An FAQ with the Center for Population Health
Fall risk is increased among older adults with many medications, including benzodiazepines. Best practices for treating insomnia now emphasize alternative solutions.
Why should benzodiazepines be avoided, when possible?
ANSWER: As people age, drugs have significant side effects. Benzodiazepines can influence symptoms, such as dizziness, confusion, memory loss, vision impairment, and loss of coordination—all of which can carry over into waking hours. Studies have found a dramatic increase in falls and fractures among patients using benzodiazepines, particularly older patients. Because falls are a leading cause of injuries, hospitalization, and death in this population, this increased risk is best avoided.
What insomnia treatments should be tried first?
ANSWER: Treatment of insomnia should always begin with nondrug therapy, which has been found to be highly effective and free of side effects. Top recommendations include:
- Improved sleep hygiene. This involves assessment and management of habits and conditions that can inhibit or enhance sleep, including nighttime screen use, light exposure, and bedroom temperature, as well as caffeine, alcohol, and nicotine use.
- Exercise. Several studies have found that exercise is as effective as benzodiazepines in treating insomnia.
- Relaxation and cognitive behavioral therapies. These have been found to be highly effective for relieving insomnia.
What alternative medication options should be considered for insomnia?
ANSWER: If nondrug options don’t relieve insomnia, or a patient needs relief right away, medication might be required. In this case, it’s recommended to try one of the newer nonbenzodiazepine hypnotics first. These include zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta). These medications are about as effective as benzodiazepines and may be less likely to cause a fall. However, they do still have side effects, such as daytime sleepiness and impaired coordination, that can lead to falls. Therefore, these drugs should be prescribed carefully, especially in older adults.
If a benzodiazepine is used, what steps should be taken?
ANSWER: If no other options are effective, a benzodiazepine can be considered. When prescribing them, be sure to educate the patient about how to use them safely.
- Review the patient’s prescription and over-the-counter medications to ensure that no other sedating drugs are being taken (such as opioids, antidepressants, or diphenhydramine).
- Start at the lowest effective dose. A lower dosage is recommended for older adults.
- Prescribe the drug for a short period, ideally no longer than two weeks. After this time, the drugs lose their effectiveness and the risk of dependence increases.
- Discuss possible side effects, including increased risk for falls.
- Warn the patient that it can be dangerous to drink alcohol while taking benzodiazepines.
- Follow up with the patient to determine how the treatment is working. Remind the patient to call if any side effects occur that are concerning.
- Have the patient taper off the medication to prevent withdrawal.