What is the best course of action for a 92-year-old patient on Xanax (alprazolam) who experienced a fall?

Management of a 92-Year-Old Patient on Xanax Who Experienced a Fall

Alprazolam (Xanax) should be discontinued in this 92-year-old patient who has experienced a fall, as benzodiazepines significantly increase fall risk in elderly patients and should generally be avoided in this population. 1, 2

Immediate Assessment and Management

1. Evaluate for injuries from the fall

   • Assess for fractures, head injury, and soft tissue damage
   • Consider imaging studies if indicated by physical examination

2. Medication review

   • Confirm current dose (0.25mg) and duration of alprazolam use
   • Review all other medications for potential interactions and additional fall risks

Discontinuation of Alprazolam

The American Geriatrics Society strongly recommends against benzodiazepine use in older adults except in specific limited circumstances (alcohol/benzodiazepine withdrawal, severe acute anxiety, periprocedural sedation, or refractory seizure disorders) 1. This patient's fall represents a serious adverse event directly associated with benzodiazepine use.

Tapering Protocol

• Do not discontinue alprazolam abruptly due to risk of withdrawal symptoms and seizures 2
• Implement a gradual taper:
  • Reduce dose by approximately 25% every 1-2 weeks 1
  • For this patient on 0.25mg (lowest available dose), consider:
    • Switching to every other day dosing for 1-2 weeks
    • Then every third day for 1-2 weeks before discontinuing

Monitoring During Taper

• Watch for withdrawal symptoms: rebound anxiety, irritability, tremors, insomnia
• If withdrawal symptoms become problematic, slow the taper further 1

Alternative Management Strategies

For the underlying condition that prompted alprazolam use:

For Anxiety:

• Consider SSRI/SNRI medications (safer alternatives for elderly)
• Non-pharmacological approaches:
  • Cognitive behavioral therapy
  • Relaxation techniques
  • Regular physical activity (with fall precautions)

For Insomnia:

• Improve sleep hygiene
• Consider low-dose melatonin
• Address underlying causes of sleep disturbance

Fall Prevention Measures

1. Home safety assessment and modifications
2. Physical therapy evaluation for gait and balance training
3. Vision assessment
4. Review and modification of all medications that may contribute to falls
5. Consider assistive devices if appropriate

Follow-up Plan

• Schedule follow-up within 1-2 weeks to assess withdrawal symptoms and fall risk
• Reassess the need for alternative treatments for the original indication
• Continue to monitor for improvements in cognitive function and balance after discontinuation

Rationale for Discontinuation

Benzodiazepines in the elderly are associated with:

• Increased risk of falls and fractures 1, 3
• Cognitive impairment and potential contribution to delirium 1, 4
• Prolonged sedation due to age-related pharmacokinetic changes 5
• Psychomotor impairment 2

Even at low doses (0.25mg), alprazolam carries significant risks in a 92-year-old patient, and the occurrence of a fall is a clear indication that the medication's risks outweigh its benefits 1, 3.