Benzodiazepines such as Klonopin (generic = clonazepam), Xanax (generic = alprazolam), Ativan (generic = lorazepam) have a long and controversial history of use to treat behavioral challenges in those with Alzheimer’s disease. These disturbances range from agitation, anxiety, delusions, and hallucinations to sleep disturbances. The controversy deepened with the recent finding of a correlation between benzodiazepine use and risk of dementia. This risk appears to develop with chronic (i.e., daily) use of these medications for three or more months.

At this time there is no agreement on use benzodiazepines as an alternative to antipsychotics, which have potentially serious side effects in the elderly. Current guidelines recommend use of benzodiazepines be limited to a few weeks despite the fact that they are often used for years. Long-term daily use of benzodiazepines is associated with increased risk of falls, dependence, and withdrawal (“discontinuation”) syndromes, which is also a problem with antipsychotic, antidepressant, and antiseizure medications.

“Use of benzodiazepines in Alzheimer’s disease: a systematic review if the literature” (International Journal of Neuropsychopharmacology, 2015, in press, PMID 25991652) provides a current update. The review was undertaken in an attempt to provide evidence-based suggestions for use of benzodiazepines in dementia. There were 657 articles between considered between 1983 and 2015. Unfortunately, after careful review there were only 18 articles that met research standards high enough to be included in the review. Among the findings were:
1) Benzodiazepine use in combination with any other psychotropic medication increased risk of falls with higher doses producing more falls.
2) Nearly 10% of Alzheimer’s patients in skilled nursing homes were treated continuously with benzodiazepines for 2 or more years. Use in skilled nursing homes may be as high as 50%.
3) Benzodiazepines are more frequently prescribed for patients with a diagnosis of Alzheimer’s than vascular dementia.
4) Benzodiazepines are often used in combination with other psychotropic medications increasing the risk of drug interactions.
5) Benzodiazepines were more often used in Alzheimer’s patients who had arthritis or rheumatism than patients without that diagnosis. This implies misdiagnosis when pain may be the source of difficult behaviors rather than dementia.
6) Long-term use of benzodiazepines – especially long-acting – is associated with increased speed of decline, increased severity of dementia, and shorter time to death.
7) Benzodiazepines further impair cognition.
8) There is little good evidence to make conclusions about the effects of benzodiazepines on sleep disorders in Alzheimer’s.
9) Targeted use of benzodiazepines is helpful in managing episodic agitation.

After review of all well designed studies the authors concluded that they could offer “no clear guidelines” for the use of benzodiazepines to manage behavioral disturbances associated with Alzheimer’s disease. Despite widespread use benzodiazepines are less than 50% effective to manage agitation. This finding may be do to the fact that much of the agitation is triggered by such things as pain, overstimulation, understimulation, or fatigue, which should be the focus of intervention. We clearly need to spend more research dollars on clarifying guidelines for use of psychotropic medications to treat behavioral disturbances in dementia.