Why would a 77‑year‑old woman have been started on long‑term Valium (diazepam) 5 mg twice daily 30 years ago despite no documented anxiety diagnosis?

Historical Indications for Long-Term Diazepam 5 mg Twice Daily

Thirty years ago (circa 1994), long-term diazepam 5 mg twice daily was commonly prescribed for chronic sustained anxiety, muscle spasm disorders, or neuropathic pain—indications that were considered acceptable at that time despite the absence of a documented anxiety diagnosis. 1, 2

Most Likely Historical Indications

Chronic Sustained Anxiety (Most Common)

• In the 1980s–1990s, long-term benzodiazepine therapy was considered justified for patients with chronic severe anxiety when symptomatic relief and improved functioning outweighed dependence risk 2
• Diazepam was the preferred agent for sustained anxiety levels due to its long half-life, typically dosed 2.5–10 mg twice daily 1, 2
• Documentation standards were less rigorous 30 years ago—many patients received chronic benzodiazepines for "nervousness" or somatic anxiety symptoms without formal DSM anxiety disorder diagnoses 2
• Depression and anxiety frequently co-occurred, and diazepam was often prescribed alongside antidepressants for the somatic/physical manifestations of anxiety that SSRIs addressed more slowly 1

Muscle Spasm or Chronic Pain Syndromes

• Diazepam's myorelaxant properties made it a common choice for chronic musculoskeletal conditions, fibromyalgia, or neuropathic pain in the 1990s 1, 3
• The dose of 5 mg twice daily falls within the typical range for muscle relaxation indications 1
• Patients with depression often had comorbid chronic pain, and diazepam was frequently used as an adjunct analgesic before gabapentinoids became widely available 4

Insomnia (Less Likely at This Dose/Schedule)

• While diazepam was used for insomnia, the twice-daily dosing pattern suggests a daytime indication rather than purely hypnotic use 1
• Single bedtime dosing or intermittent use was preferred for sleep, not standing BID administration 1

Why No Anxiety Diagnosis May Be Documented

• Prescribing culture in the 1990s: Benzodiazepines were prescribed far more liberally, often for somatic complaints, "stress," or physical tension without requiring formal psychiatric diagnoses 1, 2
• Depression with somatic anxiety: Patients with major depression frequently experienced physical anxiety symptoms (muscle tension, restlessness, GI distress) that were treated with benzodiazepines even when the primary diagnosis was depression 2
• Off-label pain management: Diazepam was commonly used off-label for chronic pain conditions before evidence-based neuropathic pain guidelines emerged 4, 3

Critical Safety Considerations After 30+ Years of Use

Age-Related Pharmacokinetic Changes

• At age 77, this patient's diazepam half-life is likely 80–90 hours (vs. 30–40 hours in younger adults), and the active metabolite desmethyldiazepam has a half-life of approximately 80 hours 5
• Steady-state plasma concentrations are 30–35% higher in elderly patients, with significantly delayed elimination 5
• After 30 years of continuous use, profound tolerance has developed, but abrupt discontinuation would still cause severe withdrawal (potentially seizures) due to physical dependence 4, 6

Current Risks Outweigh Benefits

• Long-term benzodiazepine use in elderly patients is associated with cognitive impairment, falls, fractures, increased dementia risk, reduced mobility, and increased mortality 4, 7
• The American Geriatrics Society Beers Criteria explicitly recommend avoiding all benzodiazepines in adults ≥65 years due to these risks 4, 7
• Current consensus guidelines advise benzodiazepines only for short-term use (maximum 2–4 weeks), not decades-long therapy 4, 6, 1

Recommended Management Approach

Do NOT Abruptly Discontinue

• Abrupt cessation after 30 years of daily use will cause life-threatening withdrawal, including seizures and potentially death 4, 6
• Diazepam must be tapered extremely slowly—likely over 12–24 months minimum given the duration of use 6

Initiate Gradual Taper with Adjunctive Support

• Reduce diazepam by 10% of the current dose per month (not 10% of the original dose), starting with 9 mg/day (from 10 mg/day) for 4 weeks 6
• Integrate cognitive-behavioral therapy (CBT) during the taper, which significantly increases success rates 4, 6
• Consider gabapentin 100–300 mg at bedtime, titrated cautiously, to mitigate withdrawal symptoms 6
• Optimize the existing escitalopram dose (up to 20 mg/day if tolerated) to address any underlying anxiety or depression that may emerge during tapering 4

Monitor Closely for Withdrawal Symptoms

• Follow up at least monthly during the taper, with more frequent contact during difficult phases 6
• Monitor for anxiety, tremor, insomnia, sweating, tachycardia, confusion, and seizures 6
• Pause the taper for 2–4 weeks if clinically significant withdrawal symptoms emerge, then resume at a slower rate 6

Accept Maintenance Therapy as a Legitimate Outcome

• After 30 years of continuous use, complete discontinuation may not be achievable or safe 6
• Reducing to the lowest effective dose (e.g., 2.5–5 mg/day) while minimizing fall risk and cognitive impairment is an acceptable goal 4, 6

Common Pitfalls to Avoid

• Never taper faster than 10% per month in a patient with 30+ years of use—this will cause severe withdrawal and likely failure 6
• Never abandon the patient if tapering is unsuccessful; maintain the therapeutic relationship and consider long-term maintenance at a reduced dose 6
• Never substitute another benzodiazepine or Z-drug (zolpidem, eszopiclone), as these carry similar risks in elderly patients 4, 7
• Never reduce by a percentage of the original dose—always calculate reductions based on the current dose to prevent disproportionately large final decrements 6