Why should benzodiazepines be used with caution in older adults, and what are safer alternatives for anxiety or sleep disorders?

• A. Increases risk of delirium, falls, cognitive impairment; prefer non-pharmacologic approaches; use the lowest effective dose rarely for short periods; consider SSRIs or CBT-I.
• B. They improve cognitive function; use high-dose for longer periods.
• C. They have no adverse effects in older adults; continue as prescribed.
• D. They are preferred first-line for all insomnia; avoid psychotherapy.

Answer: (A)

Older adults are especially sensitive to benzodiazepines, and these drugs can linger in the system due to age-related changes in metabolism and distribution. That heightened CNS depressant effect raises the risk of delirium, cognitive impairment, and especially falls, which can lead to serious injury. Because of these dangers, benzodiazepines should be used with caution and only at the lowest effective dose for the shortest possible duration, with a strong preference for nonpharmacologic approaches first. For anxiety or sleep problems, safer options include nonpharmacologic strategies like cognitive-behavioral therapy for insomnia (CBT-I), sleep hygiene, and relaxation techniques. If pharmacologic treatment is needed, selecting safer alternatives such as selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) for anxiety is preferred due to a more favorable cognitive and safety profile and lower risk of falls and delirium. For sleep disorders, prioritize CBT-I and reserve medications for when necessary, using the lowest possible dose and monitoring closely. This approach aligns with reducing harms while effectively addressing anxiety and sleep concerns in older adults.