CONTENTS

Table of Contents
Introduction

1. Overview
2. Recognizing Alcohol Misuse and Abuse in Older Adults
3. Alcohol and Aging
4. Diagnosing Alcohol Problems in Older Adults
5. Recognizing Other Forms of Substance Abuse
6. Prevention and Early Intervention Strategies
7. Treatment
8. Outcomes and Cost Issues in Alcohol Treatment for Older Adults
9. Legal and Ethical Issues

Supplements
Resources

At Any Age, It Does Matter:
Substance Abuse and Older Adults (for Professionals)

Suggested Protocol for Benzodiazepine Withdrawal

After identifying patients who meet the criteria for chronic use, the clinician needs to discuss with the patient why he or she is on the medication, what the initial indication for the medication was, and whether the patient continues to derive benefit from the medication.

At this point the clinician has to decide if there is sound justification for continuing the patient on the benzodiazepine. Cases that may justify continued chronic use include:

• Demonstrated effectiveness for reducing agitation associated with dementia
• Comfort care in patients with terminal illnesses
• Use in patients with anxiety disorders that are refractory to other treatments such as selective serotonin reuptake inhibitors

Disorders that are less justified include chronic insomnia, "nervousness," depression, and chronic treatment of an alcohol use disorder.

Once the provider determines that there is limited justification for long-term use, the provider must make this recommendation to the patient. The provider’s goal at this point is to educate the patient about the risks of long-term benzodiazepine use and the potential benefits of discontinuing the medication.

The provider must also determine the presence of other concurrent mental health issues such as depression and anxiety disorders. These disorders will need to be successfully treated before discontinuing the benzodiazepines.

If depression or anxiety symptoms are not treated, the probability of successfully discontinuing the benzodiazepine is markedly reduced. When managing patients who are drinking and using a benzodiazepine, the provider should eliminate alcohol use first and then address the benzodiazepine use.

Once the decision to discontinue the benzodiazepine has been made and all other mental health problems have been addressed, the medication can be slowly tapered. Based on the work of Schweizer and colleagues, the total dose of benzodiazepine should be reduced by 25 percent per week.¹ The protocol follows:

1. The patient will receive 75 percent of the total dose for 1 week.
2. Next, the patient will receive 50 percent of the total dose for 1 week.
3. Next, the patient will receive 25 percent of the total dose for 1 week.
4. By week 4, the medication should be discontinued.

Thus, over the course of 3 weeks the medication will be stopped. During this time it is advisable to see the patient frequently (each week, if possible), for support and encouragement.

Reference

1. Schweitzer, E.; Case, W.G.; and Rickels, K. Benzodiazepine dependence and withdrawal in elderly patients. American Journal of Psychiatry 1989, 146(4):529-531.

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