What is the best approach to taper or discontinue lorazepam (Ativan) in an elderly female patient with anxiety-induced tremor, who has failed propranolol (Inderal), alprazolam (Xanax), and aripiprazole (Abilify), and is currently taking 1mg of lorazepam daily, but experiences excessive sleepiness?

Tapering Lorazepam in an Elderly Female with Anxiety-Induced Tremor

Gradually taper lorazepam by 25% of the current dose every 1-2 weeks while simultaneously introducing cognitive behavioral therapy (CBT) and considering alternative pharmacological options for tremor management, as benzodiazepines pose significant risks in elderly patients including cognitive impairment, falls, and fractures. 1, 2

Evidence-Based Rationale for Discontinuation

Benzodiazepines like lorazepam are explicitly flagged as high-risk medications in elderly patients due to sedation, cognitive impairment, unsafe mobility with injurious falls, motor skill impairment, habituation, and withdrawal syndromes. 1 The Mayo Clinic guidelines specifically recommend tapering benzodiazepines using the EMPOWER technique, considering safer therapy alternatives, particularly for anxiety symptoms. 1 Your patient's complaint of excessive sleepiness is a classic adverse effect that justifies discontinuation, as this sedation directly increases fall risk and functional decline in elderly populations. 1

Recommended Tapering Protocol

Start by reducing lorazepam from 1mg daily to 0.75mg daily (25% reduction) for 1-2 weeks. 2, 3 The FDA label for lorazepam explicitly states: "To reduce the risk of withdrawal reactions, use a gradual taper to discontinue lorazepam or reduce the dosage. If a patient develops withdrawal reactions, consider pausing the taper or increasing the dosage to the previous tapered dosage level." 3

Specific Tapering Schedule:

• Weeks 1-2: Reduce to 0.75mg daily (25% reduction from 1mg) 2
• Weeks 3-4: Reduce to 0.5mg daily (approximately 33% of current dose) 2
• Weeks 5-6: Reduce to 0.25mg daily 2
• Weeks 7-8: Discontinue completely 2

The taper rate must be determined by the patient's tolerance, not a rigid schedule—pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge. 2 For elderly patients specifically, consider a more gradual taper with smaller dose reductions to minimize adverse effects. 2

Critical Monitoring During Taper

Follow up at least monthly during the taper, with more frequent contact during difficult phases. 2 Monitor specifically for withdrawal symptoms including:

• Anxiety, tremor, insomnia 2, 3
• Sweating, tachycardia, headache 2
• Weakness, muscle aches, nausea 2
• Confusion or altered mental status 2
• Seizures (rare but life-threatening) 2, 3

Clinically significant withdrawal symptoms signal the need to further slow the taper rate or pause entirely. 2 If withdrawal symptoms emerge, return to the previous stable dose and maintain that level for 2-4 weeks before attempting further reduction. 2

Adjunctive Strategies to Improve Success

Cognitive-behavioral therapy (CBT) during the taper significantly increases success rates and should be incorporated. 1, 2 CBT provides non-pharmacological anxiety management skills that replace the benzodiazepine's anxiolytic effect. 1

Patient education about benzodiazepine risks and benefits of tapering improves outcomes and engagement. 1, 2 Explain that successful withdrawal is typically followed by improved psychomotor and cognitive functioning, particularly in memory and daytime alertness. 4

Additional supportive measures include:

• Mindfulness and relaxation techniques 1
• Sleep hygiene education 1
• Exercise and fitness training 2

Alternative Pharmacological Options for Tremor

Since this patient has failed propranolol, alprazolam, and aripiprazole for anxiety-induced tremor, consider these evidence-based alternatives:

For Tremor Management:

• Primidone: First-line alternative to propranolol for essential tremor, can improve tremor in approximately 50% of patients 5
• Gabapentin: May be helpful for tremor control, starting with 100-300mg at bedtime or three times daily, titrating by 100-300mg every 1-7 days as tolerated 2
• Topiramate: Another option for tremor management 5

For Anxiety Management (Without Sedation):

• Buspirone: 5mg twice daily (maximum 20mg three times daily) for mild to moderate anxiety, though it requires 2-4 weeks to become effective and has no dependence risk 2
• SSRIs (sertraline or escitalopram): First-line pharmacotherapy for anxiety disorders with moderate-to-high strength of evidence, starting at low doses (sertraline 25mg or escitalopram 5mg) 2

Do not substitute another benzodiazepine or Z-drug (zolpidem, zaleplon) as these carry similar risks in older adults. 2

Common Pitfalls to Avoid

Never discontinue lorazepam abruptly—this can cause seizures and death, equivalent to suddenly stopping antihypertensives or antihyperglycemics. 2, 3 Abrupt benzodiazepine withdrawal can precipitate acute withdrawal reactions that are life-threatening. 3

Never abandon the patient, even if tapering is unsuccessful. 2 Maintain the therapeutic relationship and consider maintenance therapy at a reduced dose if complete discontinuation proves impossible. 2

Do not taper too quickly. Research shows that even a 10% reduction every 3 days resulted in only 24% of patients completing withdrawal successfully. 2 The taper will likely take a minimum of 6-12 months for optimal success. 2

Avoid prescribing additional CNS depressants during the tapering period. 2 The patient should be warned not to operate dangerous machinery or motor vehicles and that tolerance for alcohol will be diminished. 3

When to Refer to a Specialist

Immediate specialist referral is indicated for:

• History of withdrawal seizures 2
• Unstable psychiatric comorbidities 2
• Co-occurring substance use disorders 2
• Previous unsuccessful office-based tapering attempts 2

Expected Timeline and Realistic Goals

The taper will likely require 6-12 months minimum, possibly longer. 2 Patient agreement and interest in tapering is a key component of success. 2 Tapers may be considered successful as long as the patient is making progress—the goal is durability of the taper, not speed. 2

The greatest risk of relapse occurs in the first 8-12 weeks after discontinuing medication. 2 Close follow-up should be encouraged for at least 2-3 months after stopping medication. 2

Successful withdrawal typically results in improved psychomotor and cognitive functioning, particularly in memory and daytime alertness, with improvement in anxiety symptoms and general well-being maintained during both the taper and follow-up phases. 4