Comment on “Do Benzodiazepines Cause Alzheimer’s Disease?”

To the Editor: We write in response to Dr. Salzman’s editorial (1), published in the June 2020 issue of the Journal, on the recent Journal study that found no association between benzodiazepines and incident dementia in patients with affective disorders (2). Given the widespread nature of benzodiazepine prescribing, particularly in mid and late life (3), these findings may be reassuring for both prescribers and patients.

We were surprised to read this in the editorial: “[M]ild cognitive impairment may also be treated with low-dose benzodiazepines to improve daytime calming (as well as sleep onset), and this use may be welcomed.” We are concerned that some colleagues may interpret this as a recommendation to treat their older patients with memory concerns with a benzodiazepine, a proposition supported by no high-quality evidence. In fact, in the reference cited to support this suggestion—an article for which Dr. Salzman is first author—the Results section says: “Subjects who discontinued benzodiazepines, as compared with non-discontinuing controls, showed a significant improvement in total memory, immediate recall, and total digits…. [T]hese patients appeared more alert and less forgetful; the improvement in cognitive function was noticeable to nursing staff and family members” (4). It is puzzling that Dr. Salzman suggests using benzodiazepines to treat mild cognitive impairment when his own work demonstrates the benefit of their discontinuation.

Apart from cognition, a myriad of other harms associated with benzodiazepine use in older adults go completely unmentioned, such as fall-related injury (5) and motor vehicle crashes (6). Benzodiazepines also contribute to the ongoing opioid overdose epidemic (7), during which older adults have experienced the largest relative increases in mortality (8). Acknowledging these other risks is critical when considering the editorial’s assertion of benefit from “judicious” use of low-dose benzodiazepines in older adults. Although benzodiazepines undoubtedly have a therapeutic role for select older adults, there remains ample reason for ongoing public health concern about benzodiazepine prescribing among older adults.