What is a recommended antianxiety medication for an older adult tapering off Ativan (lorazepam) 1mg?

Recommended Antianxiety Medication for Older Adult Tapering Off Ativan

Buspirone is the recommended antianxiety medication for an older adult tapering off lorazepam (Ativan) 1mg due to its favorable safety profile, efficacy in elderly patients, and lack of withdrawal or dependence issues. 1, 2

Rationale for Buspirone Selection

• Buspirone has demonstrated effectiveness for anxiety in elderly patients at doses similar to those used in younger adults (typically starting at 5mg twice daily, with a mean effective dose of 18mg/day) 1
• Unlike benzodiazepines, buspirone does not cause dependence, withdrawal symptoms, or cognitive impairment, making it particularly suitable during benzodiazepine tapering 2
• Buspirone has shown a favorable side effect profile in elderly patients, with approximately 80% reporting no side effects 2
• It can be administered to patients aged 65 years or older without special dose adjustments 2

Benzodiazepine Tapering Considerations

• Benzodiazepines like lorazepam are associated with significant risks in older adults including sedation, cognitive impairment, unsafe mobility, injurious falls, and withdrawal syndromes 3
• Guidelines recommend gradual tapering of benzodiazepines to minimize withdrawal symptoms 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 3
• Buspirone can be initiated before beginning the lorazepam taper to help manage anxiety during the process 4, 5

Alternative Options to Consider

Antidepressants

• If the patient has comorbid depression or buspirone is ineffective, consider a sedating antidepressant such as:
  • Mirtazapine (starting at 15mg at bedtime) 3
  • Trazodone (starting at 25-50mg at bedtime) 3
• SNRIs like duloxetine may be considered for anxiety with comorbid pain conditions 3
• Avoid tertiary amine tricyclic antidepressants (amitriptyline, imipramine) in older adults due to significant anticholinergic effects, orthostatic hypotension, and cardiac conduction concerns 3

Non-Pharmacological Approaches

• Cognitive-behavioral therapy, supportive psychotherapy, and problem-solving therapy should be incorporated into the treatment plan 3
• Integrative strategies including relaxation techniques, music therapy, and mindfulness may help manage anxiety during tapering 3

Implementation Strategy

1. Initial Phase:

   • Start buspirone at 5mg twice daily while maintaining current lorazepam dose 1, 2
   • Gradually increase buspirone to 15-20mg/day in divided doses over 2 weeks 1
   • Allow 2-4 weeks for buspirone to reach full effectiveness before beginning lorazepam taper 4

2. Tapering Phase:

   • Reduce lorazepam by 25% of the original dose every 1-2 weeks 3
   • For 1mg dose, consider a schedule of: 0.75mg for 1-2 weeks → 0.5mg for 1-2 weeks → 0.25mg for 1-2 weeks → discontinue
   • Monitor for withdrawal symptoms (anxiety, insomnia, irritability) and slow the taper if needed 3

3. Post-Taper Phase:

   • Continue buspirone for at least 2-3 months after completing the lorazepam taper 5
   • Reassess the need for ongoing anxiolytic treatment periodically 3

Important Cautions

• Buspirone may be less effective in patients with extensive prior benzodiazepine exposure 6
• Buspirone takes 2-4 weeks to achieve full anxiolytic effect, unlike the immediate relief provided by benzodiazepines 3
• Monitor for common side effects of buspirone including nausea, dizziness, and headache 1, 2
• If the patient cannot tolerate buspirone, consider mirtazapine or trazodone as alternatives, but avoid other benzodiazepines 3
• Avoid antipsychotics for anxiety management in older adults due to increased risk of falls, stroke, and mortality 3