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the effects of old age the benefits of withdrawal include improved cognition alertness mobility reduced risk of incontinence and a reduced risk of falls and fractures the success of gradual tapering benzodiazepines is as great in the elderly as in younger people benzodiazepines should be prescribed to the elderly only with caution and only for a short period at low doses 102 103 short to intermediate acting benzodiazepines are preferred in the elderly such as oxazepam and temazepam the high potency benzodiazepines alprazolam and triazolam and long acting benzodiazepines are not recommended in the elderly due to increased adverse effects nonbenzodiazepines such as zaleplon and zolpidem and low doses of sedating antidepressants are sometimes used as alternatives to benzodiazepines 103 104 long term use of benzodiazepines is associated with increased risk of cognitive impairment and dementia and a reduction in prescribing levels is likely to reduce dementia risk 14 the association of a history of benzodiazepine use and cognitive decline is unclear with some studies reporting a lower risk of cognitive decline in former users some finding no association and some indicating an increased risk of cognitive decline 105 benzodiazepines are sometimes prescribed to treat behavioral symptoms of dementia however like antidepressants they have little evidence of effectiveness although antipsychotics have shown some benefit 106 107 cognitive impairing effects of benzodiazepines that occur frequently in the elderly can also worsen dementia 108 adverse effects edit see also long term effects of benzodiazepines paradoxical reaction benzodiazepines and benzodiazepine withdrawal syndrome table from the 2010 iscd study ranking various drugs legal and illegal based on statements by drug harm experts benzodiazepines were found to be the 10th most dangerous drug overall 109 the most common side effects of benzodiazepines are related to their sedating and muscle relaxing action they include drowsiness dizziness and decreased alertness and concentration lack of coordination may result in falls and injuries particularly in the elderly 89 110 111 another result is impairment of driving skills and increased likelihood of road traffic accidents 112 113 decreased libido and erection problems are a common side effect depression and disinhibition may emerge hypotension and suppressed breathing hypoventilation may be encountered with intravenous use 89 110 less common side effects include nausea and changes in appetite blurred vision confusion euphoria depersonalization and nightmares cases of liver toxicity have been described but are very rare 26 183 189 114 the long term effects of benzodiazepine use can include cognitive impairment as well as affective and behavioural problems feelings of turmoil difficulty in thinking constructively loss of sex drive agoraphobia and social phobia increasing anxiety and depression loss of interest in leisure pursuits and interests and an inability to experience or express feelings can also occur not everyone however experiences problems with long term use 115 116 additionally an altered perception of self environment and relationships may occur 117 a study published in 2020 found that long term use of prescription benzodiazepines is associated with an increase in all cause mortality among those age 65 or younger but not those older than 65 the study also found that all cause mortality was increased further in cases in which benzodiazepines are co prescribed with opioids relative to cases in which benzodiazepines are prescribed without opioids but again only in those age 65 or younger 118 compared to other sedative hypnotics visits to the hospital involving benzodiazepines had a 66 greater odds of a serious adverse health outcome this included hospitalization patient transfer or death and visits involving a combination of benzodiazepines and non benzodiazepine receptor agonists had almost four times increased odds of a serious health outcome 32 in september 2020 the us food and drug administration fda required the boxed warning to be updated for all benzodiazepine medicines to describe the risks of abuse misuse addiction physical dependence and withdrawal reactions consistently across all the medicines in the class 119 cognitive effects edit the short term use of benzodiazepines adversely affects multiple areas of cognition the most notable being that it interferes with the formation and consolidation of memories of new material and may induce complete anterograde amnesia 89 however researchers hold contrary opinions regarding the effects of long term administration one view is that many of the short term effects continue into the long term and may worsen and are not resolved after stopping benzodiazepine usage another view maintains that cognitive deficits in chronic benzodiazepine users occur only for a short period after the dose or that the anxiety disorder is the cause of these deficits while the definitive studies are lacking the former view received support from a 2004 meta analysis of 13 small studies 117 120 this meta analysis found that long term use of benzodiazepines was associated with moderate to large adverse effects on all areas of cognition with visuospatial memory being the most commonly detected impairment some of the other impairments reported were decreased iq visiomotor coordination information processing verbal learning and concentration the authors of the meta analysis 120 and a later reviewer 117 noted that the applicability of this meta analysis is limited because the subjects were taken mostly from withdrawal clinics the coexisting drug alcohol use and psychiatric disorders were not defined and several of the included studies conducted the cognitive measurements during the withdrawal period paradoxical effects edit paradoxical reactions such as increased seizures in epileptics 121 aggression violence impulsivity irritability and suicidal behavior sometimes occur 11 these reactions have been explained as consequences of disinhibition and the subsequent loss of control over socially unacceptable behavior paradoxical reactions are rare in the general population with an incidence rate below 1 and similar to placebo 8 122 however they occur with greater frequency in recreational abusers individuals with borderline personality disorder children and patients on high dosage regimes 123 124 in these groups impulse control problems are perhaps the most important risk factor for disinhibition learning disabilities and neurological disorders are also significant risks most reports of disinhibition involve high doses of high potency benzodiazepines 122 paradoxical effects may also appear after chronic use of benzodiazepines 125 long term worsening of psychiatric symptoms edit while benzodiazepines may have short term benefits for anxiety sleep and agitation in some patients long term i e greater than 2 4 weeks use can result in a worsening of the very symptoms the medications are meant to treat potential explanations include exacerbating cognitive problems that are already common in anxiety disorders causing or worsening depression and suicidality 126 127 disrupting sleep architecture by inhibiting deep stage sleep 128 withdrawal symptoms or rebound symptoms in between doses mimicking or exacerbating underlying anxiety or sleep disorders 126 127 inhibiting the benefits of psychotherapy by inhibiting memory consolidation and reducing fear extinction 129 130 131 and reducing coping with trauma stress and increasing vulnerability to future stress 132 the latter two explanations may be why benzodiazepines are ineffective and or potentially harmful in ptsd and phobias 133 anxiety insomnia and irritability may be temporarily exacerbated during withdrawal but psychiatric symptoms after discontinuation are usually less than while taking benzodiazepines 126 134 functioning significantly improves within one year of discontinuation 126 135 physical dependence withdrawal and post withdrawal syndromes edit main articles benzodiazepine dependence benzodiazepine withdrawal syndrome and post acute withdrawal syndrome diazepam 2 mg and 5 mg diazepam tablets which are commonly used in the treatment of benzodiazepine withdrawal tolerance edit tolerance and dependence are risks of chronic benzodiazepine use and can result in doses within the therapeutic range ceasing to offer meaningful symptomatic relief after prolonged use tolerance develops at different rates and to different degrees to the sedative hypnotic anticonvulsant muscle relaxant and anxiolytic effects of benzodiazepines a review 44 of benzodiazepine tolerance concluded that it appears that tolerance develops relatively quickly for the sedative and anticonvulsant actions of benzodiazepines whereas tolerance to anxiolytic and amnesic effects probably does not develop at all although the included randomized controlled trial evidence 136 46 is limited to 22 weeks a review of clonazepam in the treatment of psychiatric disorders concluded that longitudinal data supports anxiolytic benefit without tolerance during long term use 45 including an open label study finding continued benefit at three years 47 however the review concludes that long term rct evidence is scant a study of benzodiazepine sensitivity found that patients treated chronically with alprazolam did not differ from untreated patients in terms of anxiolytic response to diazepam suggesting a lack of anxiolytic tolerance 137 however controversy remains regarding tolerance to anxiolytic effects with some publications reporting that there is little evidence of continued efficacy beyond 4 6 months 108 or that dependence phenomena are common 27 34 however some of these references were published before the in depth scoping reviews of benzodiazepine tolerance and lack citations of rct evidence of tolerance studies reporting on voluntary benzodiazepine cessation and withdrawal include patient reports of tolerance and worsening anxiety 16 the question of tolerance to the amnesic effects of benzodiazepines is likewise unclear 138 some evidence suggests that partial tolerance does develop and that memory impairment is limited to a narrow window within 90 minutes after each dose 139 a major disadvantage of benzodiazepines is that tolerance to therapeutic effects develops relatively quickly while many adverse effects persist tolerance develops to hypnotic and myorelaxant effects within days to weeks and to anticonvulsant effects within weeks to months 126 therefore benzodiazepines are unlikely to be effective long term treatments for sleep while bzd therapeutic effects may disappear with tolerance depression and impulsivity with high suicidal risk commonly persist 126 several studies have confirmed that long term benzodiazepines are not significantly different from placebo for sleep 140 141 142 and question their use for anxiety disorders such as ptsd and ocd 126 143 144 145 this may explain why patients commonly increase doses over time and many eventually take more than one type of benzodiazepine after the first loses effectiveness 128 146 147 additionally because tolerance to benzodiazepine sedating effects develops more quickly than does tolerance to brainstem depressant effects those taking more benzodiazepines to achieve desired effects may experience sudden respiratory depression hypotension or death 148 most patients with anxiety disorders and ptsd have symptoms that persist for at least several months 148 making tolerance to therapeutic effects a distinct problem for them and necessitating the need for more effective long term treatment e g psychotherapy serotonergic antidepressants 149 withdrawal symptoms and management edit chlordiazepoxide 5 mg capsules which are sometimes used as an alternative to diazepam for benzodiazepine withdrawal like diazepam it has a long elimination half life and long acting active metabolites discontinuation of benzodiazepines or abrupt reduction of the dose even after a relatively short course of treatment two to four weeks may result in two groups of symptoms rebound and withdrawal rebound symptoms are the return of the symptoms for which the patient was treated but worse than before withdrawal symptoms are the new symptoms that occur when the benzodiazepine is stopped they are the main sign of physical dependence 139 the american society of addiction medicine asam in collaboration with ten other american medical associations issued a joint statement regarding benzodiazepine tapering in june 2025 they recommend that for most patients dependent on benzodiazepines the initial pace of the taper should generally include dose reductions of 5 to 10 every 2 4 weeks the taper should not exceed 25 every two weeks they emphasized that a taper that is too rapid can be dangerous and potentially life threatening 150 the most frequent symptoms of withdrawal from benzodiazepines are insomnia gastric problems tremors agitation fearfulness and muscle spasms 139 the less frequent effects are irritability sweating depersonalization derealization hypersensitivity to stimuli depression suicidal behavior psychosis seizures and delirium tremens 151 severe symptoms usually occur as a result of abrupt or over rapid withdrawal abrupt withdrawal can be dangerous and lead to excitotoxicity causing damage and even death to nerve cells as a result of excessive levels of the excitatory neurotransmitter glutamate increased glutamatergic activity is thought to be part of a compensatory mechanism to chronic gabaergic inhibition from benzodiazepines 152 153 therefore a gradual reduction regimen is recommended 13 symptoms may also occur during a gradual dosage reduction but are typically less severe and may persist as part of a protracted withdrawal syndrome for months after cessation of benzodiazepines 154 approximately ten percent of patients experience a notable protracted withdrawal syndrome which can persist for many months or in some cases a year or longer protracted symptoms tend to resemble those seen during the first couple of months of withdrawal but usually are of a sub acute level of severity such symptoms do gradually lessen over time eventually disappearing altogether 155 benzodiazepines have a reputation with patients and doctors for causing a severe and traumatic withdrawal however this is in large part due to the withdrawal process being poorly managed over rapid withdrawal from benzodiazepines increases the severity of the withdrawal syndrome and increases the failure rate a slow and gradual withdrawal customised to the individual and if indicated psychological support is the most effective way of managing the withdrawal opinion as to the time needed to complete withdrawal ranges from four weeks to several years a goal of less than six months has been suggested 13 but due to factors such as dosage and type of benzodiazepine reasons for prescription lifestyle personality environmental ...