When is it appropriate to use benzodiazepines, such as lorazepam (Ativan), in the management of delirium, specifically hypoactive delirium versus persistent hyperactive delirium?

Appropriate Use of Benzodiazepines in Delirium Management

Benzodiazepines should NOT be used for hypoactive delirium or persistent hypoactive delirium, but may be appropriate for persistent hyperactive delirium only when specifically indicated for alcohol or benzodiazepine withdrawal, or when other treatments have failed in cases of severe agitation threatening patient safety. 1, 2

Inappropriate Uses of Benzodiazepines

Hypoactive Delirium

• Benzodiazepines are strongly contraindicated in hypoactive delirium 1
• Pharmacologic treatment (including benzodiazepines) has not been shown to modify the duration or severity of hypoactive delirium 1
• The American Geriatrics Society explicitly recommends against prescribing benzodiazepines for older adults with postoperative delirium who are not agitated 1
• Benzodiazepines can worsen cognitive impairment and prolong delirium duration in hypoactive cases 1, 2

Persistent Hypoactive Delirium

• Even in persistent cases, benzodiazepines remain contraindicated for hypoactive delirium 1
• The potential harms of benzodiazepines are substantial with well-documented increased morbidity and mortality 1
• Substantial evidence points to increased delirium with benzodiazepines, longer delirium duration, and possible transition to delirium in ICU patients 1

Appropriate Uses of Benzodiazepines

Persistent Hyperactive Delirium

Benzodiazepines may be appropriate in specific circumstances:

1. Primary Indications:

   • Alcohol withdrawal delirium (delirium tremens) 1, 2, 3
   • Benzodiazepine withdrawal 1, 2, 3

2. Secondary Indications (with caution):

   • As rescue medication when other treatments have failed in severe agitation threatening patient safety 1, 2
   • In terminal delirium with persistent agitation when comfort is the primary goal 3
   • In combination with antipsychotics when antipsychotics alone are insufficient 3

Important Prescribing Considerations

When benzodiazepines are indicated for persistent hyperactive delirium:

• Use the lowest effective dose for the shortest possible duration 1
• Employ only if behavioral measures have failed or are not possible 1
• Evaluate ongoing use daily with in-person examination 1
• Lorazepam is the preferred benzodiazepine due to its rapid onset, shorter duration, low risk of accumulation, and predictable bioavailability 4, 5
• Consider combination therapy with haloperidol in cases of terminal delirium with persistent agitation 3

Common Pitfalls to Avoid

1. Inappropriate use in hypoactive delirium: Benzodiazepines can worsen cognitive function and prolong delirium 1, 2

2. Prolonged use: Continuing benzodiazepines beyond resolution of the specific indication increases risk of adverse effects 2

3. Failure to identify underlying causes: Always address the underlying etiology of delirium rather than just symptom management 2

4. Overlooking non-pharmacological interventions: Environmental strategies, reorientation, and other non-pharmacological approaches should be first-line 2

5. Inadequate monitoring: Regular reassessment using validated tools is essential when benzodiazepines are used 2

The evidence clearly demonstrates that benzodiazepines should be reserved for specific indications in persistent hyperactive delirium, particularly alcohol or benzodiazepine withdrawal, and should not be used in hypoactive delirium under any circumstances 1, 2, 3.