A 75-year-old woman arrives for a routine check-in. She’s had two falls since her last visit. Otherwise, her medical status is unchanged. You notice she’s been taking lorazepam 1 mg twice daily for over a decade. You suggest decreasing it, but she declines, explaining that she experienced severe rebound insomnia the last time she tried. What should you do?

Why deprescribe benzodiazepines in older adults?
About 9% of older adults in the US have a prescription for a benzodiazepine (BZD) (Gerlach LB et al, Harv Rev Psychiatry 2018;26(5):264–273). Many were initially prescribed these medications for short-term anxiety or insomnia but never stopped taking them.

As patients age, the risks of long-term BZD use grow significantly. Older adults metabolize medications more slowly. With BZDs, that means prolonged sedation, greater cognitive impairment, and more side effects. When combined with polypharmacy or chronic illness, the risks multiply: falls, confusion, memory issues, and impaired driving. Adding opioids increases the chance of respiratory depression or death. While the link to dementia is still debated, concern remains (Reeve E et al, Eur J Clin Pharmacol 2017;73(8):927–935). Finally, tolerance and dependence can develop within weeks. Without regular reassessment, a short-term prescription becomes a long-term problem (Pottie K et al, Can Fam Physician 2018;64(5):339–351).

What do the guidelines say?
Start with the 2023 American Geriatrics Society (AGS) Beers Criteria. This guidance recommends avoiding all BZDs and non-BZD receptor agonists (like zolpidem) in patients aged 65 or older (2023 American Geriatrics Society Beers Criteria Update Expert Panel, J Am Geriatr Soc 2023;71(7):2052–2081).

Exceptions when BZDs may be appropriate include:

• Alcohol or benzodiazepine withdrawal
• REM sleep behavior disorder
• Seizures
• Catatonia
• Rare cases of treatment-resistant generalized anxiety disorder

For insomnia, anxiety, or dementia-related agitation, the risks usually outweigh the benefits. The AGS Choosing Wisely Campaign recommends against using BZDs as first-line treatments for these conditions. Instead, offer a taper and consider non-BZD alternatives.

How to deprescribe

1. Identify good candidates

Not every older adult needs to stop. A healthy 60-year-old taking low-dose clonazepam for situational insomnia may be fine. But patients with unclear indications, long-term use, overt side effects, or high fall risk are good tapering candidates. Use tools like the Benzodiazepine Dependence Questionnaire (BDQ) to assess risk (Tan KR et al, Drug Alcohol Depend 2003;70(2):103–111) and cognitive screens like the Montreal Cognitive Assessment (MoCA) to evaluate baseline function (Nasreddine ZS et al, J Am Geriatr Soc 2005;53(4):695–699).

2. Use patient-centered communication

Once you’ve identified a need to taper, avoid saying, “We need to stop your benzo.” Instead, explore the patient’s goals and concerns, normalize withdrawal worries, and emphasize benefits like better memory, improved balance, fewer falls, and more natural sleep. Use motivational interviewing and offer support throughout. A simple way to phrase it: “Let’s talk about your goals with this medication. Tapering slowly can improve memory, balance, and sleep. Some withdrawal is normal, but we’ll support you the whole way. Want to try a gradual plan together?”

Taper gradually
Avoid abrupt discontinuation. Start by reducing the total daily dose by 10%–25% every 1–2 weeks, as recommended by the American Society of Addiction Medicine guidelines (www.tinyurl.com/57a9hnry).

Taper more slowly as you approach lower doses, as this is when withdrawal symptoms tend to emerge even with small dose reductions. If the medication can’t be split, consider alternate-day dosing to achieve smaller effective reductions. This approach is especially relevant for long-term users, older adults, or anyone who has experienced withdrawal symptoms in prior tapers. Pause the taper if needed, but try to avoid increasing the dose again (Watson NF et al, J Clin Med 2023;12(7):2493).

Monitor withdrawal symptoms

These may include:

• Insomnia
• Anxiety
• Irritability
• Tremor
• GI symptoms
• Poor concentration
• Headaches
• Seizures (rare, but serious)

Shorter-acting BZDs tend to cause more withdrawal symptoms. Although several guidelines suggest switching to longer-acting agents to ease tapering, evidence for their benefit is inconsistent, and risks such as confusion and falls may increase (Watson et al, 2023).

Check in more often during the taper. Reassure patients that symptoms usually improve over time. But be alert for BZD-induced neurological dysfunction (BIND), which can include persistent cognitive or motor difficulties, especially in long-term users. For symptomatic relief, consider low-dose adjunctive medications: propranolol 10–20 mg BID (titrate by heart rate/blood pressure), pregabalin 25–50 mg BID (increase slowly), gabapentin 100–300 mg TID (increase as tolerated), or trazodone 25–50 mg at bedtime.

Address the underlying problem
Most patients still need help with anxiety or insomnia. For anxiety, start with an SSRI or SNRI. Buspirone, gabapentin, or pregabalin are reasonable second-line choices. Don’t forget therapy, exercise, or relaxation techniques. For insomnia, the first-line treatment is CBT-I. Medication options include melatonin, ramelteon, low-dose doxepin, or dual orexin receptor antagonists (DORAs) like suvorexant. Mirtazapine may help when anxiety is also present.  

After further discussion, your patient says she wants to improve her balance before her son’s wedding. You agree to reduce her lorazepam by 25% monthly, start melatonin, and work on sleep hygiene. She feels heard, and you set up frequent check-ins to monitor her symptoms.

Six months later, she’s sleeping better, hasn’t had another fall, and is lorazepam-free for the first time in a decade.

From the Clinical Update
“How to Deprescribe Benzodiazepines in Older Adults”
by Julia Cromwell, MD
The Carlat Geriatric Psychiatry Report, Volume 5, Issue 3 & 4
April/May/June 2026
www.thecarlatreport.com

Carlat Verdict: Deprescribing BZDs in older adults starts with identifying good candidates, using shared decision-making, and tapering slowly while managing withdrawal symptoms.