Can patients take Xanax (alprazolam) the night before surgery?

Taking Xanax the Night Before Surgery

Benzodiazepines like Xanax (alprazolam) should be avoided before surgery when possible, especially in elderly patients, due to risks of cognitive impairment, delirium, and falls.

Preoperative Anxiolysis Recommendations

General Approach to Preoperative Anxiety

• Preoperative education and non-pharmacological approaches can effectively reduce patient anxiety to acceptable levels without requiring anxiolytic medication 1
• Pharmacologic anxiolysis with sedative medications (especially benzodiazepines) should be avoided before surgery when possible 1
• When anxiolytics are needed, consider alternatives to benzodiazepines:
  • Melatonin provides effective preoperative anxiolysis with few side effects and may be equally effective to midazolam 1
  • Passionflower has demonstrated reduction in anxiety with a good safety profile in perioperative settings 1

Special Considerations for Benzodiazepines

• Benzodiazepines, even after single-dose administration, may cause:
  • Psychomotor and cognitive impairment
  • Sedative effects that persist into the perioperative period
  • Risk of impaired motor function, especially at higher doses 1
• The American Geriatrics Society provides a strong recommendation (with moderate quality evidence) that benzodiazepines should be avoided in older patients (≥65 years) due to:
  • Increased sensitivity to benzodiazepines
  • Decreased metabolism of long-acting agents
  • Higher risk of cognitive impairment, delirium, and falls 1

Potential Benefits of Lower-Dose Benzodiazepines

• Some day surgery studies report minimal impact on discharge time with lower doses of benzodiazepines 1
• Benefits may include less nausea and headaches 1
• Historical studies have shown benzodiazepines can allay anxiety before operation when given the night before surgery 2

Clinical Decision Algorithm

1. First-line approach: Use non-pharmacological anxiety management

   • Provide comprehensive preoperative education
   • Consider "Surgery School" or similar educational sessions 1

2. If medication is necessary:

   • Preferred alternatives to benzodiazepines:
     • Melatonin (tablets or sublingual) 1
     • Passionflower supplements 1

3. If benzodiazepines must be used (e.g., patient already on chronic therapy):

   • Continue the medication to avoid withdrawal 1
   • Use the lowest effective dose possible 1
   • Be aware of potential for:
     • Additive effects with anesthetics causing hypotension, profound sedation 1
     • Multiple drug-drug interactions 1
     • Increased risk of postoperative delirium, especially in elderly 1

Common Pitfalls and Caveats

• Abruptly stopping benzodiazepines in chronic users can precipitate withdrawal 1
• Benzodiazepines may have synergistic effects with opioids, increasing the risk of respiratory depression 1
• Elderly patients have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents 1
• Patients who are more anxious preoperatively tend to remain anxious in the operating room regardless of premedication 3