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Deprescribing of Benzodiazepines in Older Adults (DBO) 

This measure assesses the percentage of Medicare members 67 years of age and older who were dispensed benzodiazepines and achieved a 20% decrease or greater in benzodiazepine dose during the measurement year.

Why It Matters?

The deprescribing measure is complementary to the Use of High-Risk Medications in Older Adults (DAE) measure. The DAE measure assesses potentially inappropriate use of benzodiazepines in the Medicare population by measuring “any dispensing” of benzodiazepines (defined as at least two dispensing events) in the measurement year. The deprescribing measure provides a metric to support safe transition off of benzodiazepines for those members referenced in DAE who are currently and routinely using them.

Benzodiazepines have class-level warnings for users that include dependence and withdrawal reactions, such as seizures, central nervous system depression and impaired performance.1 Benzodiazepines induce sedation, which causes drowsiness, delayed reaction times and impaired balance.2 This can result in increased risk of hip fractures, falls and fall-related injuries in older adults prescribed short- and long-acting benzodiazepines.2,3,4,5,6 Although benzodiazepines are indicated for short-term treatment of generalized anxiety disorder,7,8,9 there is risk of continued long-term use in older adults, as many chronic users are rarely encouraged to discontinue the medication.10,11 Studies have found that long-term use of benzodiazepines in older adults is also associated with increased risk of dementia.12,13,14,15 Other harms related to benzodiazepine use include impaired cognition, loss of physical function, depressed mood and suicidal thoughts.16,17,18

Despite the risks associated with benzodiazepines, these medications are inappropriately prescribed and overused in the older adult population. Older adults are prescribed benzodiazepines at the highest rate and are most at risk of adverse events among all U.S. adults.19,20 In 2015, CMS reported that 17.6% of all Medicare Part D enrollees were dispensed benzodiazepines.21 After the expansion of Medicare coverage for prescription benzodiazepines in 2013, the prevalence of benzodiazepine use increased.20,22 This increase in prevalence may be associated with both increases in fall-related injuries and medication poisoning among older adults.20

Use of benzodiazepines is associated with higher health care service use and costs. A recent study estimates that about 212,770 ED visits involving adverse medication-related events in 2016 were related to benzodiazepine use, representing approximately 10% of all ED visits attributed to adverse medication-related events.23 Specifically among older adults, it estimated that half of the ED visits involved non-therapeutic use of benzodiazepines (i.e., taking the drug inappropriately or not as prescribed).23 Among all potentially inappropriate medications, benzodiazepines were identified as the third largest medication class contributing to total medication costs of older adults living in residential care, following proton-pump inhibitors and antipsychotics.24

Given the risks and high utilization, multiple sources of clinical or other guidance recommend against benzodiazepine use in older adults. The 2023 American Geriatrics Society (AGS) Beers Criteria® for Potentially Inappropriate Medication (PIM) Use in Older Adults recommend avoiding benzodiazepines—all short-, intermediate-, and long-acting forms—for all older adults due to risk of cognitive impairment, delirium, falls, fractures and motor vehicle crashes.25 The Screening Tool of Older Persons’ Prescriptions (STOPP) CNS criteria D5 recommends that benzodiazepines should not be taken for ≥4 weeks if there is no indication for longer treatment, due to risk of prolonged sedation, confusion, impaired balance, falls and traffic accidents. The guideline continues, “all benzodiazepines should be withdrawn gradually if taken for >2 weeks, as there is a risk of causing a benzodiazepine withdrawal syndrome if stopped abruptly.”26

It is important to reduce benzodiazepine use among current users through appropriate “deprescribing,” which is the process of tapering, with the goal of stopping drugs, to improve patient outcomes. Benzodiazepines should be discontinued at a rate that is appropriate and safe for older adults. Several deprescribing guidelines for older adults (aged 65 and older) recommend starting with a larger taper amount (between 20% and 25%), holding at that dose for 2–4 weeks, then tapering by a lower amount (e.g., by 5%–12.5%). Overall, there is agreement that a slower taper is considered better to minimize withdrawal symptoms such as insomnia, anxiety, restlessness and seizures,27,28,29 Immediate discontinuation of benzodiazepines is not recommended;30,31,32 therefore, there is a need for a tapering measure to balance measures incentivizing no benzodiazepine use and to provide a path to safe discontinuation of the drug. With a deprescribing measure, there is opportunity to promote harm reduction by assessing progress in appropriately reducing benzodiazepine use in the older adult population.

Historical Results – National Averages

Performance results for this measure are currently unavailable.

References

  1. Food and Drug Administration (FDA). 2011. XANAX Prescription Label. https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/018276s045lbl.pdf 
  2. Donnelly, K., R. Bracchi, J. Hewitt, P.A. Routledge, & B. Carter. 2017. “Benzodiazepines, Z-Drugs and the Risk of Hip Fracture: A Systematic Review and Meta-Analysis.” PLOS ONE 12(4), e0174730. https://doi.org/10.1371/journal.pone.0174730
  3. Bakken, M.S., A. Engeland, L.B. Engesæter, A.H. Ranhoff, S. Hunskaar, & S. Ruths. 2014. “Risk of Hip Fracture Among Older People Using Anxiolytic and Hypnotic Drugs: A Nationwide Prospective Cohort Study.” European Journal of Clinical Pharmacology 70(7), 873–880. https://doi.org/10.1007/s00228-014-1684-z
  4. de Vries, O.J., G. Peeters, P. Elders, C. Sonnenberg, M. Muller, D.J.H. Deeg, & P. Lips. 2013. “The Elimination Half-Life of Benzodiazepines and Fall Risk: Two Prospective Observational Studies.” Age and Ageing 42(6), 764–770. https://doi.org/10.1093/ageing/aft089
  5. Woolcott, J.C., K.J. Richardson, M.O. Wiens, B. Patel, J. Marin, K.M. Khan, & C.A. Marra. 2009. “Meta-Analysis of the Impact of 9 Medication Classes on Falls in Elderly Persons.” Archives of Internal Medicine 169(21), 1952–1960. https://doi.org/10.1001/archinternmed.2009.357
  6. Xing, D., X.L. Ma, J.X. Ma, J. Wang, Y. Yang, & Y. Chen. 2014. “Association Between Use of Benzodiazepines and Risk of Fractures: A Meta-Analysis. Osteoporosis International: A Journal Established as Result of Cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA 25(1), 105–20. https://doi.org/10.1007/s00198-013-2446-y
  7. Davidson, J.R. 2001. “Pharmacotherapy of Generalized Anxiety Disorder.” The Journal of Clinical Psychiatry. 
  8. Gorman, J.M. 2003. “Treating Generalized Anxiety Disorder.” Journal of Clinical psychiatry 64(1), 24-29. 
  9. Lydiard, R.B., K. Rickels, B. Herman, & D.E. Feltner. 2010. “Comparative Efficacy of Pregabalin and Benzodiazepines in Treating the Psychic and Somatic Symptoms of Generalized Anxiety Disorder.” International Journal of Neuropsychopharmacology 13(2), 229-241. 
  10. Paquin, A.M., K. Zimmerman, & J.L. Rudolph. 2014. “Risk Versus Risk: A Review of Benzodiazepine Reduction in Older Adults.” Expert Opinion on Drug Safety 13(7), 919–934. https://doi.org/10.1517/14740338.2014.925444
  11. Sivertsen, B., S. Omvik, S. Pallesen, B. Bjorvatn, O.E. Havik, G. Kvale, et al. 2006. “Cognitive Behavioral Therapy vs Zopiclone for Treatment of Chronic Primary Insomnia in Older Adults: A Randomized Controlled Trial.” JAMA 295(24):2851-8. 
  12. He, Q., X. Chen, T. Wu, L. Li, & X. Fei. 2019. “Risk of Dementia in Long-Term Benzodiazepine Users: Evidence from a Meta-Analysis of Observational Studies.” Journal of Clinical Neurology (Seoul, Korea) 15(1), 9–19. https://doi.org/10.3988/jcn.2019.15.1.9
  13. Shash, D., T. Kurth, M. Bertrand, C. Dufouil, P. Barberger-Gateau, C. Berr, K. Ritchie, J.-F. Dartigues, B. Bégaud, A., Alpérovitch, & C. Tzourio. 2016. “Benzodiazepine, Psychotropic Medication, and Dementia: A Population-Based Cohort Study.” Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association 12(5), 604–613. https://doi.org/10.1016/j.jalz.2015.10.006
  14. Takada, M., M. Fujimoto, & K. Hosomi. 2016. “Association between Benzodiazepine Use and Dementia: Data Mining of Different Medical Databases.” International Journal of Medical Sciences 13(11), 825–834. https://doi.org/10.7150/ijms.16185
  15. Zhong, G., Y. Wang, Y. Zhang, & Y. Zhao. 2015. “Association Between Benzodiazepine Use and Dementia: A Meta-Analysis.” PLoS ONE 10(5). https://doi.org/10.1371/journal.pone.0127836 
  16. Baandrup, L., B.H. Ebdrup, J.Ø. Rasmussen, J. Lindschou, C. Gluud, & B.Y. Glenthøj. 2018. “Pharmacological Interventions for Benzodiazepine Discontinuation in Chronic Benzodiazepine Users.” Cochrane Database of Systematic Reviews, 3. https://doi.org/10.1002/14651858.CD011481.pub2
  17. Blanco, C., B. Han, C.M. Jones, K. Johnson, & W.M. Compton. 2018. “Prevalence and Correlates of Benzodiazepine Use, Misuse, and Use Disorders Among Adults in the United States.” The Journal of Clinical Psychiatry 79(6). https://doi.org/10.4088/JCP.18m12174
  18. Greller, H., & A. Gupta. 2017. “Benzodiazepine Poisoning and Withdrawal.” In S. Traub & Grayzel (Eds.), UpToDate. 
  19. Guina, J., & B. Merrill. 2018. “Benzodiazepines I: Upping the Care on Downers: The Evidence of Risks, Benefits and Alternatives.” Journal of Clinical Medicine 7(2). https://doi.org/10.3390/jcm7020017
  20. Maust, D.T., L.A. Lin, & F.C. Blow. 2018. “Benzodiazepine Use and Misuse Among Adults in the United States.” Psychiatric Services 70(2), 97–106. https://doi.org/10.1176/appi.ps.201800321
  21. Centers for Medicare & Medicaid Services (CMS). 2016. Concurrent Use of Opioids and Benzodiazepines in a Medicare Part D Population. https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Concurrent-Use-of-Opioids-and-Benzodiazepines-in-a-Medicare-Part-D-Population-CY-2015.pdf
  22. Zimlich, R. April 29, 2016. “Impact of Medicare’s Expanded Benzodiazepine Coverage.” Managed Healthcare Executive. https://www.managedhealthcareexecutive.com/managed-healthcare-executive/news/impact-medicares-expanded-benzodiazepine-coverage
  23. Moro, R.N., A.I. Geller, N.J. Weidle, et al. 2020 “Emergency Department Visits Attributed to Adverse Events Involving Benzodiazepines, 2016–2017.” Am J Prev Med. Published online February 19, 2020. https://www.ajpmonline.org/article/S0749-3797(20)30007-6/fulltext
  24. Harrison, S.L., L. Kouladjian O’Donnell, R. Milte, S.M. Dyer, E.S. Gnanamanickam, C. Bradley, E. Liu, S.N. Hilmer, & M. Crotty. 2018. “Costs of Potentially Inappropriate Medication Use in Residential Aged Care Facilities.” BMC Geriatrics 18. https://doi.org/10.1186/s12877-018-0704-8
  25. American Geriatrics Society Beers Criteria Update Expert Panel. 2023. “American Geriatrics Society 2023 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults”. Journal of the American Geriatrics Society 71(7), 2052–81. 
  26. O’Mahony, D., D. O’Sullivan, S. Byrne, M.N. O’Connor, C. Ryan, & P. Gallagher. 2015. “STOPP/START Criteria for Potentially Inappropriate Prescribing in Older People: Version 2.” Age and Ageing 44 (2), 213–18. https://doi.org/10.1093/ageing/afu145
  27. Ogbonna, C.I., & A. Lembke. 2017. “Tapering Patients Off of Benzodiazepines.” American Family Physician 96(9), 606–610. 
  28. Pottie, K., W. Thompson, S. Davies, J. Grenier, C.A. Sadowski, V. Welch, A. Holbrook, C. Boyd, R. Swenson, A. Ma, & B .Farrell. 2018. “Deprescribing Benzodiazepine Receptor Agonists.” Canadian Family Physician 64(5), 339–351. 
  29. VA National Center for PTSD. 2013. Effective Treatments for PTSD: Helping Patients Taper from Benzodiazepines (p. 2). https://www.va.gov/painmanagement/docs/OSI_6_Toolkit_Taper_Benzodiazepines_Clinicians.pdf 
  30. Hare, B. October 4, 2019. “It’s Not Just Opioids: What Doctors Want You to Know About Benzos.” CNN. https://www.cnn.com/2019/10/04/health/benzodiazepines-this-is-life-with-lisa-ling/index.html
  31. Markota, M., T.A. Rummans, J.M. Bostwick, & M.I. Lapid. 2016. “Benzodiazepine Use in Older Adults: Dangers, Management, and Alternative Therapies.” Mayo Clinic Proceedings 91(11), 1632–1639. https://doi.org/10.1016/j.mayocp.2016.07.024
  32. Reeve, E., W. Thompson, & B. Farrell. 2017. “Deprescribing: A Narrative Review of the Evidence and Practical Recommendations for Recognizing Opportunities and Taking Action.” European Journal of Internal Medicine 38, 3–11. https://doi.org/10.1016/j.ejim.2016.12.021

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