What is the next best pharmacological option for an elderly woman in her 80s with post-operative delirium (day 4 post-op), who has not responded to 0.25mg lorazepam (Ativan), and is experiencing escalating agitation and confusion?

Management of Postoperative Delirium in an Elderly Woman with Escalating Agitation

For an elderly woman in her 80s with escalating postoperative delirium not responding to lorazepam 0.25mg and non-pharmacological measures, haloperidol 0.5-1mg orally or subcutaneously is the recommended first-line pharmacological intervention.

Assessment and Initial Considerations

Before administering additional medications, quickly assess for:

• Potential underlying causes: pain, hypoxemia, electrolyte disturbances, infection, urinary retention
• Current medications that may be contributing to delirium
• Severity of agitation and risk to patient safety

Pharmacological Management Algorithm

First-line Treatment:

• Haloperidol 0.5-1mg orally or subcutaneously 1, 2
  • Start with 0.5mg in this elderly patient
  • Can be repeated every 2-4 hours as needed
  • Lower doses are recommended in elderly patients to minimize side effects
  • Monitor for extrapyramidal symptoms and QT prolongation

If inadequate response after 30-60 minutes:

• Consider increasing haloperidol dose to 1mg
• Maximum daily dose should not exceed 5mg in elderly patients 1

For severe agitation with immediate safety concerns:

• Consider adding midazolam 2.5mg subcutaneously if haloperidol alone is insufficient 1
• Alternatively, consider combination of haloperidol with lorazepam for synergistic effect 3
  • Note that while lorazepam 0.25mg was ineffective alone, it may enhance haloperidol's effect

Important Considerations

Why haloperidol is preferred:

• First-generation antipsychotics are recommended for acute management of delirium with agitation 1
• Benzodiazepines alone (like lorazepam) are not recommended as first-line agents for non-alcohol withdrawal delirium and may worsen delirium 1, 4
• The combination of lorazepam with haloperidol has shown efficacy in severe agitation but should be used cautiously in elderly patients 3

Atypical antipsychotics as alternatives:

If haloperidol is contraindicated or poorly tolerated:

• Risperidone 0.25-0.5mg orally
• Olanzapine 2.5mg orally
• Quetiapine 12.5mg orally 1

Cautions:

• Benzodiazepines alone may worsen delirium and increase risk of falls in elderly patients 1
• Combined use of antipsychotics and benzodiazepines is associated with poorer outcomes in elderly patients with delirium 5
• Avoid anticholinergic medications as they can worsen delirium 1
• Monitor for extrapyramidal symptoms, QT prolongation, and excessive sedation 2

Non-pharmacological Measures to Continue

While initiating pharmacological treatment:

• Maintain orientation (explain where the patient is, who you are)
• Ensure adequate lighting
• Have familiar people present if possible
• Continue to address potential underlying causes
• Monitor vital signs and oxygen saturation

Remember that the goal is to control symptoms while minimizing adverse effects, particularly in an elderly patient who is at higher risk for medication side effects.