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216 Substance Use in Older Adults
North America, Europe, and Australia (mean age ≥40 years) showed that
≤88% of men and ≤79% of women using sedative-hypnotics also con-
sumed alcohol (Ilomäki et al. 2013). Those who misuse benzodiazepines
are mo
scription stimulants than those who do not misuse benzodiazepines
(Ma
abuse of and dependence on alcohol, cannabis, opioids, and stimulants
(Maust et al. 2019a).
number of adverse outcomes,
2015). Older adults already being prescribed a benzodiazepine received
a new opioid prescription at 2.9% of ambulatory care visits versus 1.7%
for those not on a benzodiazepine (Ladapo et al. 2018). Among benzodiazepine users seen by nonpsychiatrist physicians, 10.0% were also
prescribed an opioid (Maust et al. 2016). A study of U.S. veterans (72%
of whom were 65 or older) found that those enrolled with both Veterans
Affairs and Medicare Part D were more likely to be coprescribed benzodiazepines and opioids than those enrolled in one program (Carico et
al. 2018). All of this highlights the critical role that clinicians and health
care systems have in addressing problematic coprescription of benzodiazepines and opioids.
pre
Psychiatric Association 1994) sedative, hypnotic, or anxiolytic abuse or
dependence in the United States is 0.2%, with a much lower prevalence
among older adults, 0.04% (Blanco et al. 2018). Of those adults age >50
who misuse benzodiazepines, 3.1% meet criteria for past-year abuse,
and 6.6% meet criteria for past-year dependence (Maust et al. 2019a).
Given the very low prevalence of sedative, hypnotic, or anxiolytic use
disorder in older adults, we focus next on problems arising from the use
and misuse of sedatives, hypnotics, and anxiolytics.
re likely to use alcohol, cannabis, prescription opioids, and pre-
ust et al. 2019a). Misuse of benzodiazepines is also associated with
Coprescription of benzodiazepines and opioids is associated with a
including lethal overdose (Park et al.
Despite the high use of sedatives, hypnotics, and anxiolytics, the
valence of use disorder is low. The prevalence of DSM-IV (American
USE AND MISUSE OF SEDATIVES,
HYPNOTICS, AND ANXIOLYTICS
Indications in Older Adults
Sedatives, hypnotics, and anxiolytics are appropriate for short-term use
in specific disorders in older adults. For example, a systematic review
of the effectiveness and tolerability of benzodiazepine use in older
adults found that 21 of 25 studies showed improvement of sleep out-
Sedative, Hypnotic, and Anxiolytic Use 217
comes (Gerlach et al. 2018b). Benzodiazepines may be appropriate for
older adults with seizure disorders, REM sleep behavior disorder, alcohol withdrawal, and benzodiazepine withdrawal (American Geriatrics
Society Beers
the treatment of choice for catatonia.
Of ambulatory visits by older adults that resulted in a new prescrip-
tion of a benzodiazepine, 21.3% were for anxiety disorders (Maust et al.
2016). Benzodiazepines
iety disorder in older adults (American Geriatrics Society Beers Criteria
Update Expert Panel 2023). However, the previously mentioned systematic review identified only one study (from 1982) demonstrating efficacy of benzodiazepines for anxiety disorders in older adults (Gerlach
et al. 2018b). Only one of five studies found benzodiazepines to be effective for behavioral and psychological symptoms of dementia (Gerlach
et al. 2018b). We caution against the use of benzodiazepines in
people with dementia or for the treatment of behavioral and psychological symptoms of dementia.
Grief can be a common major stressor in this population. Some clinicians have reported having little hesitancy about prescribing benzodiazepines for acute bereave
perspectives on benzodiazepine prescribing practices, 20% of patients
went on to have long-term use after initially being prescribed benzodiazepines for bereavement (Cook et al. 2007). Although these drugs may be
effective in reducing grief symptoms, consideration must be made for
side effects (discussed later in “Complications in Older Adults”) and firstline recommended treatments. Psychotherapy is the first-line treatment
for prolonged grief disorder, whereas no improvement in outcome has
been found for using benzodiazepines for grief-related symptoms (Simon
2013; Simon et al. 2008; Warner et al. 2001). If pharmacotherapy is being
considered for treatment of complicated grief, SSRIs are recommended,
due to lower side effect profile and improvement of adherence and outcomes when added to prolonged grief therapy (Simon 2013).
Appropriate use of benzodiazepines also depends on the time
course. Acute use refers to ≤7 days of use; intermittent use is about two to
three times a week for <90 days; continuous use is nearly-daily use for a
minimum of 4 months (Llorente et al. 2000
port the continuous use of sedative-hypnotics for management of any
hiatric disorder in older adults. Nevertheless, diagnoses associated
psyc
with prolonged use include pain disorders, depressive disorders, and
trauma-related disorders (Choi et al. 2017; Kessler et al. 2012). Nearly
one-third of older adults prescribed a benzodiazepine by a nonpsychiatrist physician went on to long-term use, defined as a “medication pos-
Criteria Update Expert Panel 2023). Benzodiazepines are
may be appropriate for severe generalized anx-
ment. In a small qualitative study of physician
). There is no evidence to sup-
218 Substance Use in Older Adults
session ratio” >30% in the year after initial prescription (Gerlach et al.
2018a). Interestingly, only 1% of ambulatory visits that resulted in a benzodiazepine prescription to an older adult also included a referral to
psychotherapy (Maust et al. 2016).
Thorough evaluation and diagnostic workup should be completed
before prescribing a sedative, hypnotic, or anxiolytic. If one is indicated,
it should be used briefly. Duration of continued prescribing should be
consistently communicated to the patient to prepare them for eventual
taper and discontinuation (Gerlach et al. 2018b). Ideally, hypnotic medications should not be used for more than 7–10 days to correct the sleepwake cycle in
be used. Inform patients that an increase in symptomology is more
likely due to withdrawal symptoms than a worsening of the underlying
disorder (Moore et al. 2015).
Medications should be prescribed in conjunction with first-line therapies such as an antidepressant and psychotherapy, especially cognitive-behavioral therapy (CBT) for anxiety disorders and insomnia.
Monitoring and r
is another condition not being addressed.
the treatment of insomnia. The lowest dose should always
eassessment are necessary to determine whether there
Complications in Older Adults
Older adults are at risk for a number of complications from the use of
these medications. Complications can arise from the changes with metabolism that occur as people age or from drug–drug interactions due
to polyph
tional Center for Health Statistics 2019). Older adults have less lean
musc
of benzodiazepines, which are fat-soluble (Kuerbis et al. 2014). Because
of the sedative properties of the medication, patients may experience
complications including falls, fractures, cognitive decline, and death
(Markota et al. 2016; Tom et al. 2016). Older adults may also experience
paradoxical reactions to benzodiazepines (Soyka 2017).
ate Medication Use in Older Adults lists benzodiazepines as medications
to av
fractures, and motor vehicle accidents (American Geriatrics Society
Beers Criteria Update Expert Panel 2023). Other sedative-hypnotics to
avoid, according to the Beers Criteria, include first-generation antihistamines (e.g., diphenhydramine, doxylamine, hydroxyzine), barbiturates (because of the high rate of physical dependence and risk of
overdose even at low doses), and z-drugs (noting minimal improve-
armacy (Colliver et al. 2006; Davies and O’Mahony 2015; Na-
le mass and more body fat, resulting in longer duration of action
The American Geriatrics Society Beers Criteria for Potentially Inappropri-
oid because of the risk of cognitive impairment, delirium, falls,
Sedative, Hypnotic, and Anxiolytic Use 219
ment in sleep latency and duration) (American Geriatrics Society Beers
Criteria Update Expert Panel 2023). Z-drugs can also result in serious
injury and death resulting from sleep behaviors such as sleepwalking
and sleep driving, which led to the FDA adding a black box warning to
these medications (U.S. Food and Drug Administration 2019a).
Using a sedative, hypnotic, or anxiolytic can affect cognition. A systematic review of 68 placebo-controlled trials in older adults without
underlying central nerv
in non-amnestic cognitive deficits, whereas benzodiazepines and zdrugs result in both non-amnestic and amnestic cognitive deficits (Tannenbaum et al. 2012). Chronic intoxication may resemble a progressive
neurocognitive
relationship between current use and prospective risk of dementia is
less clear. For example, one prospective cohort study found a slightly
increased incidence of dementia and Alzheimer’s disease over the
course of 10 years with some exposure to benzodiazepines, but not with
higher levels of use (Gray et al. 2016). Another prospective cohort study
found a marked increase in dementia risk over 8 years in users of benzodiazepines with a long half-life (Shash et al. 2016). A systematic review and meta-analysis of 15 studies found that ever having used a
benzodiazepine was associated with a significantly increased risk of dementia (Penninkilampi and Eslick 2018). We would advise older adults
se of benzodiazepines is likely contributing to current cognitive
that u
impairment and may put them at risk of future cognitive impairment.
Benzodiazepine use is associated with an increased risk of suicide
attempt and completed suicide (Dodds 2017). Even after controlling for
medical and psychiatric comorbidities, older adults who died by suicide (by both overdose and other methods) were more likely than
matched control subjects to have been taking benzodiazepines, especially longer-acting benzodiazepines and benzodiazepines at doses
consider
have been associated with suicidal ideation and suicide attempts, although it is possible that distress related to insomnia may be the driver
of increased risk (Tubbs et al. 2021).
Therapeutic use of benzodiazepines or nonbenzodiazepine hypnotics may cause mild withdrawal symptoms due to rebound of underlying symptoms in between doses (Soyka 2017). We discuss withdrawal
oms in greater detail later in “Sedative, Hypnotic, or Anxiolytic
sympt
Use Disorder.”
In the United States, gabapentin has shown abuse patterns, as evidenced by high utilization by a small proportion of users and higher
daily doses (Peckha
disorder (American Psychiatric Association 2022). The
ed too high for older adults (Voaklander et al. 2008). Z-drugs
ous disorders found that antihistamines result
m et al. 2017). Older adults with normal cognition
220 Substance Use in Older Adults
who were initiated on gabapentin were found to have increased risk of
falls and cognitive decline within 2 years of initiation (Oh et al. 2022).
Orexin antagonists are newer medications to treat insomnia. Daytime sedation is a common side effect, which is especially dangerous because it increases risk of falls. However, no significant effects were
found in healthy older adults for driving, cognitive, and psychomotor
performances (Abad and Guilleminault 2018; Herring et al. 2017; Vermeeren et al. 2016). There is a potential for abuse, and so suvorexant
was determined to be a Schedule IV drug. Compared with placebo, suvorexant’s abuse potential was similar to that of zolpidem (Born et al.
2017; Schoedel et al. 2016).
Misuse of Sedatives, Hypnotics, and
Anxiolytics
While complications may arise from clinical use of these medications, it
is important to note that older adults may also misuse them. Misuse has
many definitions, but the ma
directed (Smith et al. 2013). Misuse can be unintentional, for example, if
cognitive impairment exists, if the patient has low health literacy, or if
the patient misunderstood or misremembered instructions from the clinician. As noted earlier in “Epidemiology,” ~0.6% of older adults misuse benzodiazepines (Maust et al. 2019a). Warning signs of misuse
include re
bruises or burns, and new or worsening cognitive impairment (Kuerbis
et al. 2014; Maust et al. 2019a). Misuse may result from poor access to
care, such as for psychotherapy of anxiety disorders and insomnia
(Maust et al. 2019a). Of course, misuse may lead to or be evidence of a
substance use disorder, the topic we cover next.
quests for early refills of medications, falls or unexplained
jority refer to using the medication not as
SEDATIVE, HYPNOTIC, OR ANXIOLYTIC
USE DISORDER
Sedative, hypnotic, or anxiolytic use disorder may be difficult to identify in older adults (see Box 8–1 for DSM-5-TR criteria). Consider the
bility of use disorder in older adults who report that they “need”
possi
benzodiazepines to carry out daily activities, who have difficulty stopping or reducing the dose, who seek early refills from you or from other
clinicians (e.g., in the emergency department), who have had increased
dosage over time, or who have increased breakthrough symptoms (e.g.,
anxiety) despite continuing to take benzodiazepines (Soyka 2017).
Sedative, Hypnotic, and Anxiolytic Use 221
Box 8–1. Sedative, Hypnotic, or Anxiolytic
Use Disorder
Diagnostic Criteria
A. A problematic pattern of sedative, hypnotic, or anxiolytic use leading to
clinically significant impairment or distress, as manifested by at least
two of the following, occurring within a 12-month period:
1. Sedatives, hypnotics, or anxiolytics are often taken in larger
amounts or over a longer period t
2. There is a persistent desire or unsuccessful efforts to cut down or
control sedative, hypn
3. A great deal of time is spent in activities necessary to obtain the sedative, hypnotic, or anxiolytic; use the sedative, hypnotic, or anxiolytic; or
recover f
4. Craving, or a strong desire or urge to use the sedative, hypnotic, or
anxio
5. Recurrent sedative, hypnotic, or anxiolytic use resulting in a failure
to ful
peated absences from work or poor work performance related to
sedative, hypnotic, or anxiolytic use; sedative-, hypnotic-, or anxiolytic-related absences, suspensions, or expulsions from school; neglect of children or household).
6. Continued sedative, hypnotic, or anxiolytic use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of sedatives, hypnotics, or anxiolytics (e.g.,
arguments with a sp
physical fights).
7. Important social, occupational, or recreational activities are given
up or
8. Recurrent sedative, hypnotic, or anxiolytic use in situations in which
it is physically hazardous
machine when impaired by sedative, hypnotic, or anxiolytic use).
9. Sedative, hypnotic, or anxiolytic use is continued despite knowledge
of having
that is likely to have been caused or exacerbated by the sedative,
hypnotic, or anxiolytic.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of the sedative, hyp-
b. A markedly diminished effect with continued use of the same
Note: This criterion is not considered to be met for individuals taking sedatives, hypnotics, or anxiolytics under medical supervision.
rom its effects.
lytic.
fill major role obligations at work, school, or home (e.g., re-
reduced because of sedative, hypnotic, or anxiolytic use.
a persistent or recurrent physical or psychological problem
notic, or anxiolytic to achieve intoxication or desired effect.
amount of the sed
otic, or anxiolytic use.
ouse about consequences of intoxication;
(e.g., driving an automobile or operating a
ative, hypnotic, or anxiolytic.
han was intended.
222 Substance Use in Older Adults
11. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for sedatives, hypnot-
ics, or anxiolytics (refer to Criteria A and B of the criteria set for
ve, hypnotic, or anxiolytic withdrawal).
sedati
b. Sedatives, hypnotics, or anxiolytics (or a closely related substance,
such a
s alcohol) are taken to relieve or avoid withdrawal symptoms.
Note: This criterion is not considered to be met for individuals taking sedatives, hypnotics, or anxiolytics under medical supervision.
Specify if:
In early remission: After full criteria for sedative, hypnotic, or anxiolytic
use disorder were previously met, none of the criteria fo
r sedative, hypnotic, or anxiolytic use disorder have been met for at least 3 months but
for less than 12 months (with the exception that Criterion A4, “Craving,
or a strong desire or urge to use the sedative, hypnotic, or anxiolytic,”
may be met).
In sustained remission: After full criteria for sedative, hypnotic, or anx-
iolytic use d
isorder were previously met, none of the criteria for sedative, hypnotic, or anxiolytic use disorder have been met at any time
during a period of 12 months or longer (with the exception that Criterion
A4, “Craving, or a strong desire or urge to use the sedative, hypnotic,
or anxiolytic,” may be met).
Specify if:
In a controlled environment: This additional specifier is used if the in-
dividual is in an environment where access to sedatives, hypnotics, or
anxiolytics is restricted.
Specify current severity:
Mild: Presence of 2–3 symptoms.
Moderate: Presence of 4–5 symptoms.
Severe: Presence of 6 or more symptoms.
Source. Reprinted from American Psychiatric Association: Diagnostic and Statistical Man-
ual of Mental Disorders, 5th Edition, Text Revision. Washington, DC, American Psychiatric
As
sociation, 2022. Copyright © 2022 American Psychiatric Association. Used with per-
mission.
Because many older adults are retired or socially isolated, they may
not experience occupational or interpersonal dysfunction; instead, they
may develop problems with instrumental activities of daily living (e.g.,
driving, cooking) or personal activities of daily living (e.g., taking medications correctly, grooming, hygiene). Family members or caregivers
may expres
s concern about the older adult’s use of medications or
about their functioning. Co-occurring use with alcohol can also exist
and is important to recognize. Increased social isolation and/or a recent
life stressor (e.g., death of a loved one) may also accompany sedative,
hypnotic, or anxiolytic use disorder.
Sedative, Hypnotic, and Anxiolytic Use 223
Clinicians should be vigilant for any sign of withdrawal from sedatives, hypnotics, or anxiolytics. Symptoms can include anxiety, panic,
restles
sness, agitation, mood swings, insomnia, nightmares, muscle tension, weakness, muscle spasms, paresthesia, tremor, and flu-like symptoms (Soyka 2017). Abrupt cessation of a sedative, hypnotic, or
anxiolytic can r
esult in seizures; other severe symptoms include paranoia, hallucinations, and delirium (Soyka 2017). Because of medical comorbidities, older adults may suffer complications from tachycardia
and hypertension. The possibility of withdrawal should be considered
in any older adult taking sedatives, hypnotics, or anxiolytics who develops delirium. Of course, use of these medications, especially those
with
anticholinergic properties (e.g., diphenhydramine), could also re-
sult in delirium.
In Case Example 8–1, an astute clinician identifies warning signs of
sedative, hypnotic, or anxiolytic use disorder and appropriately updates the diagnosis and treatment plan.
Case Example 8–1: “That’s the only thing
that’s ever helped with my sleep”
Ms. Fitz is a 67-year-old widow with insomnia, generalized anxiety disor-
der, major depressive disorder in remission, and diabetes mellitus compli-
cated by neuropathy and hypertension, who presents to a geriatric
psychiatri
She had been well maintained on alprazolam 0.5 mg at bedtime, venlafax-
ine XR 37.5 mg at breakfast, and gabapentin 300 mg tid with her previous
psychiatrist for the past 15 years. Ms. Fitz was recently discharged from a
physical rehabilitation (rehab) facility after a ground-level fall. She broke
her right radius and required surgery and hospital admission before being
transferred to rehab. While in rehab, she was prescribed opioid pain med-
ication by her medical team until her next outpatient follow-up appoint-
ment (2 weeks). Today, she expresses increased anxiety about falls, as this
ma
hitting her head during her previous falls. The most recent fall was the
most serious and the first to result in a bone fracture. She currently has a
home health aide and regular outpatient physical therapy. The geriatrics
psychiatrist reviews the discharge medications with her during intake.
Upon reaching alprazolam on her medication list, Ms. Fitz states, “that’s
the only thing that’s ever helped with my sleep.”
clone, and trazodone. When asked about nonmedication strategies, she
looks puzzled and said she has not tried any. Further along during in-
take, the risks for decreased breathing are discussed because she was
still taking prescribed pain medication and gabapentin. She exclaims
c clinic for her first follow-up appointment 1 month after intake.
rks her third fall in the past 2 years. She denies losing consciousness or
Ms. Fitz told the psychiatrist that she tried a number of other medi-
224 Substance Use in Older Adults
that she was told about this but felt her anxiety was too high at the hospital and rehab facility. Further discussion touches on the risk of falls
with her alprazolam as w
ing of the risks and that she is scared to stop the alprazolam because she
has been on
cially with the pain from the recent fall. She denies any other substance
use and denies any
When coordinating care, the new doctor learns that Ms. Fitz stopped
seeing
crease her alprazolam. There was no misuse reported in the records, but
the taper attempt coincided with her first fall about 3 years ago. On further review, the new doctor finds a history of withdrawal symptoms
durin
and tremors, but no seizures or delirium tremens. Labs were completed
to rule out any potential medical conditions contributing to her anxiety,
and all were within normal limits.
During the next follow-up appointment, the psychiatrist discusses
the records from Ms. Fitz’s previous clinic. When asked about the withdrawal symptoms, she did not recognize them as withdrawal and
thought the tremors we
cusses the diagnosis of sedative, hypnotic, or anxiolytic use disorder
and the risk of withdrawal. Ms. Fitz did not realize that alprazolam was
meant for short-term use and that the risk of side effects increases with
age and continued use. She was also unaware that it was a short-acting
medication, and that the effects would not last long. She is open to another taper as long as it is slow.
The new psychiatrist switches alprazolam to clonazepam, a longeracting benzod
her that this medication will be decreased and eventually stopped. She
is told that the venlafaxine dose is low and not adequately managing
her anxiety symptoms. She also agrees to increase this medication after
being informed that antidepressants are first-line treatment for anxiety.
The new doctor coordinates care with the orthopedic doctor to ensure
there is a taper schedule for the pain medication as well to reduce Ms.
Fitz’s all-around risks.
it so long and she feels she cannot sleep without it, espe-
her previous psychiatrist because they were attempting to de-
g the previous tapering process, which included increased anxiety
iazepine, after discussing it with Ms. Fitz and informing
ell as gabapentin. She expresses understand-
withdrawal symptoms.
re part of her anxiety. The new psychiatrist dis-
Limited data are available regarding the clinical course of sedative,
hypnotic, or anxiolytic use disorder. The disorder typically starts in
one’s teens or twenties following escalation from occasional use of these
medications; alternately, the disorder may be preceded by prescription
of these medications for anxiety or insomnia (American Psychiatric Association 2022). Once the disorder develops, the course may fluctuate
between periods fr
ee from substance and then active use (Allgulander
et al. 1984). Almost 50% of individuals will return to use within 4 years
of receiving treatment (Allgulander et al. 1987). As discussed earlier,
people with sedative, hypnotic, or anxiolytic use disorder are at increased risk of accidental overdose and suicide.
Sedative, Hypnotic, and Anxiolytic Use 225
SCREENING AND ASSESSMENT
The screening, brief intervention, and referral to treatment (SBIRT) model
emphasizes universal screening for substance use disorders in health care
settings, followed by brief interventions for those with disorders or at risk
of developing them. SBIRT has been adapted for older adults, including
prescreening by asking, “In the last year, have you used prescription or
other drugs more than you meant to?” (Schonfeld et al. 2015). Positive
prescreens lead to administration of the Alcohol, Smoking, and Substance
Involvement Screening Test (ASSIST), resulting in stratification of low,
moderate, moderate to high, or high risk of substance use disorder
(Schonfeld et al. 2015). Most of the 9.6% of older adults who screened positive for alcohol or drug use received immediate brief interventions
(Sc
honfeld et al. 2015). As discussed in Chapter 2, other screening tools in-
clude ASSIST-Lite and NIDA Quick Screen V1.0 (National Institute on
ug Abuse 2011). We discuss SBIRT in greater detail in Chapter 3.
Dr
Red flags for a use disorder including long-term use, rebound anxiety and insomnia on withdrawal of the drug, strong desire to use benzodiazepi
use of benzodiazepines despite falls, use of benzodiazepines in addition to other hypnotics, and continuing to use benzodiazepines despite
physician recommendations to discontinue (Markota et al. 2016).
index of s
the next step is a thorough history of both medical and psychiatric conditions. Completing a physical examination and laboratory testing are
essential to have a better understanding of overall health and any cooccurring conditions that may impact management. Specifically, clinicians need to assess for any underlying depression (e.g., screening with
Patient Health Questionnaire-9 [PHQ-9] or Geriatric Depression Scale),
anxiety (10-item Geriatric Anxiety Scale [GAS] or 7-item Generalized
Anxiety Disorder [GAD-7]), PTSD, and cognitive impairment (Montreal Cognitive Assessment [MoCA] or St. Louis University Mental
Status
Sc
reening for elder abuse should also be completed (Hall et al. 2016).
notic, sedative, and anxiolytic use disorders in older adults. It is recommended to use it as a tool in a collaborative discussion about use rather
than a measur
viewing a state’s drug monitoring program for other potential controlled substances, or any other sedative-hypnotic prescriptions, should
nes, driving while under the influence of benzodiazepines,
For older adults who screen positive and for whom there is a high
uspicion for sedative, hypnotic, or anxiolytic use disorder,
[SLUMS]). This is discussed in greater detail in Chapter 2.
There is no clear evidence for a role in urine drug screening for hyp-
e to chastise the patient (Brett and Murnion 2015). Re-
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