Should a patient with cognitive impairment, falls, memory problems, and impaired driving ability due to Ativan (lorazepam) continue with a taper?

Yes, Absolutely Continue the Taper—Abrupt Discontinuation is Dangerous

Despite experiencing cognitive issues, falls, memory problems, and impaired driving from Ativan (lorazepam), the patient must still undergo a gradual taper rather than abrupt discontinuation, as stopping benzodiazepines suddenly can precipitate life-threatening withdrawal reactions including seizures. 1

Why Tapering Remains Essential Despite Adverse Effects

The cognitive and motor impairments this patient is experiencing are well-documented adverse effects of lorazepam that actually strengthen the case for discontinuation—but through controlled tapering, not abrupt cessation. 2

Critical Safety Concerns with Abrupt Discontinuation

• Abrupt discontinuation or rapid dosage reduction after continued benzodiazepine use can precipitate acute withdrawal reactions that are life-threatening, particularly seizures. 1
• Patients at highest risk for severe withdrawal include those on higher dosages and those with longer durations of use—characteristics that likely apply to this patient given the severity of cognitive effects. 1
• The FDA labeling explicitly warns that "abrupt discontinuation or rapid dosage reduction of lorazepam after continued use may precipitate acute withdrawal reactions, which can be life-threatening (e.g., seizures)." 1

The Adverse Effects Support Discontinuation, Not Abrupt Cessation

The patient's symptoms are consistent with known benzodiazepine toxicity:

• Benzodiazepines cause tolerance, addiction, depression, and cognitive impairment with regular use. 2
• Lorazepam specifically impairs memory encoding, increases reaction time variability, decreases reaction accuracy, and reduces attention and motor ability. 3, 4, 5
• Falls risk is significantly elevated—benzodiazepines are sedating and cause cognitive impairment and unsafe mobility with injurious falls. 2
• Driving impairment and memory problems are documented FDA-recognized adverse effects. 2

Recommended Tapering Approach

Gradual Dose Reduction Protocol

• Use a patient-specific gradual taper plan to reduce the risk of withdrawal reactions. 1
• If withdrawal reactions develop during tapering, pause the taper or increase the dosage back to the previous tapered level, then decrease more slowly. 1
• For elderly or debilitated patients, initial dosing recommendations are 1-2 mg/day in divided doses—tapering should be even more conservative than standard protocols. 1

Monitoring During Taper

• Watch for withdrawal symptoms including anxiety, insomnia, agitation, tremor, and most critically, seizures. 1
• Benzodiazepine withdrawal can manifest as protracted withdrawal syndrome with symptoms lasting weeks to more than 12 months in some cases. 1
• Monitor for improvement in cognitive function, fall risk, and driving ability as the taper progresses—these adverse effects should gradually resolve. 6, 4

Expected Cognitive Recovery

• Meta-analyses demonstrate that cognitive dysfunction improves after benzodiazepine withdrawal, though patients may not fully return to baseline functioning of benzodiazepine-free controls. 6
• The cognitive impairments (memory, attention, processing speed, visuospatial ability) are well-documented with long-term benzodiazepine use and provide strong justification for complete discontinuation. 6, 5

Common Pitfall to Avoid

The most dangerous error would be abrupt cessation because the patient is experiencing adverse effects. The very presence of significant cognitive impairment, falls, and functional decline indicates substantial benzodiazepine exposure that has created physical dependence—making gradual tapering even more critical for safety. 1

The goal is complete discontinuation through controlled tapering, which addresses both the immediate safety concern (preventing withdrawal seizures) and the long-term goal (eliminating the source of cognitive impairment and fall risk). 2, 5