Steve Iliffe, FRCGP, Professor of Primary Care for Older People, Research Department of Primary Care, University College London, UK.

Long-term benzodiazepine use in older adults with sleep disorders is potentially hazardous, but it is also becoming easier to manage as approaches to withdrawal become feasible in primary care, without adverse consequences. This article reviews the evidence and describes practical approaches to reducing consumption of benzodiazepine hypnotics.
Key words: benzodiazepines, insomnia, older adults, primary care, hypnotics.

Philippe Voyer, RN, PhD, Associate Professor, Faculty of Nursing, Laval University; Researcher, Laval University Geriatric Research Unit,St-Sacrement Hospital, Quebec, QC.
Michel Préville, MD, Associate Professor, Faculty of Medicine, Université de Sherbrooke; Researcher, Research Centre on Aging, Sherbrooke Geriatric University Institute, Sherbrooke, QC.
and Researchers of the Étude sur la santé des aînés team.

Sleep complaints by older adults constitute a very common situation faced by health care providers. However, not all professionals respond to the complaint the same way. Some will briefly assess the complaint and resort rather quickly to medication while others will assess the complaint carefully in order to exclude the diagnosis of primary insomnia and prescribe alternative interventions to improve sleep. When medicine is prescribed, the type of compound often selected is benzodiazepine. However, benzodiazepine carries a significant risk of adverse reaction, including drug dependency, both of which are clinical problems that should not be underrated, especially when treating a subjective complaint and not a specific diagnosis.
Key words: insomnia, benzodiazepine, dependency, addiction, older adults.

Paul J. Christo, MD, Assistant Professor; Director, Pain Treatment Center & Multidisciplinary Pain Fellowship, Division of Pain Medicine, Department of Anesthesiology and Critical Care, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Greg Hobelmann, MD, Postdoctoral Fellow, Division of Pain Medicine, Department of Anesthesiology and Critical Care, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Amit Sharma, MD, Postdoctoral Fellow, Division of Pain Medicine, Department of Anesthesiology and Critical Care, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. *Current Address: Assistant Professor, College of Physicians & Surgeons of Columbia University, New York, NY.

Eric M. Morrow, MD, PhD, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
William E. Falk, MD, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.

Anxiety in older patients, when excessive in degree and duration, can cause significant impairment and, if left untreated, may result in profound comorbidity--in particular, depression. Anxiety symptoms emerging in the older patient necessitate an extensive medical and psychosocial workup. There is a paucity of data for pharmacological treatment of anxiety disorders in older adults. In this review, we will discuss some of the research in the area of diagnosis and treatment of anxiety in older adults. We will also summarize some practice parameters common in our clinic when data are absent or lacking. The use of psychotherapies (such as cognitive behavioural therapy) and of medications such as the SSRIs, as well as benzodiazepines and other agents including the atypical antipsychotics, are discussed. The differential diagnosis of anxiety symptoms in the older patient, including careful attention to underlying medical and neurologic causes of anxiety, are emphasized.

Key words: SSRIs, benzodiazepines, psychotherapy, anxiety, depression, dementia.

Monica Lee, BSc (Phm), MSc
Research Pharmacist
Baycrest Centre for Geriatric Care,
Toronto, ON.

Julie Dergal, MSc
Kunin-Lunenfeld Applied Research Unit
Baycrest Centre for Geriatric Care,
Toronto, ON.

Introduction
Older people often take multiple drug therapies for the treatment of various, concomitant chronic conditions. As a result, older adults are at increased risk of developing adverse drug events. It is important for physicians to regularly review the drug regimen of any older patient, and to discontinue any drug therapies that are no longer required or indicated. Physicians may also have to discontinue a particular drug therapy for other reasons including: if the drug therapy is ineffective; if it causes intolerable adverse effects; if newer and safer alternative drug therapies become available; or if the patient refuses to continue the treatment. It is important that physicians know how to appropriately discontinue or switch an older person's drug therapy in order to avoid adverse events.

There are currently limited practice guidelines available for discontinuing or switching psychotropic drug therapies. When discontinuing a medication, physicians need to consider whether it can be withdrawn abruptly or gradually tapered.