NUR 7633 Module 4 Late-Life Anxiety Case: Benzodiazepine Deprescribing, Beers Criteria and Escitalopram Example

Twelve Years of Lorazepam and Two Falls: Tapering a Benzodiazepine and Treating Anxiety in a 78-Year-Old Woman

Student Name

M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University

NUR-7633: Advanced Assessment, Differential Diagnosis, and Management of Psychiatric Disorders: Geriatric Population, Part A

Mentor Name

Month Day, Year

Twelve Years of Lorazepam and Two Falls: Tapering a Benzodiazepine and Treating Anxiety in a 78-Year-Old Woman

The Falls

Ruth, an invented patient, is 78 and kept the books for a marina in Toms River until she retired. She has taken lorazepam at bedtime for twelve years, first prescribed after her husband's heart attack, and over time she has added a second tablet on bad days. Twice this winter she fell on her way to the toilet in the dark, the second time bruising her hip and lying on the floor for an hour before she could reach the phone. Her primary care clinician referred her because she also reports constant worry.

She worries about her husband's health, about money, about her grandson in the Navy and about falling again. She has felt this way for most of her life but worse since her husband's stroke two years ago. She is tired, tense and sleeps lightly. She is frightened of stopping the lorazepam, which she calls the only thing that lets her sleep. Her Montreal Cognitive Assessment is 24, and she says her memory for names has slipped. She also takes amlodipine, a statin and calcium with vitamin D.

Her husband, Leonard, now uses a walker after his stroke, and she is his main caregiver. She checks on him several times each night, which is part of why she gets up in the dark. She fears that without the lorazepam she will lie awake listening for him. Her daughter lives twenty minutes away and visits twice a week, and her grandson calls from his base on Sundays. These details matter because any plan that leaves Leonard less safe at night will not be accepted.

The Diagnosis

Ruth's worry is excessive, hard to control, spreads across several areas of life and has lasted far longer than six months, with tension, fatigue, poor sleep and trouble concentrating, meeting criteria for generalized anxiety disorder. Her GAD-7 is 14. Depression is screened and is mild. Her thyroid tests are normal, and her caffeine use is low. Her mild memory complaints are noted as possibly worsened by the lorazepam and will be retested after the taper.

Why the Lorazepam Is a Risk

The 2023 Beers Criteria list benzodiazepines among drugs older adults should generally avoid (American Geriatrics Society 2023 Beers Criteria Update Expert Panel, 2023), because older people are more sensitive to them and break down long-acting ones slowly, so the drugs raise the odds of forgetfulness, delirium, tumbles, fractured hips and wrists, and crashes at the wheel. The panel stresses that the criteria support shared decisions rather than replace them. For Ruth, the falls are the clearest harm, and the memory slips may be another.

Educating and Tapering

Tannenbaum et al. (2014) randomly assigned 30 community pharmacies in Quebec, with 303 long-term benzodiazepine users aged 65 to 95, to mail an education brochure or provide usual care. The brochure explained the risks, asked readers to test their own knowledge, described other ways to manage sleep and anxiety and set out a step-by-step taper. Six months later, 27 percent of those who received it had stopped their benzodiazepine compared with 5 percent of the control group, and another 11 percent had reduced their dose. Sixty-two percent of those who received it started a conversation about stopping with a physician or pharmacist.

Ruth is given a similar written explanation and time to read it with her daughter before deciding. She agrees to a slow taper. Her dose is first set at one tablet a night, without extra tablets on bad days. Then it is lowered by about a quarter every two to four weeks, with slower steps near the end, and the plan pauses if withdrawal symptoms such as rebound anxiety, poor sleep or tremor become hard to bear. She is reassured that she is in control of the pace.

Treating the Anxiety Itself

Lenze et al. (2009) randomly assigned 177 adults aged 60 or older with generalized anxiety disorder in primary care and specialty clinics in Pittsburgh to escitalopram, 10 to 20 mg a day, or placebo for 12 weeks. In the main analysis, which counted people until they dropped out, 69 percent on escitalopram responded compared with 51 percent on placebo, and worry and daily functioning improved more on the drug. A stricter intention-to-treat analysis did not find a difference in response, a limit the paper reports.

For Ruth, escitalopram starts at a low dose before the taper reaches its later steps, so that the anxiety is treated while the lorazepam is withdrawn. Sodium is checked at four weeks. She is told that it takes several weeks to help and that it does not cause the dependence lorazepam does. Cognitive behavioral therapy for worry is offered in a group at a senior center, and a separate course of cognitive behavioral therapy for insomnia addresses her sleep.

Leonard's care is also addressed, since her worry about him is real and partly practical. A home health aide is arranged for three mornings a week, and a baby monitor lets her hear him at night without getting up to check. A caregiver support group at the local senior center meets on Thursday afternoons, and her daughter offers to stay with Leonard so she can attend.

Preventing the Next Fall

A physical therapist checks her balance and starts strengthening exercises. A night-light is placed between her bed and bathroom, rugs are removed and a medical alert pendant is arranged so she will not lie on the floor again. Orthostatic readings test whether amlodipine drops her pressure when she stands.

Conclusion

Ruth has lifelong generalized anxiety, worsened by her husband's stroke, and a twelve-year lorazepam habit that has now caused two falls. The Beers Criteria explain the risk, the EMPOWER trial shows that clear written education helps older people choose to stop, and a slow taper she controls is planned. Escitalopram, supported with stated limits by a trial in older adults, and group CBT treat the anxiety, while CBT for insomnia, physical therapy and changes at home address sleep and falls. Her GAD-7, sleep, memory and any falls will be reviewed at each step of the taper.

References

American Geriatrics Society 2023 Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052-2081. https://doi.org/10.1111/jgs.18372

Lenze, E. J., Rollman, B. L., Shear, M. K., Dew, M. A., Pollock, B. G., Ciliberti, C., Costantino, M., Snyder, S., Shi, P., Spitznagel, E., Andreescu, C., Butters, M. A., & Reynolds, C. F. (2009). Escitalopram for older adults with generalized anxiety disorder: A randomized controlled trial. JAMA, 301(3), 295-303. https://doi.org/10.1001/jama.2008.977

Tannenbaum, C., Martin, P., Tamblyn, R., Benedetti, A., & Ahmed, S. (2014). Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: The EMPOWER cluster randomized trial. JAMA Internal Medicine, 174(6), 890-898. https://doi.org/10.1001/jamainternmed.2014.949