Beyond the withdrawal. Managing post-acute benzodiazepine withdrawal in older adults

INTRODUCTION Post-acute withdrawal, also described as protracted, extended or persistent withdrawal, refers to a syndrome that includes anxiety, irritability, hostility, mood instability, fatigue, insomnia and increased physical complaints often related to gastrointestinal symptoms, pain and weakness Unlike acute withdrawal, where treatment guidelines and practices are highly predictable and protocol driven;post-acute interventions are highly symptom driven and individualized Attention to co-occurring medical and psychiatric disorders is vital as well It is well-known that benzodiazepines pose greater risks to older adults including confusion, ataxia, syncope, risk of falls, fractures, delirium and excess hospitalizations There is limited literature on managing post-acute withdrawal syndromes in older adults, with few available guidelines for medication management of emerging symptoms The additional challenges of the COVID-19 pandemic have increased both the stress on older adults in need of care and of providers seeking to engage patients in therapeutic relationships We focus on representative cases of older adults seeking treatment related to benzodiazepines withdrawal and describe flexible treatment approaches for their evolving and complex needs METHODS Cases studies were identified from the patient population at Mount Sinai Beth Israel, an urban medical center serving a multicultural and socioeconomically diverse population that includes several NORC sites Patients were identified from those who presented to the ambulatory care center that offers adult, geriatric and dual-diagnosis services A personalized treatment planning approach was developed in each case and included the time period of the COVID-19 quarantine RESULTS The results will be discussed CONCLUSION Despite the proven negative outcomes of chronic use providers continue to prescribe benzodiazepines inappropriately to older adults The need to care for patients treated with these agents is high Postacute withdrawal syndrome is poorly understood and under recognized in older adults Efforts such as de-prescribing, patient centered approaches to rational prescribing and use remote education programs should be increased COVID-19 pandemic conditions lead to an increase in overall symptoms reported but did not prevent patients from engaging in successful treatment