What pharmacological intervention is recommended for an 82-year-old female (F), 3 days (D3) post-hip replacement, presenting with acute agitation and confusion, who is accepting of oral tablets?

Management of Acute Agitation in an Elderly Patient Post-Hip Replacement

For an 82-year-old female with acute agitation and confusion 3 days post-hip replacement who can take oral tablets, low-dose lorazepam 0.25-0.5mg orally is the most appropriate first-line pharmacological intervention. 1

Assessment and Initial Management

When managing acute agitation in an elderly post-operative patient, it's crucial to:

1. Rule out reversible causes first:

   • Check for hypoxia (common post-operatively)
   • Assess for urinary retention
   • Evaluate for constipation
   • Screen for pain (inadequately controlled pain is common after hip surgery)
   • Check for electrolyte abnormalities

2. Non-pharmacological approaches:

   • Ensure adequate orientation (explain where they are, who you are)
   • Provide adequate lighting
   • Use clear, simple communication
   • Have familiar objects/people present if possible

Pharmacological Management

First-line treatment:

• Lorazepam 0.25-0.5mg orally (reduced dose for elderly/debilitated patients)
• Maximum 2mg in 24 hours for elderly patients
• Oral tablets can be used sublingually if needed 1

If delirium is the predominant feature:

• Haloperidol 0.5-1mg orally at night and every 2 hours as required
• Maximum 5mg daily in elderly patients
• Can increase dose in 0.5-1mg increments as required 1

If patient remains agitated after initial intervention:

• Consider combination therapy with both lorazepam and haloperidol at the doses mentioned above 1

Rationale for Medication Choice

Benzodiazepines like lorazepam are appropriate for managing anxiety and agitation in this scenario because:

1. The patient is in the early post-operative period (day 3) where post-operative delirium is common
2. Lorazepam has a relatively fast onset of action and no active metabolites 1
3. The reduced dose (0.25-0.5mg) minimizes risk of respiratory depression in an elderly patient

Haloperidol may be considered if the clinical picture is more consistent with delirium, but should be used cautiously due to potential extrapyramidal side effects in the elderly.

Important Considerations and Pitfalls

• Avoid opioids as sole agents for agitation management as they increase the risk of respiratory depression and can worsen postoperative confusion 1
• Monitor respiratory status closely after administering benzodiazepines, especially in elderly patients
• Reassess frequently - if the patient's agitation persists or worsens, reevaluate for underlying causes
• Document response to medication to guide subsequent dosing
• Consider the impact on rehabilitation - excessive sedation can delay mobilization, which is critical for recovery after hip replacement

Follow-up Management

• After acute agitation is controlled, develop a plan to prevent recurrence
• Consider scheduled rather than as-needed medications if agitation is recurrent
• Ensure adequate pain control using multimodal analgesia to minimize opioid use 2
• Implement consistent nursing care patterns with regular orientation and reassurance 3

This approach balances the need to control the patient's acute agitation while minimizing risks associated with pharmacological interventions in an elderly post-surgical patient.