<h3>Introduction</h3> The treatment of anxiety, panic, depression, and insomnia symptoms in late life pose many challenges. The use of benzodiazepines for these symptoms offers often rapid relief in some domains but clearly poses risks. Second only to opioids, benzodiazepine prescriptions have become a major focus of public health concern and scrutiny. The use of electronic data base reporting and FDA warnings regarding abuse potential and withdrawal have lead to a movement to both deprescribe and not initiate benzodiazepine treatment in older adults. It is clear that concerns regarding side effects of falls, fractures, acute and chronic confusional states, abuse potential and drug-drug interactions are of great concern to clinicians. Patients often cite concerns regarding tapering of these agents including fear of relapse of anxiety and panic and a wish to maintain feelings of comfort with what is percieved as a stable medication regime in their advanced years of life. A challenge to clinicians is to work with aging patients over a treatment plan which balances medication safety with the therapuetic benefits of these agents. Management of older adults who have been treated chronically, often for many decades, with benzodiazepines poses a significant challenge. Many community providers no longer want to care for these patients and as a result, they present to hospital based clinics with stigma and disappointment over prior treatment. <h3>Methods</h3> Cases were identified from the patient population at Mount Sinai Beth Israel, an urban medical center serving a multicultural and socioeconomically diverse population. Mount Sinai Beth Israel has been serving the popultaion of Manhattan since 1889 and provides comprehensive behavioral health care services. Patients were identified from those who presented to the ambulatory care geriatric psychiatry service with care needs that included chronic benzodiazepine use. <h3>Results</h3> Case presentations: Ms. A: A 69 year old woman with history of Generalized Anxiety Disorder and Dysthymia whopresented for treatment after her long-term provider could no longer see her. Medication regime includes Citalopram 40mg once daily, Clonazepam 2.5mg daily in divided doses, Gabapentin 400mg daily in divided doses and Zolpidem 10mg at bedtime. The patient presents with complaints of nervousness and anxiety which impair her function. She is resistive toward any changes in her regime and also she is reluctant to engage in psychotherapy. Ms. B: A 69 year old woman has been enrolled in the clinic for many years. She has a history of Generalized Anxiety Disorder, Panic Disorder, Alcohol Use Disorder in sustained remission and Opioid Use Disorder in remission on Methadone 45mg daily. The patient has been treated with Mirtazapine 60mg at bedtime, Clonazepam 1mg three times daily and Gabapentin 200mg at bedtime. Her course has been complicated by her goal of ending her Opioid Treatment Program and undergoing a taper of her Methadone dose over time. She presents with many complaints of anxiety, abdominal pain and GI upset. While she is able to describe a history of significant childhood trauma and abuse, engaging in truama focused care has been a challenge and her visits focus on dose increases in current medications. Ms. C: A 70 year old woman with a history of Major Depressive Disorder and Generalized Anxiety Disorder has been stable for many years. He current medication regime incldues Venlafaxine 100mg daily, Gabapentin 100mg daily and Clonazepam 0.75mg daily in divided doses. The patient is very devoted to her medication regime, with specific times of the day when she takes her pills and how she divides the Clonazepam doses. She explains that she is very satisifed with this regime, has tolerated reduction from a higher does of Clonazepam in the past and feels does not want to risk any relapse at present. <h3>Conclusions</h3> The risk potential of benzodiazepines is exponentially higher in geriatric patients compared to younger adults. This does not imply that these medications should always be discontinued among those who have been treated chronically. It is clear that despite Beers Criteria inclusion and FDA warnings, patients and providers both have difficulties making long term treatment plans regarding individual risk verus benefit decisions. A finding from our hospital-based clinic population includes an increasing number of patients who enter treatment after prior providers have refused to continue prescribing controlled substances. This fracture in a prior relationship creates greater challenges in fostering the therapuetic alliance necessary to gain trust, offer adjuntive therapies and adequately discuss medication risks and benefits. Finding the best balance for the patient in mitigating risk while maintaining quality of life requires individual assessment and shared treatment goals. We want to reduce polypharmacy, maintain patient comfort and safety with a focus on harm reduction. <h3>This research was funded by</h3> Mount Sinai Beth Israel Department of Psychiatry