Beyond the Prescription: Benzodiazepines & the Aging Brain

What if some of the changes we accept as “getting older” aren't aging at all?

Memory becomes less reliable. Thinking feels slower. Balance changes. A person becomes more tired during the day, less steady on their feet, or simply not as mentally sharp as they once were. When this happens later in life, age is an easy explanation.

But there is another question worth asking: What medications are in the picture?

This subject is personal for me. My grandmother took benzodiazepines and tried for years to get off them. She couldn't. Long before I understood the pharmacology of these drugs, I saw what it looked like when someone wanted to stop taking a medication and found that she simply could not.

That stayed with me. Today, knowing what we know about benzodiazepines, physical dependence, withdrawal, cognition, and the particular vulnerability of the aging brain, I think this is a medication history that deserves much more attention.

The Prescription That Makes Sense at First

Benzodiazepines include familiar medications such as alprazolam (Xanax), lorazepam (Ativan), diazepam (Valium), clonazepam (Klonopin), and temazepam (Restoril). They may be prescribed for anxiety, panic, insomnia, seizures, muscle spasms, alcohol withdrawal, and certain medical procedures.

And their immediate effects explain why people can find them so helpful. Benzodiazepines enhance the activity of gamma-aminobutyric acid, or GABA, the brain's major inhibitory neurotransmitter. GABA essentially applies a brake to neuronal activity. Benzodiazepines strengthen that braking effect.

Anxiety can decrease. Muscles relax. Sedation increases. Sleep may come more easily. A nervous system that feels as though it is running at full speed can suddenly become quieter.

But that same mechanism raises a different question when exposure becomes prolonged: What happens when we repeatedly increase inhibition in the central nervous system?

When the Brain Adapts

The nervous system is not static. It continually adapts to its chemical environment.

With repeated benzodiazepine exposure, the brain can adapt to the drug's presence. This is part of the biology behind tolerance and physical dependence. The medication is no longer simply producing an effect from the outside; the nervous system has begun adjusting around its continued presence.

This distinction matters because physical dependence is not the same thing as addiction. A person can take a benzodiazepine exactly as prescribed, never misuse it, never seek escalating doses recreationally, and still become physically dependent.

Dependence means the body has adapted sufficiently that reducing or removing the drug can produce withdrawal symptoms.

That is a very different story from “drug abuse.”

And it is one reason people can find themselves taking a medication far longer than they originally expected.

The Aging Brain Changes the Equation

Age adds another layer.

Older adults are generally more sensitive to benzodiazepines, and metabolism of some longer-acting drugs becomes slower. That can mean greater or more prolonged exposure from a dose that may once have been better tolerated.

The American Geriatrics Society's Beers Criteria, which identifies medications that may be problematic in adults 65 and older, specifically includes benzodiazepines. The concerns include cognitive impairment, delirium, falls, fractures, and motor vehicle crashes. Continued use can also produce clinically significant physical dependence.

This creates an important clinical problem because several of those effects can resemble problems commonly attributed to aging. A person may become increasingly forgetful or confused, seem less steady on their feet, or experience slower reaction times. Balance and coordination can decline, increasing the likelihood of falls.

The assumption may be that the person is simply getting older. But medication effects belong in that conversation.

When Side Effects Look Like Aging

Benzodiazepines suppress central nervous system activity. That is their therapeutic mechanism, but it can also affect memory formation, attention, reaction time, coordination, and psychomotor performance.

In a younger person, some of these effects may be noticeable primarily as sedation. In an older person whose neurological reserve, metabolism, balance, vision, muscle strength, or medication burden has already changed, the consequences can be much greater.

One medication also rarely exists in isolation.

An older adult may simultaneously be taking an antidepressant, sleep medication, antihistamine, pain medication, blood pressure medication, or another drug that affects the central nervous system. The biological question is no longer simply, “What does this benzodiazepine do?” It becomes, “What is the cumulative effect of everything this nervous system is being asked to process?”

What About Dementia?

This is where the conversation needs precision.

Numerous observational studies have reported an association between benzodiazepine use and dementia. Meta-analyses have also reported higher dementia risk among benzodiazepine users, particularly in relation to longer exposure in some analyses.

Those findings matter, but they also need context. One major issue is reverse causation. Anxiety and sleep disturbances can appear years before dementia is diagnosed, and benzodiazepines may be prescribed for those early symptoms. That makes it difficult to separate medication exposure from the neurological changes that may already have been developing.

A 2023 umbrella review examining multiple meta-analyses found a consistent association between benzodiazepine exposure and dementia, while also identifying methodological limitations and variability across the underlying studies.

So the important point is not to dismiss the association simply because observational medicine cannot neatly isolate every variable. The more useful question is how that association fits with the rest of what we already know.

We know benzodiazepines can impair cognition. We know older adults are more vulnerable to those effects. We know the American Geriatrics Society identifies cognitive impairment and delirium among the concerns with benzodiazepine use in older adults. And we have a body of observational literature reporting an association between benzodiazepine exposure and dementia.

Taken together, that is enough to justify careful medication review, especially when cognitive changes appear in someone using these drugs long term.

The Dependence Nobody Planned On

For many people, the most consequential part of long-term benzodiazepine use is not addiction. It is physical dependence.

The FDA requires a boxed warning for the entire benzodiazepine class addressing abuse, misuse, addiction, physical dependence, and withdrawal. Physical dependence can develop even when these medications are taken therapeutically.

That means someone may begin with a legitimate prescription during an exceptionally difficult period—a death, divorce, severe anxiety, panic attacks, insomnia, surgery, or another crisis—and discover months or years later that stopping is far more complicated than starting ever was.

This is the part that brings me back to my grandmother.

She tried to get off them for years and couldn't. I cannot go back and reconstruct every biological reason that happened to her. But I can now understand something I did not understand then: a nervous system can adapt profoundly to the continued presence of these drugs.

Wanting to stop and being physiologically able to stop quickly are two entirely different things.

Why Withdrawal Can Be So Difficult

If the brain has adapted to enhanced inhibitory signaling, removing that influence too rapidly can leave the nervous system in a state of excessive excitation.

Withdrawal can include anxiety, insomnia, irritability, tremor, sweating, gastrointestinal symptoms, sensory disturbances, difficulty concentrating, and other neurological or psychological symptoms. Severe withdrawal can include seizures and delirium.

Some people also experience symptoms that persist well beyond the immediate withdrawal period.

This is why the modern conversation around benzodiazepine deprescribing is not simply “stop taking the drug.” In 2025, a multidisciplinary clinical practice guideline led by the American Society of Addiction Medicine emphasized individualized, gradual tapering for people who are physically dependent and specifically recommended against abrupt discontinuation.

For many adults 65 and older, that guideline recommends considering tapering when the risks of continued use outweigh the benefits, while recognizing that individual circumstances differ.

A Medication Review Is Part of a Health Review

This is where I think conventional symptom-based thinking can miss an important part of the picture.

If an older person develops brain fog, memory problems, dizziness, poor balance, daytime fatigue, sleep disruption, or confusion, those symptoms can generate an entirely new series of evaluations and diagnoses.

But the medication list should be part of the investigation from the beginning.

What was prescribed?

When was it started?

Why was it started?

Is the original reason for taking it still present?

What other central nervous system medications have been added?

Did the symptoms begin or worsen after a medication or dosage change?

And has anyone ever gone back and looked at the entire medication history as one biological picture?

These are basic questions, but they can disappear when healthcare is organized around individual prescriptions and individual symptoms rather than the total physiological picture.

Beyond the Prescription

Benzodiazepines illustrate exactly why I created this series.

A prescription has a reason. It has a mechanism. It has an intended effect.

But the story does not end when the prescription is written.

The body adapts. Age changes physiology. Other medications are added. Metabolism changes. The original problem may change. And a drug that once solved an immediate problem can eventually become one of the variables that needs to be reconsidered.

For older adults especially, new problems with memory, cognition, balance, sedation, or confusion deserve a wider lens.

Sometimes the question should not simply be, “What new condition is developing?”

It should also be:

“What has this brain been exposed to, for how long, and could any part of the medication history be contributing to what we're seeing now?”

References

American Geriatrics Society. 2023 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults.
[LINK: AGS Beers Criteria]

U.S. Food and Drug Administration. Boxed Warning Updated to Improve Safe Use of Benzodiazepine Drug Class.
[LINK: FDA Benzodiazepine Boxed Warning]

American Society of Addiction Medicine and partner organizations. Joint Clinical Practice Guideline on Benzodiazepine Tapering: Considerations When Risks Outweigh Benefits.
[LINK: 2025 Benzodiazepine Tapering Guideline]

Wu CC, et al. Benzodiazepine Use and the Risk of Dementia in the Elderly Population: An Umbrella Review of Meta-Analyses. Journal of Personalized Medicine. 2023;13(10):1485.
[LINK: Dementia Umbrella Review]