What is the next step in managing an elderly patient with a history of anxiety or panic disorder, currently taking Xanax (alprazolam) 1mg twice daily, who has experienced two recent falls?

Immediate Benzodiazepine Taper and Multifactorial Fall Risk Assessment

You must initiate a gradual taper of alprazolam (Xanax) immediately, as benzodiazepines are consistently associated with falls in elderly patients and medication reduction is a prominent component of effective fall-prevention interventions. 1

Primary Action: Benzodiazepine Discontinuation

Taper Protocol

• Reduce alprazolam by no more than 0.5 mg every 3 days, as recommended by the FDA label for elderly patients 2
• Current dose is 2 mg/day (1 mg BID), so the taper will take approximately 12 days minimum, though many elderly patients require an even slower reduction 2
• If withdrawal symptoms develop (anxiety, insomnia, tremors, muscle cramps), reinstitute the previous dose temporarily, then attempt a slower taper 2
• Monitor closely for withdrawal seizures, which can occur even after brief therapy at doses within the recommended range 2

Critical Safety Rationale

• There is a consistent association between benzodiazepine use and falls across all settings (community, long-term care, hospital) 1
• The American Geriatrics Society guidelines specifically state that patients who have fallen should have particular attention given to reducing psychotropic medications 1
• Alprazolam at 1 mg BID is a relatively high dose for an elderly patient—the FDA recommends starting elderly patients at 0.25 mg given 2-3 times daily 2
• There is no clear difference in fall risk between long- and short-acting benzodiazepines, so switching to another benzodiazepine is not protective 1

Concurrent Multifactorial Fall Risk Assessment

While tapering the benzodiazepine, conduct the following evaluations as recommended by the American Geriatrics Society for patients with 2 or more falls 1:

Essential Components to Evaluate

• Balance and mobility assessment (gait speed, Timed Up and Go test) 1
• Orthostatic vital signs to assess for postural hypotension 1
• Vision screening and formal assessment if problems reported 1
• Complete medication review beyond just the benzodiazepine—particular attention if taking 4 or more total medications 1
• Home environment assessment if patient will be discharged or is community-dwelling 1

Alternative Anxiety Management

First-Line Replacement Strategy

• Initiate an SSRI as first-line treatment for anxiety in elderly patients 3
• SSRIs and SNRIs are efficacious, well-tolerated, and considered first-line for anxiety disorders in the elderly 3
• Choose an SSRI with favorable pharmacokinetic profile and fewer drug interactions (avoid fluoxetine, fluvoxamine, paroxetine due to strong CYP450 inhibition) 4, 3
• Start at low doses to avoid initial anxiety exacerbation, then gradually titrate to therapeutic range 5

Short-Term Bridging (If Necessary)

• If severe anxiety during taper, consider short-term adjunctive lorazepam 0.25-0.5 mg rather than continuing alprazolam 6, 5
• Lorazepam is preferred over alprazolam in elderly due to intermediate half-life, lack of active metabolites, and more predictable pharmacokinetics 6
• Maximum 2 mg in 24 hours 6
• This should only be used temporarily during the transition to an SSRI, not as long-term replacement 5

Alternative Non-Benzodiazepine Options

• Buspirone may have benefit (starting 5 mg twice daily, maximum 20 mg three times daily), though it lacks robust studies in elderly populations and is not appropriate for acute anxiety 6, 3
• Mirtazapine and vortioxetine are considered safe options for anxiety in elderly 3

Additional Fall Prevention Interventions

Exercise and Balance Training

• Offer long-term exercise and balance training programs, as older people with recurrent falls benefit from this intervention 1
• Tai Chi is a promising balance exercise option 1

Vitamin D Supplementation

• Initiate vitamin D 800 IU daily for fall prevention in elderly patients 1
• The American Geriatrics Society recommends 800 IU per day for persons at increased risk for falls 1

Critical Pitfalls to Avoid

• Do not abruptly discontinue alprazolam—this can precipitate withdrawal seizures even at therapeutic doses 2
• Do not switch to another benzodiazepine as a "safer" alternative—all benzodiazepines carry similar fall risk 1
• Do not underestimate the difficulty of benzodiazepine discontinuation—patients on higher doses for extended periods often experience considerable difficulty tapering, and some may prove resistant to all discontinuation regimens 2
• Do not assume anxiety will worsen permanently—distinguish between withdrawal-emergent symptoms (new symptoms appearing during taper that decrease with time) versus recurrence of underlying anxiety disorder (similar to pre-treatment symptoms that persist) 2
• Do not ignore the possibility that falls may improve significantly once the benzodiazepine is discontinued—medication reduction was a prominent component of effective fall-reducing interventions in multiple Class I studies 1