How do you taper alprazolam (Xanax) in an elderly patient with dementia who is currently taking 0.5 mg PRN (as needed) once a day?

Tapering Alprazolam 0.5 mg PRN Once Daily in an Elderly Patient with Dementia

Critical First Assessment: Is This Medication Appropriate?

Alprazolam should be discontinued entirely in this elderly patient with dementia, as benzodiazepines are explicitly contraindicated in this population due to substantial risks of cognitive impairment, delirium, falls, fractures, and worsening dementia. 1, 2

• The American Geriatrics Society Beers Criteria explicitly recommends avoiding all benzodiazepines in older adults with dementia due to increased sensitivity and substantial risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes 3
• Benzodiazepines worsen cognitive function in dementia patients and cause paradoxical agitation in approximately 10% of elderly patients 1
• Observational data demonstrates that benzodiazepines with prolonged use are associated with dementia, with the effect being greatest for higher-dose hypnotics 3
• Benzodiazepines should not be used for routine behavioral management in dementia, as they are associated with tolerance, addiction, depression, cognitive impairment, reduced mobility, unsafe driving skills, decline of functional independence, falls, and fractures 1, 2

Recommended Tapering Protocol

For a patient taking alprazolam 0.5 mg PRN once daily, reduce the dose by 0.125 mg (25% of current dose) every 1-2 weeks, which translates to reducing from 0.5 mg to 0.375 mg for weeks 1-2, then to approximately 0.25 mg for weeks 3-4, continuing this pattern until complete discontinuation. 3, 4

Specific Tapering Schedule

• Week 1-2: Reduce from 0.5 mg to 0.375 mg daily (25% reduction) 3
• Week 3-4: Reduce to 0.25 mg daily (approximately 33% of 0.375 mg) 3
• Week 5-6: Reduce to 0.125 mg daily 3
• Week 7-8: Discontinue completely 3

Important Modifications for This Population

• The FDA label states that elderly or debilitated patients require more gradual dosage adjustments and lower dosage levels, and it is suggested that the dose be reduced by no more than 0.5 mg every 3 days, with the understanding that some patients may benefit from an even more gradual discontinuation 4
• For elderly patients with dementia, consider an even slower taper with reductions of 10% of the current dose per month rather than 25% every 1-2 weeks, especially if the patient has been on the medication for more than 1 year 3
• The taper rate must be determined by the patient's ability to tolerate reductions, not by a rigid schedule, and pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge 3

Critical Safety Warnings

Abrupt discontinuation of alprazolam can cause seizures and death—never stop suddenly. 3, 4

• Withdrawal seizures have been reported upon rapid decrease or abrupt discontinuation of alprazolam 4
• Benzodiazepine withdrawal carries greater risks than opioid withdrawal and should always be conducted gradually 3
• If significant withdrawal symptoms develop, the previous dosing schedule should be reinstituted and, only after stabilization, should a less rapid schedule of discontinuation be attempted 4

Monitoring for Withdrawal Symptoms

Monitor closely for withdrawal symptoms including anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, confusion, and seizures. 3

• Follow up at least monthly during the taper, with more frequent contact during difficult phases 3
• Clinically significant withdrawal symptoms signal the need to further slow the taper rate 3
• Monitor for mood changes and suicidal ideation, and screen for depression, anxiety, and substance use disorders that may emerge during tapering 3

Do NOT Substitute Another Benzodiazepine

Do not substitute another benzodiazepine or Z-drug (zolpidem, zaleplon) as these carry similar risks in older adults with dementia. 3

• Switching to a longer-acting benzodiazepine like diazepam or clonazepam is NOT recommended in elderly patients with dementia, as long-acting agents pose particular concerns due to sedation, cognitive impairment, and fall risk with injuries 3

Adjunctive Strategies to Improve Success

Integrate cognitive-behavioral therapy (CBT) during the taper, as this significantly increases success rates. 3

• Patient education about benzodiazepine risks and benefits of tapering improves outcomes and engagement 3
• Additional supportive measures include mindfulness and relaxation techniques, sleep hygiene education, and exercise and fitness training 3
• Consider gabapentin 100-300 mg at bedtime or three times daily to help mitigate withdrawal symptoms, starting with lower dosages and titrating cautiously to avoid dose-dependent dizziness and sedation 3
• SSRIs (particularly paroxetine) may help manage underlying anxiety during tapering 3

Alternative Treatment for Behavioral Symptoms

If the alprazolam was being used for agitation or behavioral symptoms in dementia, non-pharmacological interventions must be implemented first, with SSRIs (citalopram 10 mg/day or sertraline 25-50 mg/day) as the preferred pharmacological option if behavioral approaches fail. 2

• Non-pharmacological interventions include environmental modifications (adequate lighting, reducing noise), structured daily routines, calm tones and simple one-step commands, and addressing reversible causes such as pain, urinary tract infections, constipation, and dehydration 1, 2
• Antipsychotics should only be used when the patient is severely agitated, threatening substantial harm to self or others, and behavioral interventions have failed, due to increased mortality risk (1.6-1.7 times higher than placebo) 2, 5

Realistic Timeline and Expectations

The taper will likely take 6-12 weeks minimum for this patient on a low dose, and possibly longer if withdrawal symptoms emerge. 3

• Patient agreement and interest in tapering is a key component of success, using shared decision-making and explaining the risks of continued use versus benefits of discontinuation 3
• Successful withdrawal is typically followed by improved psychomotor and cognitive functioning, particularly in memory and daytime alertness 3
• Never abandon the patient, even if tapering is unsuccessful—maintain the therapeutic relationship and consider maintenance therapy if complete discontinuation proves impossible 3

When to Refer to a Specialist

Refer immediately to a specialist if the patient has a history of withdrawal seizures, unstable psychiatric comorbidities, co-occurring substance use disorders, or previous unsuccessful office-based tapering attempts. 3