Ms B., a 69-year-old woman with a history of hypothyroidism, hypertension, coronary artery disease, and gastroesophageal reflux disease, was taking 100 µg levothyroxine daily, 200 mg of labetalol twice per day, 25 mg of losartan daily, and 40 mg of pantoprazole daily. She had been taking a variety of benzodiazepines (which she sometimes misused) for anxiety since her teenage years. Most recently, she had been taking 2 mg of lorazepam 3 times per day. During a stressful event (the end of her mother's life), she “double dosed” the medication, depleting the prescription prematurely. Thus, she experienced withdrawal and was hospitalized. She was initially disoriented, with fluctuations in her level of consciousness, but these symptoms improved with 10 mg of diazepam 3 times per day. Workup revealed unremarkable findings on magnetic resonance imaging, complete blood cell count, blood chemistry analysis, thyroid stimulating hormone level, and urinalysis, and negative findings on hepatitis A, B, and C and HIV screening. At discharge, she was prescribed a 3-week tapering course of diazepam followed by discontinuation of the drug.
Within a few days of the last dose of diazepam, Ms B. had difficulty with concentration and problems with memory that fluctuated during the day and worsened at night. At times, she had difficulty articulating words clearly. She had occasional muscular twitching and jerks. These findings were consistent with a diagnosis of delirium.
9 Because her husband did not like the hospital, he cared for her at home for several weeks and reported that she often had trouble with memory and concentration during that time. He finally took her to a psychiatric clinic for evaluation. There, she demonstrated cognitive impairment (oriented to person, place, and year, but not to month or date; unable to perform calculations; unable to draw a clock; recalled 0 of 5 words from a previously learned list of simple words). Her Montreal Cognitive Assessment (MOCA) score was 14/30. The cognitive impairment had not been noted at previous visits to her primary care physician. Her husband insisted that her problems with cognition had developed with cessation of the diazepam. She was prescribed 1.0 mg of clonazepam twice daily. A week later, her cognition was noticeably improved (MOCA score, 20). Two weeks later, her MOCA score improved to 25, and her husband described her as “almost normal.”
Because of her history of misusing her medication, it was felt that she could not be treated with benzodiazepines long term. Her clonazepam dose was decreased to 1.5 mg daily. Her husband reported that she started getting confused again about 5 days later. At her next visit, the MOCA score had dropped to 20. The dose was increased back to 1.0 mg twice daily, and she began to think more clearly (MOCA score, 24). Subsequently, she underwent tapering of the clonazepam in increments of 0.25 mg per dose over a period of several months. She had some difficulty because of rebound anxiety but was able to tolerate the process. A month after the final dose, her MOCA score was 26.