The American Geriatrics Society’s Beers Criteria lists benzodiazepines as potentially inappropriate medication in older adults. Older adults have increased sensitivity to benzodiazepines and decreased metabolism, which may lead to clinically significant physical dependence.
In general, all benzodiazepines increase the risk of cognitive impairment, delirium, falls, fractures and motor vehicle crashes in older adults (Source: Journal of the American Geriatrics Society). Nevertheless, these medications are often overprescribed.
The FDA recommends that benzodiazepine dosage and duration be limited to the minimum needed to achieve the necessary clinical effect. When prescribing benzodiazepines to patients, it may be helpful to discuss an anticipated length of therapy. Psychotherapy should be considered for anticipatory anxiety associated with tapering (Source: College of Psychiatric and Neurologic Pharmacists).
It is important to regularly assess the need for benzodiazepine use in patients, and to discuss strategies for discontinuation (Source: Oregon State Drug Review). When benzodiazepine therapy is no longer indicated or when the risk associated with benzodiazepine use outweighs the benefit, a benzodiazepine taper may be indicated.
Strategies that can help with tapering include gradual dose reduction and discontinuation, educational interventions and psychotherapy.
Finally, it is important to involve the patient in decisions about the taper schedule. Provide frequent monitoring and follow up with the patient. Allow schedule flexibility based on the patient’s response to dose reductions (Source: National Center for PTSD).
If the patient is struggling with withdrawal or rebound symptoms, consider stabilizing the patient on the reduced dose before making further reductions. It may also be helpful for some patients to re-address the underlying condition before starting or continuing the discontinuation.
|Example of Slow Benzodiazepine Taper|
|Week||Milestone Suggestions||Example: Lorazepam 4mg twice daily converts to 40mg daily diazepam equivalents|
|2||Decrease dose by 25%||30mg/day (25%)|
|4||Decrease dose by 25%||20mg/day (50%)|
|5-8||Hold dose 1-2 months||Continue at 20mg/day for 1 month|
|11-12||Decrease dose by 25% at week 11||10mg/day|
|13-14||Decrease dose by 25% at week 13||5mg/day|
For more information, including examples of benzodiazepine tapers, refer to the DHCS Clinical Review: Recommendations for the Tapering of Benzodiazepines.