Prolonged use of benzodiazepines in general practice: Cognitive consequences and dependence

Prolonged benzodiazepine (BZD) prescribing in primary care represents a persistent gap between clinical guidelines and real-world practice, with significant implications for cognitive health and dependence. This narrative review aimed to analyze the neurobiological mechanisms underlying tolerance and dependence, evaluate long-term cognitive consequences—including the debated association with dementia—and examine clinical and systemic factors sustaining chronic use in general practice. A structured search was conducted in PubMed, Scopus, and the Cochrane Library for peer-reviewed studies published between 2004 and 2024, prioritizing systematic reviews, meta-analyses, cohort studies, and clinical guidelines. Evidence consistently demonstrates that chronic BZD exposure induces neuroadaptive changes in GABA-A receptors, leading to tolerance and physical dependence. Long-term use is associated with impairments in episodic memory, attention, and psychomotor speed, while data on dementia risk remain inconclusive due to potential reverse causation and confounding by indication. Contributing factors to chronic prescribing include patient fear of withdrawal, physician time constraints, and systemic practices such as automatic prescription renewals. Gradual tapering, shared decision-making, substitution strategies when appropriate, and integration of non-pharmacological interventions—particularly cognitive behavioral therapy for insomnia—are essential for safe deprescribing. Strengthening clinician education and public health policies is crucial to reduce iatrogenic harm and promote rational pharmacotherapy in primary care.