What is the best anxiety medication for an elderly female on benzodiazepines (BZD) 10mg for many years and zopiclone (non-benzodiazepine hypnotic) 5mg daily?

Gradual Benzodiazepine Tapering with Antidepressant Substitution

The priority for this elderly female on long-term benzodiazepines and zopiclone is not to add another anxiety medication, but to implement a gradual deprescribing protocol while transitioning to safer alternatives, as prolonged benzodiazepine use in the elderly is associated with cognitive impairment, falls, fractures, and addiction. 1

Critical Context: Why Not to Continue Current Regimen

• Long-term benzodiazepine and zopiclone use in elderly patients is considered high-risk by Beers criteria and current consensus guidelines advise their use solely on a short-term basis 1
• Both benzodiazepines and zopiclone (which acts on the benzodiazepine GABA receptor complex) are associated with cognitive impairment, reduced mobility, unsafe driving, functional decline, falls, fractures, and addiction in the elderly 1
• Zopiclone has similar risks to benzodiazepines despite being chemically distinct, as it acts on closely related receptor sites 2, 3

Recommended Treatment Algorithm

Phase 1: Initiate Safer Alternative for Anxiety (Week 0)

Start a sedating antidepressant as the primary anxiety treatment:

• First-line option: Trazodone 25-50 mg at bedtime, which has minimal anticholinergic activity compared to other sedating antidepressants 1
• Alternative options include mirtazapine (though associated with weight gain) or low-dose doxepin 1
• These antidepressants address both anxiety and sleep concerns without the fall risk and cognitive impairment of benzodiazepines 1

Phase 2: Begin Gradual Benzodiazepine Taper (Week 2-4)

After establishing the antidepressant, initiate a very slow taper:

• Reduce the total daily benzodiazepine dose by 10% every 2-4 weeks (slower is better for patients on long-term therapy) 4
• For patients on benzodiazepines for many years, 10% monthly reductions are better tolerated than weekly reductions 5, 4
• Calculate each reduction as a percentage of the current dose, not the original dose, to prevent disproportionately large final reductions 5
• Never discontinue abruptly as this can cause seizures, delirium, and death 4

Phase 3: Address Zopiclone Simultaneously or Sequentially

Zopiclone 5 mg daily should be tapered using similar principles:

• Zopiclone has a short half-life (approximately 6 hours) and is rapidly eliminated 2
• Consider reducing by 1.25 mg (25%) every 2-4 weeks after benzodiazepine taper is established 4
• Alternatively, taper zopiclone first if sleep is less problematic than daytime anxiety 1

Phase 4: Adjunctive Support During Taper

Add pharmacological and non-pharmacological support:

• Gabapentin 100-300 mg at bedtime can mitigate withdrawal symptoms, increasing by 100-300 mg every 1-7 days as tolerated 5
• Cognitive-behavioral therapy (CBT) during taper significantly increases success rates 1, 5
• Patient education about benzodiazepine risks and withdrawal expectations improves outcomes (EMPOWER trial showed 27% cessation vs 5% in controls) 1

Monitoring Protocol

• Schedule follow-up appointments at least monthly during the taper 4
• Weekly follow-up is recommended during critical taper phases to monitor withdrawal symptoms, mood changes, and suicidal ideation 5
• If withdrawal symptoms become significant, pause the taper temporarily and resume at a slower rate 5, 4
• Monitor specifically for: rebound anxiety, insomnia, tremor, confusion, falls, and cognitive changes 1

Critical Pitfalls to Avoid

• Do not switch to long-acting benzodiazepines like clonazepam in older adults due to increased risk of daytime sedation and falls 4
• Avoid prescribing other CNS depressants during the taper period 4
• Do not use flurazepam due to its extended half-life and risk of residual daytime drowsiness in elderly patients 1
• Elderly patients require more gradual tapers with smaller dose reductions than younger adults 5
• Warn patients about increased overdose risk if they return to previous doses after tolerance is lost 5

Special Considerations for Elderly Females

• Elderly females are the demographic most frequently prescribed benzodiazepines and most likely to experience side effects due to comorbid medical conditions and polypharmacy 6
• Age-related pharmacokinetic changes increase exposure to medications (41% increase in AUC for eszopiclone in patients ≥65 years) 2
• At age 59+, patients may be more sensitive to withdrawal effects and require slower tapers 4
• Expect the complete taper to take several months to over a year given the duration of use 5, 4

Why Not Simply Add Another Anxiolytic

Adding another medication would compound polypharmacy risks and does not address the fundamental problem: this patient is already on two high-risk medications that should be discontinued 1. The evidence strongly supports deprescribing rather than adding to the medication burden in elderly patients on chronic benzodiazepines 1.