Benzodiazepine Users Aged 85 and Older Fall More Often

To the Editor: Older people, and the oldest old in particular, those aged 85 years and older, constitute the fastest growing segment of the population. Older individuals are also more likely to take medications because of the high prevalence of chronic illness. As a result of altered pharmacokinetics and pharmacodynamics in older people, adverse drug reactions are more frequent and more severe. However, adverse drug reactions are associated more consistently with polypharmacy than with the effect of age itself.1,2 Falls are an important risk factor in older people, leading to fractures, hospitalization, loss of independence, and mortality.3 Falling is a multifactorial problem, to which benzodiazepine use may be one of the contributing factors.3–5 Both benzodiazepine elimination half-life and dosage have been implicated.4,6 The incidence of falls and fractures, as well as the use of benzodiazepines, increases with age. So far, the association between benzodiazepine use and falling has not been established unequivocally.3–7 This letter addresses the relationship between benzodiazepine use and falls in the oldest old. This work was part of the “Leiden 85-plus monitoring project.” At the entry date, August 1, 1990, the number of inhabitants aged 85 and older was 1478, representing 1.3% of the total population. A sample of 368 subjects was selected randomly. Of these, 63 declined to participate, and 66 died before they could be approached. A physician visited participants at their residence. The medical history included a question about the number of falls in the last 6 months. Respondents were asked to show all drugs that they actually used, thus including both prescription and over-the-counter medications. In the case of doubt of the validity of the data obtained, the actual use of medications and the number of falls was verified through caregivers or nursing staff. Data were incomplete for 19 subjects, leaving 220 participants (mean age 90 + 3; 157 women and 63 men; 122 living independently, 79 in homes for the elderly, and 19 in nursing homes). This sample is representative of the general Dutch population aged 85 years and over in regard to demographic characteristics.8 The mean number of medications used was 3.2 + 2.4 (+SD). Diuretics were the medication used most frequently (41%), followed by benzodiazepines (27%). Women used more benzodiazepines than men, 32% versus 16% (P = .02). Thirty percent of the subjects studied used potentially dangerous combinations, most of which involved diuretics. Four percent of the subjects used two different benzodiazepines. A single fall was not associated with the use of benzodiazepines (RR = .9, 95% CI = .4–2.3). Recurrent falls, however, occurred three-times more frequently in those using benzodiazepines and 15 times more frequently in those using two different benzodiazepines (Table 1). Recurrent falls occurred 10 times more often in those using benzodiazepines with a long elimination half-life, whereas they occurred 2.5 times more often in those using benzodiazepines with short to moderate elimination half-life (Table 1). There was no statistically significant correlation between falling and the number of medications, the use of antidepressants, antiepileptics, antipsychotics, opioids, analgesics, β-blocking agents, or diuretics (data not shown). These data confirm that polypharmacy and its sequelae exist in the oldest old and stress the importance of reviewing medications periodically in the oldest old. There is hardly any justification for long-term prescription of benzodiazepines in any age group. Nevertheless, the present population-based study shows that 27% of the oldest old used benzodiazepines. Moreover benzodiazepine use in the oldest old represents an up to 15-fold increased risk of recurrent falls. In particular, the prescription of more than one benzodiazepine and of benzodiazepines with long elimination half-life should be avoided because this exposes the oldest old to an avoidable risk. This implies that both physicians and pharmacists should maximize their efforts to minimize benzodiazepine use. In the sixties, the Rolling Stones’ song “Mother's Little Helper” drew attention to the indiscriminate use of benzodiazepines. Today, with the growing awareness of the needs of the aging population it should not be accepted that benzodiazepines are prescribed as “Grandmother's Little Helper.”