How Do You Taper Long-Term Benzodiazepines in Older Adults?
Most older adults on long-term benzodiazepines can successfully taper. Switch short-acting agents (alprazolam, lorazepam) to a diazepam or clonazepam equivalent, then reduce 10–25% every 2–4 weeks, slowing the last 25% further. The EMPOWER trial showed a patient-focused educational letter doubled 6-month cessation rates. Do not abruptly stop — seizure and delirium risk is real.
Evidence review
Pivotal trials, effect sizes, and the populations they studied. PubMed identifiers link directly to the source.
EMPOWER (2014)
PMID 24733354303 community-dwelling adults ≥65 on chronic benzodiazepine
Patient educational letter (direct-to-consumer deprescribing) — 27% discontinuation at 6 months vs 5% usual care (RR 5.5, 95% CI 2.4–12.3).
Beers 2023 update (2023)
PMID 37139824Consensus review
Benzodiazepines listed as 'avoid' in elderly due to cognitive impairment, falls, and delirium. Taper when clinically feasible.
Practical decision algorithm
| If | Then |
|---|---|
| Short-acting benzodiazepine (alprazolam, lorazepam, temazepam) | Convert to diazepam equivalent using a published conversion table (commonly cited Ashton Manual: alprazolam 0.5 mg ≈ diazepam 10 mg; lorazepam 1 mg ≈ diazepam 10 mg). Verify with your institution's preferred reference; equivalencies are approximate. |
| Low-moderate dose (≤10 mg diazepam eq.), cognitively intact | Reduce 1–2 mg diazepam eq. every 2 weeks. Slow the last 25%. |
| High-dose (>20 mg diazepam eq.) or long duration (>5 years) | Consider inpatient/structured outpatient taper; 5–10% reduction every 2–4 weeks. CBT-I for sleep. |
| Taper withdrawal symptoms (anxiety, tremor, insomnia) | Slow by 50% or pause taper. Do not restart original dose unless severe. |
| Rebound anxiety | Add SSRI (sertraline), CBT, or hydroxyzine PRN. Do not add an alternative benzodiazepine. |
Guideline position
AGS Beers Criteria 2023: benzodiazepines potentially inappropriate in ≥65. Choosing Wisely (AGS): avoid benzodiazepines for insomnia, agitation, or delirium in older adults. Canadian deprescribing.org: structured 6-month taper protocols.
Contraindications and cautions
- Active alcohol withdrawal or severe DTs — continue benzodiazepine
- Refractory seizure disorder on benzodiazepine
- End-of-life comfort care
- Patient with severe unstable psychiatric illness (e.g., catatonia on benzo)