(PO-077) (PO-077) Alprazolam problems: A prolonged withdrawal delirium in an older woman with chronic benzodiazepine use

Background: Age-related changes in the body affect the sensitivity to and metabolism of benzodiazepines in an unpredictable manner (Olfson, 2015). This report presents a case of an older adult with long-term alprazolam use and subsequent complicated withdrawal illustrating the clinical importance of altered metabolism of benzodiazepines in this vulnerable population.

Case: A 72-year-old female with a medical history of hypertension, metastatic lung cancer, and a reported past psychiatric history of “anxiety and bipolar disorder” managed for several years on alprazolam 1mg twice daily presented to the emergency department after a physical altercation with her grandson resulting in a facial hematoma. Admission workup was significant only for elevated AST and ALT, and the patient was admitted to medicine for safe discharge planning. On hospital day 3, the patient was found to be increasingly confused, agitated, and showing signs of hyperactive delirium, complicated by possible dementia at baseline. Collateral information revealed she was admitted to another hospital 2 weeks prior following an intentional alprazolam overdose and had been without alprazolam for at least 1 week. Her symptoms improved with only low-dose chlordiazepoxide (5-10 mg) once daily over 3 days. Given the collateral and her response to chlordiazepoxide, her delirium was attributed to prolonged benzodiazepine withdrawal.

Discussion: In the United States, more than 10% of women and 6% of men aged 65 to 80 years filled at least one benzodiazepines prescription in a 1-year period, with nearly one-third of patients receiving benzodiazepines for longer than 120 days in a year (Olfson, 2015). Age-related physiologic changes, including increases in body fat, decreases in muscle mass, decreased serum albumin, and variation in hepatic and renal function can cause unpredictable changes to the volume of distribution, and hence the half-life, of benzodiazepine medications (Singh, 2016). Because cessation of chronic use of short-acting benzodiazepines would be expected to precipitate withdrawal in as early as 24-48 hours, it is likely that age-related metabolic factors likely played a role in this patient’s presentation (Greller, 2021). As a result, this case highlights persistent withdrawal as an etiologic factor of delirium in older adults.

Conclusion: This case illustrates that the adage “start low, go slow” pertains to not only medication titration but also medication cessation and withdrawal syndrome management. When managing benzodiazepine withdrawal in the elderly, age-related pharmacokinetic changes and medical comorbidities must all be considered by the CL psychiatrist in order to avoid adverse outcomes.

References

1. Singh S. Sarkar S. Benzodiazepine among the elderly. Journal of Geriatric Mental Health. 2016; Volume 3, Issue 2: 123-130


2. Olfson M. King M. Schoenbaum M. Benzodiazepine use in the United States. JAMA Psychiatry. 2015; 72: 136-142


3. Greller, Howard. Gupta, Amit. Benzodiazepine poisoning and withdrawal. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2021.