What considerations are necessary when tapering benzodiazepines in elderly patients?

From the Guidelines

When tapering benzodiazepines in elderly patients, a slower and more gradual approach is essential, starting with a reduction of only 10-25% of the daily dose every 2-4 weeks, to minimize the risk of withdrawal symptoms and adverse effects. This approach is supported by the most recent and highest quality study, which emphasizes the importance of gradual tapering to reduce the risk of rebound or withdrawal symptoms 1. For example, if an elderly patient is taking lorazepam 1mg twice daily, consider reducing by just 0.25mg (to 0.75mg twice daily) for the first step and maintain this dose for 2-4 weeks before further reductions.

Key Considerations

• Commonly used benzodiazepines in the elderly include lorazepam, oxazepam, and temazepam, which have shorter half-lives and no active metabolites.
• Watch carefully for withdrawal symptoms such as anxiety, insomnia, irritability, and tremor, which may be more severe or prolonged in older adults due to age-related changes in pharmacokinetics, including decreased hepatic metabolism and renal clearance.
• Monitor for falls, confusion, and cognitive changes during the tapering process, as elderly patients are particularly vulnerable to these adverse effects.
• Consider using non-pharmacological interventions, such as cognitive-behavioral therapy, to support the tapering process and reduce the risk of withdrawal symptoms.

Tapering Schedule

• The EMPOWER trial demonstrated success with a gradual reduction over many weeks, with a target of reducing the daily benzodiazepine dose by 25% every 1-2 weeks 1.
• However, a more gradual approach may be necessary, with reductions of 10-25% every 2-4 weeks, to minimize the risk of withdrawal symptoms and adverse effects.
• It is essential to individualize the tapering schedule based on the patient's response and tolerance to the reductions.

Education and Support

• Educating patients about the risks and benefits of benzodiazepine tapering is crucial, as demonstrated by the EMPOWER trial, which showed that 62% of independent seniors expressed interest in benzodiazepine changes, with 27% of patients stopping benzodiazepines compared with 5% in the control group 1.
• Providing support and guidance throughout the tapering process can help patients manage withdrawal symptoms and stay motivated to achieve their goals.

From the FDA Drug Label

In elderly patients, in patients with advanced liver disease or in patients with debilitating disease, the usual starting dose is 0. 25 mg, given two or three times daily. This may be gradually increased if needed and tolerated. The elderly may be especially sensitive to the effects of benzodiazepines. If side effects occur at the recommended starting dose, the dose may be lowered. The elderly may be more sensitive to the effects of benzodiazepines They exhibit higher plasma alprazolam concentrations due to reduced clearance of the drug as compared with a younger population receiving the same doses. The smallest effective dose of alprazolam tablets should be used in the elderly to preclude the development of ataxia and oversedation

When tapering benzodiazepines in elderly patients, caution is necessary due to their increased sensitivity to the effects of benzodiazepines. Key considerations include:

• Using the smallest effective dose to minimize the risk of adverse effects such as ataxia and oversedation
• Gradually increasing the dose if needed and tolerated
• Monitoring for side effects and lowering the dose if they occur
• Being aware that elderly patients may exhibit higher plasma concentrations of the drug due to reduced clearance 2 2

From the Research

Considerations for Tapering Benzodiazepines in Elderly Patients

• A patient-centered approach to reduction is necessary, taking into account the unique cognitive and functional abilities and comorbidities of older adults 3.
• Protocols for tapering benzodiazepines in elderly patients may include taper alone, taper plus cognitive behavioral therapy, or taper plus medication substitution 3.
• Common schedules for tapering benzodiazepines include a 25% dose reduction over 1-2 weeks until the patient is drug-free 3.
• Monitoring and support are crucial during the tapering process, and taper modifications may be necessary for patients who struggle with withdrawal symptoms 3.
• The severity of withdrawal symptoms in elderly patients may be less severe than in younger patients, and tapered benzodiazepine withdrawal does not appear to be more risky for the elderly group than for the younger patients 4.
• Standardized advice and a tapering off schedule can be effective in withdrawing patients from long-term benzodiazepine use, and this approach is feasible in primary care 5.
• Gradual tapering of benzodiazepines over 4 weeks on an outpatient basis is suggested for low-dose withdrawal, while high-dose withdrawal may require inpatient tapering at a rate of 10% per day 6.
• Combining cognitive-behavioral therapy with gradual tapering can be superior to tapering alone in achieving long-term discontinuation of benzodiazepines in older adults with insomnia 7.