Tapering Off Benzodiazepines in Older Adults

Risks and Considerations

Benzodiazepines like lorazepam are associated with significant risks in older adults, including sedation, cognitive impairment, unsafe mobility, injurious falls, and withdrawal syndromes, according to the Mayo Clinic Proceedings 1, 2
Guidelines recommend gradual tapering of benzodiazepines to minimize withdrawal symptoms, as suggested by the Mayo Clinic Proceedings 3
A recommended approach is withdrawing 25% of the daily benzodiazepine dose each week, though more gradual tapering may be necessary for long-term users, as recommended by the Mayo Clinic Proceedings 3

If the patient has comorbid depression or buspirone is ineffective, consider a sedating antidepressant such as mirtazapine (starting at 15mg at bedtime) or trazodone (starting at 25-50mg at bedtime), as suggested by the Journal of the American Geriatrics Society and American family physician 4, 5, 6, 7
SNRIs like duloxetine may be considered for anxiety with comorbid pain conditions, according to the Journal of the American Geriatrics Society 4
The American Geriatrics Society recommends avoiding tertiary amine tricyclic antidepressants (amitriptyline, imipramine) in older adults due to significant anticholinergic effects, orthostatic hypotension, and cardiac conduction concerns 4, 5

Cognitive-behavioral therapy, supportive psychotherapy, and problem-solving therapy should be incorporated into the treatment plan, as recommended by the Mayo Clinic Proceedings 3
Integrative strategies including relaxation techniques, music therapy, and mindfulness may help manage anxiety during tapering, according to the Mayo Clinic Proceedings 3

The Mayo Clinic Proceedings recommends reducing lorazepam by 25% of the original dose every 1-2 weeks, and monitoring for withdrawal symptoms (anxiety, insomnia, irritability) and slowing the taper if needed 3
The American Academy of Family Physicians suggests that buspirone takes 2-4 weeks to achieve full anxiolytic effect, unlike the immediate relief provided by benzodiazepines, and recommends monitoring for common side effects of buspirone including nausea, dizziness, and headache 6
The Mayo Clinic Proceedings advises avoiding antipsychotics for anxiety management in older adults due to increased risk of falls, stroke, and mortality 3