What medications can be used acutely for anxiety and delirium in the hospital?

Medications for Acute Anxiety and Delirium in the Hospital Setting

For acute anxiety and delirium in hospitalized patients, second-generation antipsychotics like olanzapine (2.5-5 mg) or quetiapine (25 mg) are recommended as first-line pharmacological interventions, with benzodiazepines like lorazepam (0.5-1 mg) reserved for severe anxiety or as adjuncts in severe agitation. 1

First Steps: Addressing Reversible Causes

Before initiating pharmacological treatment:

1. Identify and treat reversible causes:

   • Hypoxia
   • Pain
   • Urinary retention
   • Constipation
   • Medication side effects

2. Implement non-pharmacological measures:

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

Pharmacological Management Algorithm

For Anxiety:

Patient able to swallow:

• Lorazepam 0.5-1 mg orally four times daily as needed (maximum 4 mg/24 hours)
• Reduce to 0.25-0.5 mg in elderly or debilitated patients (maximum 2 mg/24 hours)
• Oral tablets can be used sublingually if needed 1

Patient unable to swallow:

• Midazolam 2.5-5 mg subcutaneously every 2-4 hours as needed
• Consider subcutaneous infusion if needed frequently (starting with 10 mg over 24 hours)
• Reduce to 5 mg over 24 hours if eGFR <30 mL/minute 1

For Delirium:

Mild to moderate delirium:

• Haloperidol and risperidone are NOT recommended as they have been shown to worsen symptoms 1

Moderate to severe delirium with distressing symptoms:

Patient able to swallow:

1. Second-generation antipsychotics (preferred):

   • Olanzapine: 2.5-5 mg orally or subcutaneously once daily (usually at bedtime)
   • Quetiapine: 25 mg orally twice daily
   • Aripiprazole: 5 mg orally once daily 1

2. First-generation antipsychotic (if second-generation unavailable):

   • Haloperidol: 0.5-1 mg orally at night and every 2 hours as needed
   • Increase in 0.5-1 mg increments as needed (maximum 10 mg daily, or 5 mg in elderly)
   • Consider higher starting dose (1.5-3 mg) only if patient is severely distressed or dangerous 1

Patient unable to swallow:

• Levomepromazine: 12.5-25 mg subcutaneously hourly as needed (6.25-12.5 mg in elderly)
• Maintain with subcutaneous infusion of 50-200 mg over 24 hours 1

For Severe Agitation/Crisis Intervention:

• Add benzodiazepine to antipsychotic:
  • Lorazepam 0.5-1 mg orally/subcutaneously/IV
  • Midazolam 2.5 mg subcutaneously/IV
  • Use lower doses in elderly, frail patients or those with COPD 1

Special Considerations

Alcohol or Benzodiazepine Withdrawal:

• Benzodiazepines are first-line treatment (not antipsychotics) 1

Hypoactive Delirium:

• Consider methylphenidate if no delusions or perceptual disturbances are present 1

Elderly Patients:

• Use lower doses of all medications
• Monitor closely for:
  • Extrapyramidal symptoms
  • Sedation
  • Falls
  • Respiratory depression 1, 2

Medication Precautions:

• Antipsychotics:

  • Monitor for QTc prolongation (baseline and follow-up ECG)
  • Use with caution in Lewy body dementia or Parkinson's disease
  • Watch for extrapyramidal symptoms 1, 2

• Benzodiazepines:

  • Avoid in patients with severe respiratory insufficiency
  • Avoid in severe liver disease
  • Avoid in myasthenia gravis
  • Monitor vital signs, particularly respiratory rate
  • Assess sedation level every 15-30 minutes after administration 2
  • Caution: fatalities reported with concurrent use of benzodiazepines and high-dose olanzapine 1

Dosing Adjustments

• Elderly patients: Use 25-50% of standard doses
• Hepatic impairment: Reduce doses of olanzapine, quetiapine, and haloperidol
• Renal impairment: Reduce doses of risperidone and midazolam if eGFR <30 mL/minute 1

Remember that medications should be used for the shortest period possible and at the lowest effective dose to manage distressing symptoms or safety concerns 1.