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.
Kate says
I’ve now started prickly itching skin arms legs chest and head could this be related
Leslie Kernisan, MD MPH says
Not sure, seems to me it’s possible that such symptoms could be related to a benzo taper, but there are also other things that can cause itching. I would recommend seeing your health provider about these symptoms.
Kate says
Thank you so much for your reply itching seems to have calmed thankgod was awful . I’ve now dropped to .69 mg next drop in 6 days I’m planning to go .65 mg does this sound sensible . As I get lower should I stay at 5-10% weekly my doc seems to think I can jump of at .5 mg I really don’t think this is the case . Does it get easier or harder the lower you get . I’ve been given escitipram to help with reduction x thankyou Kate ?
Leslie Kernisan, MD MPH says
Generally the slower the taper, the more manageable it feels to the body. If your doctor suggests a larger step down, you can perhaps discuss your preference to taper more slowly if at all possible.
You might also find it helpful to find an online community of people working on benzo tapers, that would be a good source of moral support. good luck!
Dennis Dz says
I’m 40 and have been on a single nightly 0.5mg dose of ativan for roughly a year.
I consider this a small dose. Can I go cold turkey without too many side effects?
Leslie Kernisan, MD MPH says
Lorazepam 0.5 mg is not a very big dose, but it’s not trivial either. I think it’s unlikely that you’d provoke life-threatening withdrawal symptoms by quitting cold-turkey, but I think you probably WILL experience some withdrawal symptoms, such as rebound insomnia, anxiety, and/or irritability.
I would recommend discussing your interest in stopping with your prescribing doctor. Ask for help figuring out a reasonable taper schedule. Good luck!
Kate says
I’ve now got to .72 last 2 weeks
Kate says
Anyone else razor and weigh the meds
Kate says
Hi little info needed please I’ve been taking lorazapam after having insomnia after taking antihistamine . Yes I’m very sensitive to medication. . I took .5 mg for 3 weeks then doc gave me escitipram 5 mg which then upset my sleep again so at 3 weeks I went on 1 mg lorazapam 4 weeks after this doc gave me 10 mg escitilipram which was very hard to get on side effects were awful but did that . So after 7 weeks I wanted of lorazapam doc said drop 10% evey other days which I’ve done over 9 days and felt awful ?. Since found out the drop is to much been told should be 10% a week I’m now on .8 mg so should I drop 4 then leave 3-4 days gap then drop another 4 . Thank you Kate xxx
Leslie Kernisan, MD MPH says
Congrats on your efforts to get off this medication. Yes, it’s generally best to taper slowly, and if you are struggling or having side effects, talk to your doctor about making the taper even slower. Using a liquid form of lorazepam can make it easier to manage the small dose reductions.
I can’t comment on just what your dose should be. I would recommend bringing Dr. Tannenbaum’s pamphlet to your doctor, reviewing the suggested taper together, and then asking for help making the taper as slow as possible. Good luck!
Kate says
Oh in reply to the liquid form is it the same ingredient as doc never suggested this to me
Leslie Kernisan, MD MPH says
yes, it should be the same ingredient. Talk to your doctor or ask the pharmacist.
Linda says
I take it for a tic thing. It is like a tourettes person and I was so relieved when I started taking this along with blood presure medication. My doctor wants to discuss it. Also I am chemically sensitive to everyday products so it also helps with coping. Really stressed now they say I have osteoporisis and that medication sounds horrible. I am so careful not to use anything except these medications. I don’t want to twitch myself into a fracture. I was already so stressed about the bone density but now feels like I can’t plan anything. Thanks.
Leslie Kernisan, MD MPH says
Well, for every medication one needs to consider the likely benefits and risks, and also what are the available alternatives. There are often viable and safer alternatives for managing insomnia and anxiety, but that may be less true for your condition. If your twitching is problematic and there aren’t reasonable alternatives, then it might be reasonable to conclude that the benefits outweigh the risks.
I think it sounds like a good idea to discuss with your doctor. Especially if you look into other ways to manage anxiety, perhaps you and your doctor will find it’s possible to reduce your dose of benzos somewhat.
Dialogue, considering alternatives, and trying a potentially better approach are what is most important. Good luck!
Emily says
First, thankyou for taking the time to reply to so many questions! You obviously care about people very much.
I am a retired nurse going back to school to be a high-school art teacher. I have always battled cognitive impairment that I think originated with learning disabilities caused from a horse accident when i was fifteen (sub-dural hematoma that was delayed brain surgery, and little to no extra help in school afterrwards )
I have fought my whole life to remain functional. I finally gave in to medication a few years ago when I developed chronic pain in all my joints, but mainly my hips in the girdle area. I have taken Norco 7.5mg, 3-4x/day for about 4 yrs, then added 1mg Lorazepam @ hs about 3 yrs ago for restless leg and insomnia (never had insomnia of any degree before the onset of pain), then I tried Cymbalta for pain, getting up to 90mg with positive results and even being able to reduce norco to 1-2x/day. After about a year on Cymbalta I realized I was increasing the norco again and decided to quit taking it. It has been 3 months and weaning down to 15mg, but I still cannot stop it due to the tingling in my face and lips along with severe vertigo, and now I feel like I have severe dementia some days. I feel like I became “old” overnight and although it seemed natural to take “medicine” for all these new symptoms, I am feeling now that it was a huge mistake! I feel very trapped by these medicines and want to get off of them. My question is, should I start making a plan with my doctor to stop the Lorazepam now, or after the Cymbalta?(even though Im having severe withdrawal difficulty from it) Or after I am out of college ? (this is difficult enough at 45yrs old) I love my doctor but I also know she is too busy to really understand these drugs. It takes extra effort but I really believe in a natural healthy lifestyle now, rather than drugs. I was very unaware of the end result. Thankyou for taking the time to hear my story.
Leslie Kernisan, MD MPH says
Thanks for sharing your story. Well, sounds like you have a particularly complicated situation at hand. Chronic pain can be a challenge to manage in the long-term. Sorry but I don’t have much personal experience discontinuing Cymbalta on its own, much less in combo with lorazepam.
Unfortunately, most doctors tend to have much more experience starting medications than discontinuing them. As a general rule, you want to taper slowly if you are experiencing side-effects or withdrawal. It’s also probably a good idea to look into some kind of multimodal non-drug pain management program, such as this one: Chronic Pain Self-Management Program.
There are also “functional medicine” practitioners who take a more detailed and holistic approach to healthcare. Not sure their services will be covered by your insurance, but if this is very important and you can’t find a usual doctor to help you with this, it might be worth paying out of pocket. Good luck!
CATHERINE PETROCELLI says
I’m interested in getting a copy of Dr. Cara Tannenbaum’s Patient Education Tool. I couldn’t find a link to order it or download a copy. Can you please provide information on how to go about getting a copy of it. Thank you so much.
Leslie Kernisan, MD MPH says
There is a link in the article, but perhaps it’s not very obvious. The actual URL for the brochure is static/file/caregiving_ten_tips.authcheckdam.pdf.
Mahendra says
Hello Doctor:
Thanks you very much for giving hope to many people to come out of this addiction. I am on 2 medications Ativan 2 mg and lonazep 0.5 mg . The first one for about 12 years and the second about 6 years . I am 62 yrs old with a history of diabetes, heart disease and hypertension with hypothyroidism . I would like to come out of this anxiety drugs and not sure which one to address first . Ativan or lonazep ? Can you please give some idea to wean away from these drugs ? I am single and don’t have much support from family or friends. I don’t have a clue how to proceed . Could you please help. I am desperately seeking guidance and help.
Thanks and regards
Mahendra
Leslie Kernisan, MD MPH says
I had to look up lonazep, looks like it is clonazepam, which has the brand name Klonopin in the US. Clonazepam is longer acting than lorazepam (brand name Ativan).
By far the best way to explore and manage a taper is to do so under the supervision of a health professional. They would be able to talk with you and help determine which is better to taper first. In some cases, the shorter-acting benzo (lorazepam for you) is first converted to a roughly equivalent dose of longer-acting benzodiazepine, and then the longer-acting benzodiazepine is very slowly tapered down. The “Ashton Manual” describes some slow benzo tapers (including the substitution to longer-acting benzos) here: SLOW WITHDRAWAL SCHEDULES.
While doing this, it’s also very important to work on non-drug ways to manage any anxiety, insomnia, or other problem that was being controlled by the benzo.
The more slowly your benzo dose is reduced, the more likely it is that the withdrawal will feel tolerable. Do try to find professional help. good luck!
Steve Perez says
Hello,
My 89 year old mother has been taking 2MG (Mylan) Lorazepam 4X/ day for over 30 years. Mylan is discontinuing the drug and she has to switch manufacturers. She just tried a 2MG (Leading) Lorazepam and experienced enhanced side effects of stomach upset, “woozieness” and nasal congestion (?). She has degeneration in her spine and knees, but has more recently been experiencing more “minor” falls. Her muscle degeneration along with long-term Lorazepam use could be making this worse. She lives alone and this worries me. Her doctor was out today, but I think they may consider lowering her dose to 1MG with this “new” manufacturer to see if she gets lessened side effects.
I’m not sure what to do next. She is really dependent on this drug and is literally freaking out that she can no longer get the particular brand of generic that her body is used to. Any suggestions? – Thank you
Leslie Kernisan, MD MPH says
Hm. Honestly, I don’t know much about the difference between different generic lorazepam formulations.
8mg of lorazepam per day is a lot for someone who is 89 and it certainly might reduce her fall risk if she can taper down or off. But going from a 2mg dose to a 1mg dose is a big drop, I would expect a person to experience a lot of discomfort due to that drop and that might be contributing to her “freaking out.”
I would recommend talking to her doctors about a smaller reduction, at least for now, and then your mother could consider working with her health professionals on a slow taper.
It is safer for people her age to not be on benzos, but this safety benefit has to be weighed against the work and quality of life impact of reducing the drug. Good luck!
Ellen says
Last year I realized a 75 year old family member was addicted to Ativan and kept it secret. What a terrible revelation. Falls…sleeping every day past noon…balance issues…dizziness…I am grateful they never had a car accident. I had NO IDEA what was really going on. At least if someone is a drinker there are well-known signs.
Why in the world are doctors so willing to write scrips for these dangerous drugs? Why isnt every patient given a detailed explanation of the risks? It is unethical in my opinion.
I wonder how big drug companies are not forced to be more TRANSPARENT. I think these drugs are just as destructive as opioids. They lead to a very poor quality of life and wreak chaos on unwitting family members.
Your thoughts would be appreciated.
Leslie Kernisan, MD MPH says
Sorry to hear about your family member. You’re right, it’s unfortunate that for a long time doctors were quite willing to prescribe these medications and there wasn’t enough transparency about the risks.
Honestly, I think most doctors who were prescribing benzodiazepines to older adults simply had no idea that it could be so risky or problematic. It seems that doctors create their prescribing and medical practice habits fairly on during their training, and then those can be hard to change. We are very lucky to have lots of pharmacological options but at the same time, pharma is a business and they are more interested in getting doctors to prescribe than to talk about the risks and maybe prescribe less.
So, it’s important for older adults and families to be informed and ask lots of questions. I do believe that most health providers are well-intentioned, but they are busy and no one has more of a stake in getting things right than do patients and families. Hope things work out with your older relative’s Ativan use.
Sylvia W says
I am 84 years old and have been on ativan for approx. 15 years.. The dosage I am on is 0.5 mg only at bedtime.. In the past couple of years I have noticed several changes eg: memory loss, confusion, irritability, muscle weakness etc etc and I desperately want to get off of this drug. I want to reduce the dosage but because the pill is so small, I have difficulty in cutting it into a smaller dosage. I would appreciate any suggestion that you may have for me.. Thank you
Leslie Kernisan, MD MPH says
Lorazepam (brand name Ativan) does exist in liquid form. This can be easier to work with, when tapering down to small doses. I would recommend discussing your desire to taper your lorazepam with your prescribing clinician, so that they can assist you and prescribe a liquid form if appropriate.
If you’re concerned about your memory or other changes, I would also recommend bringing this up with your usual doctors so that they can do an appropriate evaluation. You should not assume all of this is due to lorazepam, as there are many reasons that someone your age might develop such symptoms.
I describe the most common causes of changes to memory or thinking in this article:
Cognitive Impairment in Aging: 10 Common Causes & 10 Things the Doctor Should Check.
Good luck!