Shorr R I, Robin D W
Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.
Drugs Aging. 1994 Jan;4(1):9-20. doi: 10.2165/00002512-199404010-00002.
In the 40 years since the introduction of benzodiazepines into clinical practice, considerable controversy has surrounded their use. While there is little evidence to suggest widespread abuse or long term use in most age groups, benzodiazepines continue to be widely prescribed to older adults in both community and long term care settings. Several studies have described an increased sensitivity to the clinical effects and toxicity of benzodiazepines in older adults. However, it is unclear whether these observations are attributable to age-related changes in benzodiazepine pharmacokinetics or pharmacodynamics. Benzodiazepines are the safest and most effective agents available for the pharmacological management of symptoms of anxiety and insomnia. However, the acute administration of benzodiazepines is associated with impairments in cognition, memory, coordination and balance, and long term use, even at therapeutic dosages, has been associated with symptoms of withdrawal upon abrupt discontinuation. Therefore, it is essential that the practitioner develop a treatment plan when utilising these agents to treat older patients. This plan may also involved the implementation of psychotherapy or other nonpharmacological modalities in the management of anxiety or insomnia. Although we recommend initiating benzodiazepines using the lowest available dosage, older patients should be treated with enough drug to produce a therapeutic response. For most clinical situations of anxiety or insomnia, we recommend prescribing limited quantities (e.g. a 2-week supply with a return visit for re-evaluation of effectiveness and adverse effects) of a drug with a short elimination half-life. Persistent anxiety or insomnia in the elderly may require a medical and possibly psychiatric evaluation. If benzodiazepines are used continuously for 6 weeks or longer, we recommend a gradual taper over 2 to 12 weeks with frequent follow-up to evaluate for signs of withdrawal or the return of symptoms.
自苯二氮䓬类药物引入临床实践的40年来，围绕其使用一直存在相当大的争议。虽然几乎没有证据表明在大多数年龄组中存在广泛滥用或长期使用的情况，但苯二氮䓬类药物在社区和长期护理机构中仍被广泛开给老年人。几项研究描述了老年人对苯二氮䓬类药物的临床效果和毒性的敏感性增加。然而，尚不清楚这些观察结果是否归因于苯二氮䓬类药物药代动力学或药效学方面与年龄相关的变化。苯二氮䓬类药物是可用于焦虑和失眠症状药物治疗的最安全、最有效的药物。然而，苯二氮䓬类药物的急性给药与认知、记忆、协调和平衡受损有关，即使是治疗剂量的长期使用，也与突然停药后的戒断症状有关。因此，从业者在使用这些药物治疗老年患者时制定治疗计划至关重要。该计划还可能涉及在焦虑或失眠管理中实施心理治疗或其他非药物治疗方法。虽然我们建议使用可用的最低剂量开始使用苯二氮䓬类药物，但老年患者应使用足够的药物以产生治疗反应。对于大多数焦虑或失眠的临床情况，我们建议开具有限量（例如2周的供应量，并复诊以重新评估疗效和不良反应）的消除半衰期短的药物。老年人持续的焦虑或失眠可能需要进行医学和可能的精神科评估。如果连续使用苯二氮䓬类药物6周或更长时间，我们建议在2至12周内逐渐减量，并频繁随访以评估戒断迹象或症状复发情况。
