What is the next step for a 93-year-old agitated patient given Ativan (lorazepam)?

Management of Agitation in a 93-Year-Old Patient After Lorazepam Administration

For a 93-year-old patient who remains agitated after receiving Ativan (lorazepam), the next step should be to assess for reversible causes of agitation and consider adding haloperidol 0.5-1 mg orally or 0.5 mg subcutaneously if the patient is unable to swallow.

Assessment of Current Situation

First, evaluate if the initial lorazepam dose was appropriate for this elderly patient:

• For elderly patients (93 years old), the recommended lorazepam dose should be reduced to 0.25-0.5 mg (maximum 2 mg in 24 hours) 1
• Excessive sedation may occur in patients over 50 years who may experience more profound and prolonged effects 2

Algorithm for Management

Step 1: Assess for Reversible Causes

• Check for underlying medical conditions causing or exacerbating agitation:
  • Hypoxia
  • Urinary retention
  • Constipation
  • Infection (especially UTI or pneumonia)
  • Metabolic disturbances
  • Pain
  • Medication effects or withdrawal 1

Step 2: Non-Pharmacological Approaches

• Ensure effective communication and orientation
• Provide adequate lighting
• Explain to caregivers how they can help
• Create a calm environment 1

Step 3: Pharmacological Management

If the patient remains agitated despite appropriate lorazepam dosing and addressing reversible causes:

For patients able to swallow:

• Add haloperidol 0.5-1 mg orally at night and every 2 hours as needed
• Increase dose in 0.5-1 mg increments as required (maximum 5 mg daily in elderly patients) 1

For patients unable to swallow:

• Haloperidol 0.5-1 mg subcutaneously as needed
• OR consider levomepromazine 6.25-12.5 mg subcutaneously for severe agitation 1

Special Considerations for Geriatric Patients

1. Start low, go slow: Use the lowest effective dose of medications

   • Elderly patients are more sensitive to both therapeutic and adverse effects of medications

2. Monitor closely for adverse effects:

   • Respiratory depression with benzodiazepines
   • Extrapyramidal symptoms with antipsychotics
   • QT prolongation with haloperidol
   • Fall risk with all sedating medications 2

3. Avoid certain combinations:

   • Be cautious with combining multiple CNS depressants
   • Monitor for excessive sedation when using both benzodiazepines and antipsychotics 2

Monitoring and Follow-up

• Monitor vital signs, especially respiratory status
• Assess level of sedation regularly
• Evaluate for extrapyramidal symptoms if antipsychotics are used
• Reassess the need for continued medication every 24 hours

Common Pitfalls to Avoid

1. Overmedication: Elderly patients are more sensitive to medications and have altered pharmacokinetics and pharmacodynamics

2. Overlooking delirium: Agitation may be a manifestation of delirium, which requires treatment of the underlying cause rather than just sedation

3. Inadequate assessment: Failing to identify and address reversible causes of agitation before adding more medications

4. Prolonged use: Benzodiazepines should be used for the shortest duration possible to avoid dependence and withdrawal 2

5. Ignoring non-pharmacological approaches: Medications should complement, not replace, non-pharmacological management strategies 1, 3

Remember that in elderly patients, the goal is to achieve calm behavior with the lowest effective dose of medication while maintaining the patient's ability to communicate and participate in care as much as possible.