What oral benzodiazepine tablet is preferred for pre‑operative anxiety in a healthy adult, and what dose should be administered?

Oral Midazolam 10 mg is the Preferred Preoperative Anxiolytic

For healthy adults under 60 years with significant preoperative anxiety, oral midazolam 10 mg administered 30–60 minutes before surgery is the preferred benzodiazepine due to its rapid onset, short half-life (1.5–2.5 hours), and favorable safety profile 1. However, non-pharmacologic interventions should be attempted first 2, 3.

Age-Stratified Approach

Adults Under 60 Years

• Midazolam 10 mg orally 30–60 minutes preoperatively is the first-line benzodiazepine choice 1
• Alternative options if midazolam is unavailable:
  • Lorazepam 1–2 mg sublingually 20–30 minutes preoperatively 1
  • Diazepam 5–10 mg orally 20–30 minutes preoperatively 1
• Avoid long-acting benzodiazepines (diazepam, clonazepam, chlordiazepoxide) as they cause prolonged psychomotor impairment lasting more than four hours, hampering early mobilization and recovery 2

Adults 60 Years and Older

• Benzodiazepines should be avoided entirely in patients ≥60–65 years due to increased sensitivity, cognitive impairment risk, delirium, and falls 2, 3
• The American Geriatrics Society provides a strong recommendation with moderate quality evidence against benzodiazepine use in elderly patients 3
• If anxiety is severe and non-pharmacologic methods fail, consider melatonin as an alternative, which provides effective anxiolysis with fewer side effects and is equally effective to midazolam 2

Critical Safety Considerations

Absolute Contraindications

• Never combine benzodiazepines with other CNS depressants (opioids, sedatives) due to significantly increased respiratory depression risk 3
• Patients receiving benzodiazepines require arranged transportation home 1

Documentation Requirements

• Document prior benzodiazepine tolerance and any history of paradoxical reactions 3
• Create a perioperative anxiety management plan and communicate it to surgical and anesthetic teams 3

Non-Pharmacologic Interventions Should Be First-Line

Benzodiazepines should be reserved only for selected individuals who continue to experience significant anxiety after non-pharmacologic strategies have been applied 2. The evidence strongly supports this approach:

• Preoperative education sessions about the surgical pathway successfully reduce anxiety and improve perioperative experience 2, 4
• Effective communication strategies should begin days prior to admission, as high anxiety levels occur well before surgery day 3, 4
• Additional non-pharmacologic options include relaxation techniques, aromatherapy, and music therapy 4

Common Pitfalls to Avoid

Outdated Practices

• Avoid routine benzodiazepine premedication for all patients—this is an outdated practice where cognitive impairment and delirium risks outweigh anxiety reduction benefits, especially in elderly patients 2
• Do not use diazepam routinely despite its historical popularity; its long half-life impairs postoperative recovery 2

Timing Errors

• Administering benzodiazepines too close to surgery reduces efficacy (insufficient time for absorption and onset) 1
• Administering too early may cause peak sedation before the patient reaches the operating room

Dose Selection

• Use the lowest effective dose, particularly in patients with no prior benzodiazepine exposure 3
• Higher doses (e.g., midazolam >10 mg) increase amnesia risk without proportional anxiety reduction 5

Evidence Quality Considerations

The recommendation for midazolam comes from recent 2025 American Journal of Obstetrics and Gynecology guidelines 1, which specifically address procedural anxiolysis. While this guideline focuses on IUD placement, the pharmacologic principles and benzodiazepine selection criteria apply directly to preoperative anxiolysis. The 2026 ERAS Society guidelines strongly recommend against long-acting benzodiazepines and routine benzodiazepine use 2, reinforcing the preference for short-acting agents like midazolam when pharmacologic anxiolysis is necessary. Research evidence supports triazolam as another short-acting option 5, but midazolam remains preferred due to wider availability and more extensive clinical experience in the preoperative setting.