How to taper diazepam (benzodiazepine) in an elderly female patient who has been on 10mg for years?

Tapering Diazepam in an Elderly Female on Long-Term Therapy

For an elderly female on diazepam 10 mg daily for years, implement a gradual taper reducing by 10-25% of the current dose every 1-2 weeks, starting with a reduction to 7.5 mg daily, with the understanding that this patient population requires particularly cautious dose reductions and extended taper durations. 1

Critical Safety Considerations

Abrupt discontinuation of benzodiazepines can cause seizures and death - this is as inappropriate as suddenly stopping antihypertensives or antihyperglycemics. 1 Benzodiazepine withdrawal carries greater risks than opioid withdrawal and must always be conducted gradually. 1

Specific Risks in Elderly Patients

• Benzodiazepines in the elderly are associated with cognitive impairment, reduced mobility, unsafe driving skills, decline of functional independence, falls, fractures, and addiction. 2
• Long-acting agents like diazepam pose particular concerns due to sedation, cognitive impairment, and fall risk with injuries. 2
• Dose reduction is specifically required in debilitated or elderly patients per FDA labeling. 3

Recommended Tapering Protocol

Initial Taper Schedule

Reduce by 25% of the current dose every 1-2 weeks as the standard approach: 1

• Weeks 1-2: Reduce from 10 mg to 7.5 mg daily (25% reduction)
• Weeks 3-4: Reduce to 5.5-6 mg daily (approximately 25% of current dose)
• Continue reducing by 10-25% of the current dose every 1-2 weeks 1

Important Modification for Long-Term Users

For patients on benzodiazepines for more than 1 year (which applies here), strongly consider extending the taper to 10% per month rather than 10-25% every 1-2 weeks. 1 This slower approach is particularly appropriate for elderly patients to minimize adverse effects. 1

Key Tapering Principles

• Calculate each reduction as a percentage of the CURRENT dose, not the original dose - this prevents disproportionately large final reductions. 1
• The taper rate must be determined by the patient's ability to tolerate reductions, not by a rigid schedule. 1
• Pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge. 1

Monitoring Requirements

Follow-Up Schedule

• Follow up at least monthly during the taper 1
• More frequent contact may be needed during difficult phases 1

Symptoms to Monitor

Monitor for withdrawal symptoms including: 1

• Anxiety, tremor, insomnia
• Sweating, tachycardia, headache
• Weakness, muscle aches, nausea
• Confusion
• Mood changes and suicidal ideation

Screen for depression, anxiety, and substance use disorders that may emerge during tapering. 1

Adjunctive Strategies

Non-Pharmacological Interventions

Cognitive-behavioral therapy (CBT) during the taper increases success rates and may be particularly helpful for patients struggling with discontinuation. 1 Psychological or supportive therapies including mindfulness, relaxation techniques, and psychotherapy should be incorporated. 1

Pharmacological Adjuncts (If Needed)

Consider the following to mitigate withdrawal symptoms: 1

• Carbamazepine - can help with withdrawal symptoms (though may affect metabolism of some benzodiazepines)
• Pregabalin - has shown potential benefit in facilitating tapering
• Antidepressants (particularly SSRIs like paroxetine) - may manage underlying anxiety during tapering

Gabapentin can also help mitigate withdrawal symptoms: 1

• Start with 100-300 mg at bedtime or three times daily
• Increase by 100-300 mg every 1-7 days as tolerated
• Adjust dosage in patients with renal insufficiency

When to Refer to a Specialist

Refer to a specialist if: 1

• History of withdrawal seizures exists
• Unstable psychiatric comorbidities are present 1
• Co-occurring substance use disorders exist
• Office-based tapering has been unsuccessful

Common Pitfalls to Avoid

• Do not reduce by a fixed amount each time - always calculate the reduction as a percentage of the current dose 1
• Do not rush the taper - elderly patients may need months to complete withdrawal safely 1
• Do not abandon the taper if withdrawal symptoms emerge - pause and stabilize, then resume more slowly 1
• Warn patients about increased overdose risk if they return to previous doses after tolerance is lost 1

Rationale for Discontinuation

Current consensus guidelines advise use of benzodiazepines solely on a short-term basis. 2 Discontinuation is usually beneficial as it is followed by improved psychomotor and cognitive functioning, particularly in the elderly. 4 The benefits of long-term benzodiazepine use are increasingly questioned while adverse effects have been extensively documented. 4