Benzodiazepine dependence and withdrawal in the older adult

Scale of the problem. Benzodiazepines are among the most prescribed drugs in old age — about 10% of community-dwelling over-65s, and up to 25% of nursing-home residents. Roughly 70% of users continue two to four years later, and women are twice as likely as men to be taking one.

Risk factors for dependence. Female sex, increasing age, duration of use beyond 4 weeks, short-acting high-potency agents (alprazolam, lorazepam), insomnia, comorbid anxiety and depressive disorders, bereavement, poor physical health, institutionalisation, and multiple prescribers.

Harms in the elderly. Falls and hip fracture, cognitive impairment and delirium, daytime sedation, road traffic accidents, respiratory depression (especially with opioids), paradoxical excitement, and dependence. Listed as potentially inappropriate for all older adults in the AGS Beers Criteria.

Detection. Watch for drug-seeking behaviour — early repeat prescription requests, requests for dose escalation, and obtaining medication from multiple sources. The Severity of Dependence Scale (5 items, each scored 0–3) is validated in older adults — a total score ≥6 indicates problematic use (sensitivity 97.9%, specificity 94.2%).

Withdrawal syndrome. Rebound insomnia and anxiety, tremor, sweating, palpitations, perceptual hypersensitivity, depersonalisation, and in severe cases confusion and delirium, psychosis, and seizures. Withdrawal in the elderly is far more likely to be complicated by confusion than in younger adults.

Management. Convert to a long-acting benzodiazepine (diazepam) and taper gradually over months. Avoid rapid detoxification — it causes breakthrough symptoms and may precipitate convulsions; if unavoidable, conduct it as an inpatient. Add sleep hygiene education, relaxation training and CBT-I; treat comorbid depression and anxiety. A simple GP letter urging reduction cut total use by one-third at six months. Never stop abruptly.

ASAM Joint Clinical Practice Guideline on Benzodiazepine Tapering (2025, J Gen Intern Med). Recommends that clinicians taper benzodiazepines in most older adults unless there is a compelling reason to continue; use gradual, symptom-based (hyperbolic) reductions of about 5–10% every 2–4 weeks with shared decision-making; forced or abrupt discontinuation is not recommended; and it formally recognises Benzodiazepine-Induced Neurological Dysfunction (BIND) as a protracted withdrawal state.