What is the recommended approach for tapering long-term benzodiazepines (BZD) use in elderly patients?

Benzodiazepine Tapering in Elderly Patients

Benzodiazepines in elderly patients should be tapered gradually with dose reductions of approximately 25% every 1-2 weeks, with elderly patients requiring more conservative and slower reductions to minimize withdrawal symptoms. 1

Risks of Long-Term Benzodiazepine Use in the Elderly

Long-term benzodiazepine use in elderly patients is associated with significant risks:

• Reduced mobility and functional independence
• Increased risk of falls and fractures
• Cognitive impairment
• Dependence and tolerance
• Potential for withdrawal symptoms including seizures 1, 2

Recommended Tapering Protocol

Initial Assessment

• Evaluate current dose, duration of use, and indication
• Assess for comorbidities that may complicate tapering
• Screen for depression and suicidal ideation
• Evaluate cognitive function and fall risk 1

Tapering Schedule

1. Standard approach: Reduce dose by approximately 25% every 1-2 weeks 1
2. For elderly patients: Use a more conservative approach with slower reductions
   • Consider reducing by no more than 0.5 mg every 3 days for medications like alprazolam 3
   • Some patients may benefit from an even more gradual discontinuation 3
   • For long-term users, tapering may need to extend over many weeks 4

Monitoring During Tapering

• Regular assessment of withdrawal symptoms
• Monitoring vital signs
• Evaluating emergence of underlying anxiety or depression
• Assessing for suicidal ideation 1

Patient Education and Support

Patient education is crucial for successful tapering. The EMPOWER trial demonstrated that 27% of seniors stopped benzodiazepines when educated about risks compared to 5% in the control group 4, 1. Education should include:

• Information about risks of continued use
• Benefits of discontinuation
• Expected withdrawal symptoms
• Coping strategies 5

Adjunctive Therapies

Non-Pharmacological Approaches

• Cognitive behavioral therapy (CBT) significantly increases tapering success rates 1, 5
• Relaxation techniques
• Sleep hygiene education
• Support groups 1

Pharmacological Adjuncts

• For anxiety disorders: Consider SSRIs or SNRIs as alternatives 1
• For severe agitation during withdrawal: Short-term use of antipsychotics may be considered (olanzapine 2.5-5 mg, quetiapine 25 mg, or risperidone 0.5 mg) 1

Management of Withdrawal Symptoms

If withdrawal symptoms become severe:

• Temporarily pause the taper
• Return to the previous stable dose
• Resume tapering with smaller increments once stabilized 1, 3

Special Considerations

Patients with Liver Disease

• Require dose adjustments due to altered metabolism 1

Patients with History of Seizures

• Need specialized care and more gradual tapering 1, 2

Patients Taking Multiple Benzodiazepines

• Consider converting to equivalent doses of a single long-acting benzodiazepine (like diazepam) before tapering 6

Common Pitfalls to Avoid

1. Abrupt discontinuation: Can lead to severe withdrawal symptoms including seizures, delirium tremens, and rarely death 1, 2
2. Tapering too quickly: Elderly patients require slower tapering than younger adults 1
3. Ignoring psychological dependence: Many older chronic users have come to rely on benzodiazepines for their soothing properties and may resist discontinuation 7
4. Inadequate support: Without proper education and support, patients are more likely to resume use 5
5. Concurrent use with opioids: Increases risk of fatal overdose and should be avoided 1

Outcomes of Successful Tapering

Successful discontinuation is associated with:

• Improved psychomotor and cognitive functioning
• Reduced risk of adverse events
• Better overall quality of life 8, 6

Tapering success rates are favorable (mean 60%, median 67%, range 25-85%) and independent of dose or duration of use when proper protocols are followed 8.