, thereby empowering patient advocacy. The knowledge of pharmacists is often underutilized as medication experts in these processes.
This quality improvement program targeted adults aged 65 years and older receiving chronic benzodiazepines prescribed by their primary care physician (PCP). PCPs opted out patients who were not suitable for deprescribing. Subsequently, pharmacists and physicians from the research team mailed a brief customized letter summarizing the increasing risks of benzodiazepine use with age to eligible patients. The letter also discussed patient-specific risk factors such as co-prescription of opioids, muscle relaxants, or gabapentinoids. It advised patients to discuss deprescribing with their PCP or the clinic’s Safe Prescribing Team, which consisted of a clinic pharmacist and 2 physicians. Pharmacists were crucial in supporting the prescriber and helping patients safely tapering down their benzodiazepines.
The one-time educational mailing led to a quarter of patients discussing benzodiazepine deprescribing with a clinician within 90 days, and one-quarter of these patients initiated a taper. At 12 months, 36% took a lower benzodiazepine dose, and 28% discontinued benzodiazepines completely.
Chronic benzodiazepine use can lead to physical dependence, causing withdrawal symptoms if abruptly discontinued. However, patient-centered goals may not always require complete discontinuation. In this study, the clinic pharmacist virtually monitored patients who initiated a gradual taper every 2 to 6 weeks to ensure ongoing care. Furthermore, PCPs are often so busy with competing priorities that they don’t have the time to be trained to deprescribe or train their patients. In this study, only 1 of 50 PCPs scheduled an education session. This underscores pharmacists’ critical contributions to the deprescribing process, particularly in monitoring and education.
While many clinical trials study safe and effective benzodiazepine deprescribing, few examine implementation in real-world clinical practice. As a result, deprescribing often takes place after an adverse drug event occurs. This low-intensity, proactive benzodiazepine deprescribing program provides insight and a practical model to clinicians and health systems in safely reducing benzodiazepine usage with older adults. It shows that even a single passive intervention can prompt discussions and actual dose reductions in real-world situations. Moving forward, this program can be expanded to include more thorough patient outreach, multiple mailings to patients, deprescribing training for clinicians, and adjustments to outreach intensity based on medication-related harms.
About the Author
Alvin Tan is a 2025 PharmD candidate at the University of Connecticut.
Reference
Chae S, Lee E, Lindenberg J, Shen K, Anderson TS. Evaluation of a benzodiazepine deprescribing quality improvement initiative for older adults in primary care. J Am Geriatr Soc. Published online December 26, 2023. doi:10.1111/jgs.18728
