Clinical features classification and diagnosis

Younger benzodiazepine abusers consume the drug outside medical supervision, use for euphoriant effects, escalate the dose over time, and continue use despite adverse social, economic, or legal consequences. This pattern of abuse is distinctly rare among older people. Thus the ICD or DSM criteria for drug use disorders are usually not adequate for diagnosis. Instead, in elderly patients, long-term prescribing of benzodiazepines may lead to physical dependence at therapeutic doses that is only recognized if characteristic withdrawal symptoms emerge when the drug is discontinued. Long-term therapeutic benzodiazepine use also induces subtle but significant adverse effects on cognition, mood, and behaviour, especially in elderly people (see complications below).

Discontinuance symptoms, listed in Table..?, include recurrence symptoms (the re-emergence and persistence of the anxiety symptoms for which the drug was originally prescribed), rebound anxiety (i.e. recurrence symptoms that are temporarily worse than before treatment), and a true withdrawal syndrome (signs and symptoms of which are time-limited and unlike symptoms of the disorder for which the drug was originally prescribed). (15) Clinically significant discontinuance symptoms occur in over 90 per cent of patients withdrawing from long-term benzodiazepines, and true withdrawal symptoms occur in 20 to 50 per cent of cases. (4> Benzodiazepine dependence and withdrawal may be overlooked in elderly patients when entering the hospital, and a deteriorating course may be misdiagnosed as myocardial infarction, hypertensive crisis, or infection. Delirium may be a more common presentation of withdrawal in older patients and be misattributed to other causes.

Table 2 Benzodiazepine discontinuance symptoms

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