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.
Marion W. says
I’m 67 years old and my primary stopped my Ativan cold turkey on the 18th of January. A few days later I went to see a nurse practictioner because of my anxiety levels increasing and suicidal thinking. She referred me to see a Psychiatrist. Made an appointment, went and he called primary told her to get me off of Ativan. So no more Ativan. Which I don’t mind. BUT since last thrusday I have been going thru withdrawal. I called primary today and she said that withdrawal should have happened around the 18th. The literature I have read say that withdrawal could happen anytime. So she put me on Buspar, asked why the Psychatrist wasn’t taking care of this, and I said he wants the primary to are care of this. Benzo’s and the elderly is one big circle. Doctors including psychiatrists are so book learned nowadays that taking care of patients isn’t a priority. No wonder there is much Medicare fraud. I was placed on disability about 10 years ago due my memory loss. Every time I see someone they say the things I am supposed to do but I can’t remember things. I was a chemo nurse so I knew I couldn’t do it anymore. I have a neuropsychiatrist in a week. So putting me on Ativan which I didn’t remember was addictive was a big Nono what does a neuropsychiatrist do.
Leslie Kernisan, MD MPH says
Yikes, I am sorry to hear that a provider would stop a benzodiazepine cold turkey, that is not considered optimal practice as most people experience distressing withdrawal symptoms. (People on higher doses of benzos can also experience life-threatening physical withdrawal symptoms.) It sounds like you need to have health providers working closely and compassionately with you at this time, I hope you will be able to connect with someone suitable soon.
Neuropsychiatry is a somewhat newer subspecialty, it is also sometimes called behavioral neurology, and basically draws from both psychiatry and neurology. You can learn more here:
Neuropsychiatry: Where Are We And Where Do We Go From Here?
Linda Gail Hargraves says
My doctor put me on .5 Lorazepam three times a day four years ago because I was having severe panic attacks. He didn’t explain the side effects or tell me how difficult it is to come of this medication. Now I want to come off it. I tried to taper slowly by cutting one dose daily in half, but I experienced heightened anxiety and loud ringing in my ears. My doctor really does not seem interested in helping me come off this med. I am 74 years old, have heart disease and high blood pressure. What can I do? Is it best that I remain on this medication for the rest of my life if it is controlling my anxiety?
Leslie Kernisan, MD MPH says
Cutting a dose in half is still a big step down for the body. I would recommend printing out Dr. Tannenbaum’s brochure and bringing it to your doctors. Let them know you are interested in reducing your lorazepam but you need their help figuring out a very slow taper. You should also discuss other ways to manage anxiety or other symptoms that are currently being treated by lorazepam. For instance, some people benefit from special therapy programs to help manage their anxiety.
It’s certainly possible that you and your doctors may conclude that it’s better for you to remain on lorazepam. But it’s often a good idea to at least explore alternatives before coming to that conclusion. Good luck!
Robert says
Hi –
My mom has been prescribed .5 mg Ativan by her GP for the past two years to help her fall asleep. During this time, my dad and I have witnessed major differences in her personality, most noticeably rage and irritability have emerged in a person who has never exhibited such behavior.
It has been particularly challenging as we can’t seem to discuss what we perceive to be a major issue without her becoming enraged. I’ve spoken to my therapist about this, because I wanted to be sure that I was approaching her in a way that was non-confrontational — nonetheless, her recommendations have proven ineffective.
I’m at a loss on what to do anymore. I want to call her doctor, but I also don’t want my mom to see it as a personal attack.
Leslie Kernisan, MD MPH says
Sorry to hear of your mother’s personality changes. This is a tough situation, especially when you feel that soliciting help from doctors will upset your parent.
Honestly I would not expect Ativan to cause these major changes in personality. Benzos can certainly disinhibit someone, which can lead to certain sides of their personality becoming more visible, but a significant change in underlying personality would not be expected.
So, I would recommend your mother get further medical evaluation for her personality changes, as these can be the signs of the brain changing or of another underlying medical condition.
If she gets upset when you mention evaluation: this is really common, and also really challenging to deal with. It can be helpful to get advice from a professional who specifically has experience in constructively communicating with people who may be cognitively impaired (your current therapist may not have this experience). Otherwise, you will need to decide whether to communicate your concerns to her doctor. This is allowable from a privacy law perspective, but does often upset the older parent if they find out about it. Many doctors are willing and able to be discreet, when family calls/writes to express concerns, and hence don’t tell the patient that family has called to relay concerns. (Although, what you communicate will probably end up in your mother’s medical record, and if she ever requests the records, she can find out about your communication in that way.)
For more on what should be assessed as part of an evaluation, see this article:
Cognitive Impairment in Aging: 10 Common Causes & 10 Things the Doctor Should Check
You may want to hold off on trying to address the Ativan use until her personality changes have been further evaluated…in these situations, it’s important to “pick your battles” and generally it’s impossible to push people to address more than one thing at a time.
Good luck!
Kate says
Thank you x
Swapnali Bhosale says
My mom took Depranil plus 5mg a diazpam tab for 28yrs continuously now she is taking ativan 2mg from past 3 months instead of Depranil plus, her sleep is good but Dr. Recommended she can stop taking Ativan too completely but I’m sceptical about this cause of her dependency on diazpam for so many years. What should I do should I give her half a tablet instead of full in such tapering down or can I abruptly stop it?
Leslie Kernisan, MD MPH says
I’m not familiar with depranil; seems it’s a version of imipramine, which is a tricyclic antidepressant. These are usually sedating. They are also anticholinergic and can interfere with memory and thinking somewhat.
It’s not really clear to me whether she is now taking both diazepam and lorazepam, or just the lorazepam. Regardless, it is never a good idea to abruptly stop a benzodiazepine. People almost always get distressing withdrawal symptoms (e.g. insomnia, anxiety, irritability), and especially when it comes to higher doses of benzos, they can also experience life-threatening withdrawal reactions.
I would recommend bringing Dr. Tannenbaum’s brochure to your mother’s health providers, and asking about a slow careful taper.
Amy says
My mom is 91yrs old and takes .5 Ativan, one in the morning and 2 at night. She has been taking Ativan for 20+ yrs. When the first FDA tapering came about her doctor was going to stop her cold turkey by not prescribing her anymore. So had to find another doctor who would work with her on tapering. Even after finding a new doc they didn’t help to taper. I had to find something online and began tapering her down. I got her down to the dose I mentioned at the beginning. Now there was a new FDA tapering in October and the office nurse treats my mom as if she’s a drug addict off the street. No compassion whatsoever. I have to call every month to get a new script for my mom, and this month they are giving me a hard time. They sent the script out but it can’t be filled until Friday, which means my mom has to go 2 days without any Ativan. Been arguing with office nurse, but she told me deal with it. You’re lucky you got the script. How can medical professions be so cruel? Thought they took an oath to protect and save..?? I’m beside myself on what to do.
Leslie Kernisan, MD MPH says
Well, it’s probably good that you are helping your mother taper her Ativan, but it’s really unfortunate that the health providers haven’t been more supportive of you and her. They are probably overworked and under a lot of stress, but still.
For the future, you could see if the prescribing clinician would be willing to prescribe liquid lorazepam. This can be easier to taper down slowly. Good luck, your mother is very fortunate to have you looking out for her.
Kate says
Hi I’m now down to .55 lorazepam is it normal to notice effects of reduction 7 days after last drop it seems worse when I am in the middle of my period thank you x
Leslie Kernisan, MD MPH says
I cannot advise as it has been a very long time since I took care of women who were still getting their periods. Would recommend addressing this query to your treating clinician. Good luck!
Jill Smith says
My 82 year old mother has been taking 4 mg of Ativan every night for at least a year or two. The doctor was prescribing 3 mg every night however she called and asked if she could take an extra 1 mg. He said ok to do so every now and then. Apparently she was doing 4 mg every night. He then decided that 4 was too much and dropped her to 3mg. She immediately started having serious withdrawal symptoms and panic attacks. The doctor put her back to 4 mg Ativan and added Clonazepam 5mg. She was feeling very zombie like ( of course she was !) so he told her to cut back on the Clonzepam by 12.5 mg 2 nights a week. She is feeling withdrawal again. I have no idea where to turn, this Dr has over medicated her for years and now the withdrawal symptoms seem to be too much for her to take. Any advice would be greatly appreciated. I think she needs an inpatient detox type of treatment.
Leslie Kernisan, MD MPH says
Yikes. Sounds like she has been on pretty substantial doses of benzodiazepines, for a person of her age. I cannot make specific recommendations but in general, the more slowly the dose is reduced, the better. So reducing the weekly dose by 10% is usually more tolerable than decreasing by 25%. It’s also often more tolerable to reduce a longer-acting benzodiazepine (clonazepam is longer-acting than lorazepam).
Regarding inpatient detox, it’s not clear to me that this is generally available for chronic benzodiazepine use. Tapering off benzodiazepines can take 3-6 months, that would be a long time to remain as an inpatient. So I’m not sure you’ll be able to find that. But perhaps you can find a health provider who is willing to work carefully with your mom and your family on slowly tapering her benzos? Alternatively, have you discussed your benzo concerns with your mother’s doctor, and would that provider be willing to take a different approach?
You may also find it helpful to connect with other people concerned about aging parents. There is an active online caregiver forum at AgingCare.com. This is a way to get moral support and encouragement as you explore your options. Good luck!
Debbie says
Hi I was on 3mg Ativan for over a year taking at bedtime I was also on Ritalin and reglan I began having extreme anxiety and shaking and confusion as I cut Down on reglan an had stopped the Ritalin. Doctor said it was caused by Ativan so switched me to klonopin. I got vertigo bad after starting klonopin so after 2 months was switched to Valium. I have been on Valium for almost 2 months only 2.5 mg at bed along with trazadone And remeron and melatonin. Still can’t sleep and wake with bad shaking and anxiety. Seems only thing that helps is Ativan again. I tried a .5 dose and it calmed me down. Now doctor wants to know if I want to go back to Ativan. Should I stick with Valium or go back to Ativan? It been 4 months since I got off Ativan and withdrawals were bad from both Ativan and klonopin. Should I just take more Valium. I have advanced cancer and Mets to liver so I’m afraid of Valium effect on liver with all the other meds I take also. Would it take time again to get tolerance to Ativan or will it work at small dose as if starting over again?
Leslie Kernisan, MD MPH says
Your situation sounds exceptionally complicated, both because of the many medications you have taken and are taking, and also because you have advanced cancer and metastases to the liver.
I would recommend you consult with a palliative care specialist. Palliative care is a discipline focused on helping people manage difficult symptoms and helping people cope with serious illness. (They are also experts in end-of-life care and hospice, but that’s not necessarily what you need right now.) Learn more about palliative care here: Get Palliative Care.
Among other things, they should be able to discuss the big picture of your health and the likely benefits versus burdens of trying to taper off benzodiazepines at this time. Good luck!
Michelle Haselwood says
My elderly grandmother, 93, was placed on hospice 2 months ago. 2 weeks ago, she started having difficult sleeping and while lucid during the day, became confused throughout the night. She is bedridden but would attempt to get out of bed, remove her diaper and not know where she was in the middle of the night. The hospice nurse suggested starting her on .5mg to 1mg of lorazepam at bedtime. Twice I gave her 1mg, as the .5 didn’t seem effective, but got nervous about the dosage and resumed the .5. As I said, I’ve been giving her L for only 2 weeks, but she has started sleeping more throughout the day and seeking more confused. She was awake throughout the night last night be disoriented with the same behavior mentioned above after having been given .5mg. I am not sure what to do and an wondering if I need to step her down even after only 2 weeks of use. Thank you for your guidance
Leslie Kernisan, MD MPH says
Sorry to hear of these challenges. Lorazepam is often used in hospice patients of all ages, but as I explain in this article on medications in hospice, there’s not really a good evidence base for this, and it’s not at all clear that it’s advisable to use lorazepam in elderly hospice patients.
Q&A: Hospice in Dementia, Medications, & What to Do If You’re Concerned
Initially, it would’ve been good for the hospice team to investigate what symptoms or distress or underlying issue were causing her nighttime symptoms. Could it have been pain or shortness of breath or something else?
Now that she has been on lorazepam for a few weeks, it’s possible that she might experience some withdrawal or rebound insomnia if you stop or reduce it.
You could talk to the hospice team about trying to taper down the lorazepam. That said, it may or may not be realistic to hope that she can be managed without any confusion or difficulty whatsoever. Really it depends on what is her hospice diagnosis and her other conditions affecting her health, but declining and dying often do affect the brain, even in people much younger than 93.
Good luck and hang in there. Remember that even if her experience doesn’t seem perfect or as good as you want it to be, she is very lucky to have you there accompanying her on this journey. What is most important is that she feels you are there for her, which I’m sure she does.