Xanax and other benzodiazepines (“benzos”) are widely prescribed to treat symptoms like anxiety and depression in people living with dementia. But do they work — and are they safe?
Dementia is most widely associated with its cognitive symptoms, like memory loss. But it often brings a host of behavioral symptoms, too, like agitation and sleep problems. In fact, as many as half of all people with dementia develop symptoms of agitation, which can lead to behaviors like pacing, restlessness, and aggression, both verbal and physical. Meanwhile, around one in four develop sleep disturbances like insomnia. To treat insomnia and anxiety symptoms in dementia, doctors often prescribe benzodiazepines, like Xanax.
These drugs come with substantial side effects and safety concerns especially for older adults. Dr. Paula A. Rochon, professor at the Women’s College Hospital told Being Patient that benzodiazepines are drugs that are considered to be potentially inappropriate for older adults and persons living with dementia.” She added that benzodiazepines are considered potentially inappropriate for prescribing to older individuals according to European guidelines and the American Geriatrics Society.
According to Dr. Christina Reppas-Rindlisbacher, a clinician and PhD candidate at Women’s College Hospital could lead to emergency room visits, hospitalization and further loss of independence. “Known risks of benzodiazepines for older persons include lethargy, increased confusion or delirium, increased risk of falls and fractures, and significant impairment of driving with increased crash risk,” Reppas-Rindlisbacher added.
Ultimately, it is up to doctors and patients to discuss the potential risks and benefits of benzodiazepines and any other medications before prescribing. “The decision to prescribe any medication should involve a discussion between the patient and the clinician about risks and benefits,” Rochon said.
The first line of treatment is non-pharmacological
“Where possible, non-pharmacologic interventions such as reminiscence therapy and changes in environment should be tried first,” Rochon said. “Sometimes these symptoms are a response to an underlying medical condition, discomfort or unmet basic needs. As such, a comprehensive assessment by a dementia care team is invaluable to guide the development of a tailored management plan.”
Some of these environmental changes can include:
- Removing tripping hazards and clutter
- Rearranging the bedroom to provide more room to maneuver
- Ensuring hallways are clear and well-lit
- Reducing noise levels
Other non-pharmacological ways to treat these symptoms include:
- Reminiscence therapy which uses different images, sounds, smells, touch, and other modalities to help dementia patients recall parts of their memory.
- Listening, dancing, or singing along to familiar music
- Therapeutic interactions with real and robotic pets
Do benzodiazepines work better than other treatments?
According to the American Geriatrics Society, benzodiazepines aren’t recommended for people over 65 because they may increase the risk of falls, fractures, and hospital admissions related to these side effects. And for people living with dementia, there is no strong evidence that benzodiazepines work any better in the treatment of dementia’s behavioral symptoms than other potential drugs like antipsychotics.
A 2014 study looked at all of the clinical trials of these drugs conducted in patients with dementia. The authors concluded no support for the routine use of benzodiazepines. Compared to antipsychotics, they were less effective and had more side effects. Benzodiazepines may still be used when other drugs don’t work or have too many side effects for the patient to tolerate.
That said, antipsychotics are largely untested in people living with dementia, and they have their problems and risks, too. Some antipsychotics are prescribed off-label for treating agitation in patients with dementia, but they are also linked with increased rates of hospitalization among patients. Z-drugs meanwhile are prescribed for treating insomnia for dementia patients, but studies show these could increase their risk of falls or fractures.
“Apathy and withdrawal, and a tendency to get agitated, are common symptoms of dementia,” Dr. Donovan Maust, a geriatric psychiatrist at the University of Michigan and the VA Ann Arbor Healthcare System, said upon the release of his team’s study into the percentage of older adults with dementia who are on off-label, ineffective, or unsafe prescriptions. Maust and colleagues found as many as 75 percent of adults are on prescriptions that aren’t helpful to their symptoms, and that could even be making things worse. As much as health care providers want to help these patients and their family caregivers, these medications are just not helpful enough to justify this amount of prescribing.”
So far, the FDA has approved drugs to treat agitation and insomnia in people living with dementia
The FDA has approved some drugs specifically for treating these symptoms in Alzheimer’s.
FDA-approved treatments for agitation
In May 2023, the FDA approved Rexulti for treating agitation in people with Alzheimer’s dementia. The drug, which goes by the generic name brexpiprazole, is an antipsychotic initially developed for treating symptoms of clinical depression and schizophrenia.
In clinical trials, patients who took the drug showed more improvement in agitation over 12 weeks than the placebo group. However, the trial data also showed that the drug increased mortality from 0.3 percent to 0.9 percent. This is consistent with the known risks of antipsychotic medications when given to older patients.
Banner Sun Health Research Institute Director Dr. Pierre Tariot said that the results from the trial were a “major advance.” “We had efficacy without all the toxicity that has plagued the other drugs we’ve been studying for agitation,” he added.
FDA-approved treatments for insomnia
In 2020, the FDA approved Belsomra, a drug for treating sleep disturbances in Alzheimer’s dementia. Belsomra is also known by its generic name, suvorexant. In clinical trials, patients who took the drug for four weeks slept on average 28 more minutes than the group receiving the placebo.
If a loved one is taking a drug that isn’t working or has too many side effects, speak with a physician about changing the treatment strategy.