Have you heard of Ativan (generic name lorazepam), and of the risks of benzodiazepines drugs in older adults? Is an older person you care for taking prescription medication for sleep, anxiety, or “nerves”?
Would you like an easy, practical tool to help someone stop a drug whose risks often outweigh the benefits?
If so, I have good news: a wonderful patient education tool has been created by a well-respected expert in geriatrics, Dr. Cara Tannenbaum. Best of all, a randomized trial has proved that this tool works.
As in, 62% older adults who received this tool — a brochure with a quiz followed by key information — discussed stopping the medication with a doctor or pharmacist, and 27% were successful in discontinuing their benzodiazepine. The brochure includes a handy illustrated guide on slowly and safely weaning a person off these habit-forming drugs.
This is big news because although experts widely agree that long-term benzodiazepine use should be avoided in older adults, getting doctors and patients to work together to stop has been tough. It is, after all, generally easier to start a tranquilizer than to stop it!
But through a patient education brochure, Dr. Tannenbaum’s team was able to make this tricky process much more doable for older adults, their families, and their doctors.
Why it’s important to try to stop lorazepam & other benzodiazepines
Ativan (generic name lorazepam) is a tranquilizing medication in the group called benzodiazepines (also known as “benzos”). These drugs are usually prescribed for sleep, anxiety, or agitation.
Lorazepam (brand name Ativan) is a fairly popular benzo, as the effect lasts for what is considered a “medium” length of time (the half-life is 10-20 hours).
Other benzodiazepines that are sometimes prescribed include:
- Long-acting benzos, such as Valium and Klonopin (generic names diazepam and clonazepam, respectively),
- Fast-acting tranquilizers such as Xanax (generic name alprazolam), which has historically been prescribed for panic attacks,
- Restoril (generic name temazepam), which has often been prescribed for sleep.
However, benzodiazepines are much riskier than many older adults realize. Common side effects include drowsiness and unsteadiness when walking. Research has also found that these drugs:
- Worsen balance, memory, and thinking;
- Increase the risk of falls, and of fractures;
- Can make dementia symptoms worse;
- Can easily cause physical or psychological dependency (or even addiction)
- Are linked to a higher risk of dying within a few years.
Benzodiazepines can also cause death if there is an accidental (or intentional) overdose, as high doses will slow down breathing to dangerously low levels.
Because of these problems, in 2013 the American Geriatrics Society’s Choosing Wisely list included benzodiazepines as one of the “5 Things Physicians and Patients Should Question,” when it comes to healthcare for older adults. They are also included on the Beer’s List of medications older adults should avoid or use with caution, and are at the top of my own personal list of “4 Types of Medication to Avoid if You’re Worried About Memory.”
But unfortunately, benzodiazepines are easily habit-forming, meaning that the body becomes dependent on them quite quickly. (And occasionally, some patients develop problematic abuse of these drugs.)
So it’s important to offer an older adult the right approach, and a lot of support, when it comes to getting off these drugs.
I especially recommend avoiding benzodiazepines in people with memory concerns or a dementia such as Alzheimer’s disease. Benzodiazepines act on the same brain receptors as alcohol, and they almost always keep people with dementia from thinking at their best level.
Studies have also found that people who take benzodiazepines have an increased risk of developing dementia.
For these reasons, geriatricians almost never prescribe a drug like Ativan to older adults, and we’re big fans of trying to get our older patients to taper off of benzodiazepines, whenever possible.
The must-read information brochure on Ativan and older adults
If you or your older relative is taking Ativan (generic name lorazepam) — or any type of sedative or tranquilizer — I highly recommend you read Dr. Tannenbaum’s brochure. It provides excellent information about these drugs, and includes practical tips on addressing sleep and anxiety issues without using drugs.
You can get a copy of the brochure — which includes a sample taper schedule — here: You May Be At Risk: You are Taking a Sedative-Hypnotic.
Note: It can be dangerous — as well as physically very uncomfortable — to suddenly stop benzodiazepines. Discontinuing benzodiazepines should always involve a gradual lowering of the dose. This process should always be done with the supervision and support of a healthcare professional.
Other sedatives to consider stopping
The brochure above covers Ativan along with other benzodiazepines, such as Valium, Xanax, Klonopin, and Restoril (generic names diazepam, alprazolam, clonazepam, and temazepam, respectively). It also covers commonly-used sleeping pills such as zolpidem (brand name Ambien).
Frequently asked questions about Ativan
Here are some of the questions people sometimes ask me about Ativan:
Q: Is 0.5mg of lorazepam a low dose, and is a lower dose safer?
A: 0.5mg of lorazepam is a very common dosage, and is probably the most common starter dose. The risk of side effects goes up with the dose, so yes, 0.5mg is a little safer than 1mg, and 0.25mg will be even less risky than 0.5mg.
Along with the dose of the tablet, it’s also important to consider the schedule that is prescribed. It could be prescribed just at bedtime, or sometimes it’s prescribed “as needed” two or three times per day, for anxiety (or even agitation, especially in people who have Alzheimer’s or a related dementia).
In general, the greater the total quantity of lorazepam that a person consumes every 24 hours, the greater the risks.
I’ll be honest: no matter what the dose or schedule, I consider this to be an unsafe medication for older adults, and would only recommend using it when all other alternatives have been tried first. If it must be used, it’s best to use the smallest doses that have an effect, the fewest times per day.
Q: Is it ever okay for an older adult to take a benzodiazepine?
A: Benzodiazepines, like all drugs and medical interventions, need to be considered by balancing their likely benefits with their burdens and harms.
There are some older patients — often with severe chronic anxiety — who seem to overall benefit from a low dose of these drugs.
But ideally, benzodiazepines should be used as a last resort, after making a serious attempt to treat insomnia and anxiety with non-drug approaches. These can include techniques such as cognitive-behavioral therapy, regular exercise, and stress-reduction techniques. For people with Alzheimer’s, providing caregivers with coaching on managing difficult dementia behaviors can also help.
I do have some older patients who are on benzodiazepines. I don’t like it, but usually we’ve tried other things, discussed the risks with the family, and concluded that this balance of benefits versus risks is acceptable. We also usually work to find the lowest possible dose.
Q: I can’t sleep when I don’t take Ativan. How am I supposed to get off of it?
A: It’s not always easy to taper off benzodiazepines, but research shows it’s definitely doable.
For instance, in a randomized trial to help older adults taper off benzodiazepines for insomnia, 76 older adults were assigned to one of three 10-week interventions: supervised benzodiazepine taper, cognitive-behavioral therapy for insomnia, or a combination of the two. All three groups were able to decrease their benzodiazepine use, and 63% of participants were drug-free at 7 weeks. In other words, it IS possible to learn to sleep without these medications, even if you’ve been taking them for years.
Again, if you’d like to taper off a medication such as lorazepam (brand name Ativan), please print out Dr. Tannenbaum’s brochure and bring it to your health provider, so that you can discuss tapering off together. You can find the brochure here: You May Be At Risk: You are Taking a Sedative-Hypnotic.
Q: Is it ok to use Ativan in Alzheimer’s, to manage sleep or agitation?
A: In geriatrics, we do NOT recommend using Ativan (generic name lorazepam) in people with Alzheimer’s, other forms of dementia, or any type of memory loss. That’s because it tends to make their memory and thinking even worse, and also increases the risk of falls.
Benzodiazepines also sometimes make people with cognitive impairment paradoxically agitated, by disinhibiting them. (This effect is also seen with alcohol: it can relax and quiet people, but also can make some people rowdier.)
That said, it is very common for people with Alzheimer’s to have trouble sleeping, or to sometimes become agitated and upset, and historically doctors have prescribed lorazepam or other benzodiazepine tranquilizers for these purposes. Unfortunately, this is not a safe approach. (Also unfortunate: there is basically no safe and easy way to medicate behavior problems in Alzheimer’s, as I explain in this article: 5 Types of Medication Used to Treat Difficult Dementia Behaviors.)
I’ll say it again: Ativan and other benzodiazepines should ONLY be used as a last resort, after all safer options have been exhausted.
Last but not least: I’ve found it’s more difficult to taper off benzos in people with cognitive problems. This is because to successfully taper off, the older person may have to tolerate some increased stress or difficulty sleeping in the short-term…and this can be very difficult for people who are already dealing with memory and thinking problems. (The stress of trying to taper often makes their memory and thinking worse in the short-term, even though being off benzos generally helps memory in the longer term.)
If you are caring for someone with Alzheimer’s or a related dementia, and are struggling with sleep issues, I explain options for managing this concern here: How to Manage Sleep Problems in Dementia.
Tips for aging adults & family caregivers
If you or your older loved one is taking a benzodiazepine:
- Do make sure you are properly informed about the side effects, risks, and alternative options for treating insomnia or anxiety. Dr. Tannenbaum’s brochure is a terrific resource for this.
- Do talk to the doctors about attempting a taper off the drug. It’s usually worthwhile in the long run. Even a reduction in dose can help reduce side-effects and risks.
- Don’t try to suddenly stop the benzodiazepines. Reducing these medications should be done gradually, and under medical supervision.
If your older loved one complains of insomnia or anxiety:
- Do question things if the doctor proposes a benzodiazepine or other tranquilizer as a solution. Ask for help with lifestyle changes and cognitive therapy instead. Remember that these drugs are much easier to start than they are to stop!
Here are two additional resources to help if you want to learn more about tapering benzodiazepines:
- The “Ashton Manual” is a detailed online resource, created an English psychopharmacology professor who is an expert on benzodiazepines. Find it here: Benzodiazepines: How they work and how to withdraw.
- This article describes a journalist’s experience trying to taper off benzodiazepines, and her frustrations with medical professionals who seemed to underestimate the risks of using these drugs: I Tried to Get Off Ativan.
But again, probably the most practical and usable resource for older adults is Dr. Tannenbaum’s brochure, which is specially designed to help older adults reduce their use of risky benzodiazepines such as lorazepam (brand name Ativan) and other commonly prescribed sedative/tranquilizers.
If you or someone in your family is taking this type of medication, please print it out and bring it to your doctor. Again, it’s here: You May Be At Risk: You are Taking a Sedative-Hypnotic.
Good luck making your medications safer!
This article was first published in 2014, and was significantly updated in March 2023.