How should a 74‑year‑old woman on nightly lorazepam for 15 years and half‑bottle nightly wine be tapered to temazepam for insomnia?

Transitioning a 74-Year-Old Woman from Lorazepam to Temazepam: A Critical Safety Protocol

Do not transition this patient to temazepam—instead, implement a gradual lorazepam taper to complete discontinuation while addressing her alcohol use and insomnia with evidence-based non-pharmacologic and safer pharmacologic alternatives. 1

---

Why Temazepam Is Not the Solution

• The American Geriatrics Society explicitly recommends avoiding all benzodiazepines—including both lorazepam and temazepam—in older adults due to markedly increased risks of cognitive impairment, delirium, falls, fractures, motor-vehicle crashes, and dementia. 1
• Switching from one benzodiazepine to another does not reduce harm; it perpetuates the same risks while complicating the clinical picture. 1, 2
• After 15 years of nightly lorazepam, this patient has established physical dependence; substituting temazepam will maintain that dependence and delay the only intervention proven to improve long-term outcomes: complete benzodiazepine discontinuation. 1, 3
• Temazepam carries identical risks to lorazepam in elderly patients—cognitive decline, falls, respiratory depression when combined with alcohol, and paradoxical agitation in approximately 10% of elderly patients. 1, 4

---

The Correct Clinical Approach: Gradual Lorazepam Taper

Step 1: Address Concurrent Alcohol Use First

• Benzodiazepine withdrawal carries greater risk than opioid withdrawal and must never be attempted while the patient continues nightly alcohol consumption (half-bottle of wine ≈ 2–3 standard drinks). 2
• Concomitant alcohol and benzodiazepine use dramatically increases respiratory depression risk, cognitive impairment, and fall risk; this combination must be addressed before any taper begins. 4
• Refer the patient for alcohol-use assessment and brief intervention; consider involving addiction medicine or psychiatry if she meets criteria for alcohol use disorder. 2
• Once alcohol intake is stable or eliminated, proceed with benzodiazepine taper; attempting both simultaneously obscures the source of withdrawal symptoms and increases failure risk. 1

Step 2: Lorazepam Taper Protocol

• Reduce lorazepam by 25% of the current dose every 1–2 weeks for patients on benzodiazepines less than 1 year; for this patient with 15 years of use, slow to 10% of the current dose per month to minimize withdrawal symptoms. 1, 2
• Example taper schedule (assuming current dose is 2 mg nightly):
  • Weeks 1–4: 1.8 mg nightly (10% reduction) 1
  • Weeks 5–8: 1.6 mg nightly (10% of 1.8 mg) 1
  • Weeks 9–12: 1.45 mg nightly (10% of 1.6 mg) 1
  • Continue reducing by 10% of the current dose every 4 weeks until reaching 0.25 mg, then discontinue. 1
• Total expected taper duration: 16–20 months minimum; some patients require up to several years. 1, 2
• Abrupt discontinuation can precipitate seizures and death—never stop suddenly. 1, 2, 5

Step 3: Monitoring During Taper

• Weekly visits during the first 8 weeks, then every 2 weeks thereafter. 1
• At each visit, assess for withdrawal symptoms: anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, confusion, and seizures. 1, 2
• If significant withdrawal symptoms appear, slow the taper or pause for 2–4 weeks before continuing. 1, 2
• Monitor for re-emergence of insomnia, anxiety, or depression; screen for substance use disorders at each visit. 1, 2

Step 4: Adjunctive Pharmacologic Support

• Gabapentin 100–300 mg at bedtime, titrated as tolerated, may lessen withdrawal symptoms. 1, 2
• Typical gabapentin titration: start 100–300 mg nightly, increase by 100–300 mg every 1–7 days as tolerated; adjust dose in renal insufficiency. 2
• Do not substitute another benzodiazepine or Z-drug (zolpidem, zaleplon, eszopiclone) for lorazepam, as they carry comparable risks in older adults. 1, 6

---

Evidence-Based Insomnia Management During and After Taper

First-Line Non-Pharmacologic Therapy (Essential)

• Cognitive Behavioral Therapy for Insomnia (CBT-I) is the standard of care for chronic insomnia, offering superior long-term efficacy compared with medications and preserving benefits after drug discontinuation. 7, 6
• Integrating CBT-I during the benzodiazepine taper significantly increases success rates and reduces relapse risk. 1, 2, 3
• Core CBT-I components: stimulus control (leave bed when unable to sleep within 20 minutes), sleep restriction (time in bed = actual sleep + 30 minutes), relaxation techniques (progressive muscle relaxation), and cognitive restructuring of maladaptive sleep beliefs. 7, 6
• CBT-I can be delivered via individual therapy, group sessions, telephone-based programs, or web-based modules. 6

Sleep Hygiene Education

• Establish a predictable daily routine with consistent bedtimes and wake times. 1, 6
• Limit daytime naps to a single 15–20 minute nap before 3 PM. 6
• Avoid caffeine after noon and eliminate alcohol in the evening. 6
• Do not eat heavy meals within 3 hours of bedtime. 6
• Create a comfortable sleep environment (earplugs, eye-shades, noise/light reduction). 6

Safer Pharmacologic Alternatives (If Non-Pharmacologic Measures Insufficient)

• Low-dose doxepin (3–6 mg at bedtime) is the preferred first-line hypnotic for older adults with sleep-maintenance insomnia who are tapering benzodiazepines. 6
• Moderate-quality evidence shows low-dose doxepin reduces wake after sleep onset by approximately 22–23 minutes, improves sleep efficiency, total sleep time, and overall sleep quality, with minimal anticholinergic activity at this dose. 6
• Low-dose doxepin has no abuse potential, is not a controlled substance, and carries no black-box warnings. 6
• Ramelteon 8 mg shortens sleep-onset latency without abuse potential or withdrawal symptoms; appropriate for difficulty falling asleep. 7, 6
• Suvorexant 10 mg (not 20 mg) decreases wake after sleep onset by 16–28 minutes and carries lower risk of cognitive and psychomotor impairment than benzodiazepine-type agents. 7, 6

Medications to Avoid

• Trazodone is not recommended for insomnia in older adults because it yields only ~10 minutes reduction in sleep latency, does not improve subjective sleep quality, and produces adverse events in roughly 75% of this population. 6
• Over-the-counter antihistamines (diphenhydramine, doxylamine) lack efficacy for insomnia and cause pronounced anticholinergic side-effects (confusion, urinary retention, falls, delirium); they should be avoided. 6
• Antipsychotics (quetiapine, olanzapine) carry a black-box warning for roughly two-fold increase in mortality in older adults and should not be used for insomnia. 6

---

Expected Outcomes and Timeline

• Total deprescribing period: 16–20 months minimum for lorazepam taper. 1
• Successful withdrawal typically yields improved psychomotor and cognitive function, especially memory and daytime alertness. 1, 3
• Reduced sedation is usually noticeable within 2–4 weeks after completing the lorazepam taper. 1
• When reversible benzodiazepine-induced toxicity is present, cognitive function typically improves within weeks to months after drug cessation. 1

---

Common Pitfalls to Avoid

• Never substitute another benzodiazepine or Z-drug for lorazepam; this perpetuates the same risks and delays definitive treatment. 1, 2
• Never taper lorazepam and address alcohol use simultaneously; this obscures the source of emerging symptoms. 1
• Do not abandon the patient if tapering fails; maintain therapeutic relationship and consider low-dose maintenance as an acceptable outcome. 1, 2
• Avoid straight-line reductions from the starting dose; always reduce by a percentage of the current dose to prevent disproportionately large final decrements. 1, 2
• Never taper too quickly; research shows that even a 10% reduction every 3 days resulted in only 24% of patients completing withdrawal successfully. 2

---

Referral Criteria

• History of withdrawal seizures from prior benzodiazepine cessation. 1, 2
• Unstable psychiatric comorbidities (e.g., severe depression, suicidal ideation). 1, 2
• Previous unsuccessful office-based taper attempts. 1, 2
• Co-occurring substance use disorders (including alcohol use disorder). 2
• Patient refuses to taper or is unable to tolerate even minimal dose reductions. 2

---

Bottom Line

Switching from lorazepam to temazepam in a 74-year-old woman with 15 years of nightly benzodiazepine use and concurrent alcohol consumption is clinically inappropriate and perpetuates harm. 1 The evidence-based approach is a gradual lorazepam taper (10% of current dose per month) combined with alcohol cessation support, CBT-I, and—if pharmacotherapy is needed—low-dose doxepin 3–6 mg or ramelteon 8 mg. 1, 2, 6 This strategy reduces fall risk, cognitive impairment, and mortality while addressing the root cause of her insomnia through non-pharmacologic means. 1, 6, 3