
- Vol 38, Issue 1
- Volume 38
- Issue 01
Benzodiazepine Use and the Risk of Dementia
Nearly half of the prescriptions for benzodiazepine among older adults are potentially inappropriate, so how best to do no harm?
CLINICAL
Available evidence indicates that benzodiazepines are commonly used to treat various disorders including anxiety, insomnia, agitation, alcohol withdrawal, and seizures.1 The
Consequences of Benzodiazepine Use
The use of
Now, there is also emerging evidence that the use of
Exploring the Literature and Evidence
A review of the literature indicates that there is a total of 15 studies that have evaluated the association between benzodiazepine use and the development of dementia.12-26 Four of the 15 studies were published prior to 201012-15 and 11 of the studies were published since 2010.16-26
Although there are no randomized controlled trials (RCTs) looking at the association between benzodiazepine use and the risk for dementia, 6 prospective cohort studies,12,14,17,22,23,25 6 case control studies,13,15,16,20,21,24 and 1 retrospective cohort study18 explore the relationship. Two studies had both a prospective cohort and a case control component.19,26 Three of the studies were conducted in France,13,19,22 3 in Taiwan,15,16,18 3 in Canada,14,20,25 2 in the United Kingdom,17, 21 and 1 each in Sweden,14 the United States,23 Switzerland,24 and Denmark.26
Of the 15 studies, 8 showed a positive association between benzodiazepine use and the development of dementia.13,15,16-20,22 Of these 8 studies, 2 were prospective cohort studies,17,22 4 were case control studies,13,15,16,20 and 1 was a retrospective cohort study.18
Four studies found benzodiazepines were not associated with the development of dementia.21,24,25,26 The negative studies included 2 case control studies,21,24 1 prospective cohort study,25 and 1 study that had a prospective cohort and a case control arm.26
Two studies showed mixed results.14,23 One study found that previously using benzodiazepines was associated with the development of dementia, but current use was not.14 The other study found that short-term use of benzodiazepines was associated with the development of dementia, but long-term use was not.23 Finally, 1 prospective cohort study found that the use of benzodiazepines had a protective effect against the development of dementia.12
More than half of the studies (8 out of 15, 53%) identified in the literature search showed a positive association between benzodiazepine use and the development of dementia. It is unclear whether there is any significant difference between men and women. This is true with higher doses; when the duration of use is shorter; for current users; for shorter-acting drugs; and study design (eg, cohort studies). (see
Discussion
Despite the evident association between benzodiazepine use and the development of dementia, a causality cannot be established, as none of the identified studies were RCTs.
Three important reviews have evaluated the association between benzodiazepine use and the development of dementia.27-29 In the first review, the investigators evaluated 3 studies that found an increased risk of cognitive decline among those using benzodiazepine, and 2 studies that found a lower risk of cognitive decline in former or ever users of benzodiazepines, and 2 studies that found no association between the use of benzodiazepines and the development of dementia.27 In another review that evaluated 10 studies, the investigators found that 9 studies showed an increased risk of dementia among those who used of benzodiazepines.28 The investigators opined that the risk of dementia increases with cumulative doses of medication, longer treatment duration, and when long-acting agents are used. In the third review that evaluated data from 11 studies, the investigators
Three recent meta-analyses evaluated the risk of developing dementia among individuals who use benzodiazepines.30,31,32 In the
The
The
In his recent
The available evidence for the association between benzodiazepine use and the development of dementia should be evaluated based on the heterogeneity between the studies and limitations of each of these studies. These studies were conducted in different countries and had differing methodologies. In addition, many studies did not control for confounding variables including educational attainment, the presence of depression, anxiety, insomnia, and alcohol use. Also, 4 studies used the older DSM III-R criteria for the diagnosis of the dementia, causing concerns regarding the validity of the diagnosis. It is unclear whether the observed association between the use of benzodiazepines and the development of dementia is really a causal effect, or the result of unmeasured confounding variables, as none of these studies were RCTs.
Protopathic
There are 3 possible mechanisms that have been postulated for the association between benzodiazepine use and the development of dementia.28,29 For one, benzodiazepines possibly decrease activity of β-amyloid precursor protein-cleaving enzyme 1 (BACE-1) and c-secretase activity, thus promoting β-amyloid accumulation in the brain. Secondly, astrocytes near the β-amyloid accumulation in the brain secreting γ-aminobutyric acid (GABA), thereby promoting the negative cognitive effects of benzodiazepines. Finally, benzodiazepines may reduce the cognitive reserves by lowering brain activation levels.
Concluding Thoughts
Available evidence indicates a positive association between the use of benzodiazepines and the development of dementia, although causality cannot be inferred from this data. Despite the lack of evidence proving causality, the association between benzodiazepine use and the
Dr Tampi is the chairman of the department of psychiatry and behavioral sciences, Cleveland Clinic Akron General, Akron, OH. Dr Bennett is a psychologist in the Department of Psychiatry and Behavioral Sciences, Cleveland Clinic Akron General, Akron, OH. The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript.
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