What is the recommended dosing for lorazepam (Ativan) in an 80-year-old female?

Lorazepam Dosing in an 80-Year-Old Female

For an 80-year-old female, the recommended starting dose of lorazepam is 0.25-0.5 mg orally, with a maximum daily dose of 2 mg in 24 hours. 1, 2

General Dosing Principles for Elderly Patients

• Initial dosing should be lower in elderly or debilitated patients due to increased sensitivity to benzodiazepines and higher risk of adverse effects 2
• Lorazepam should be administered at the lowest effective dose for the shortest duration possible to minimize side effects 1
• Gradual dose titration is recommended when efficacy needs to be improved 2
• When discontinuing lorazepam, a gradual taper is essential to avoid withdrawal reactions 2

Specific Dosing by Indication

For Anxiety or Agitation

• Oral administration: 0.25-0.5 mg orally up to four times daily as needed (maximum 2 mg in 24 hours) 1
• Sublingual administration: Oral tablets can be used sublingually (off-label) at the same dosage 1

For Delirium Management

• When used as an adjunct for delirium management: 0.25-0.5 mg orally or parenterally every 1-2 hours as needed 1
• Consider co-administration with an antipsychotic if the patient has severe agitation or distress 1

For Sleep Disturbances

• For insomnia due to anxiety: 0.25-0.5 mg at bedtime 2
• Avoid higher doses as they significantly increase risk of adverse effects in elderly patients 3

Route of Administration Considerations

• Oral route: Preferred when the patient can swallow
• Subcutaneous/IV route: If unable to swallow, 0.25-0.5 mg can be administered parenterally 1
• When using lorazepam oral concentrate, it should be mixed with liquid or semi-solid food (water, juice, applesauce) and consumed immediately 2

Important Precautions in Elderly Patients

• Elderly patients are especially sensitive to benzodiazepines and at higher risk for adverse effects 1, 3
• Monitor closely for:
  • Excessive sedation and cognitive impairment 4
  • Increased risk of falls 1
  • Paradoxical agitation or confusion 1, 4
  • Respiratory depression, especially if combined with other CNS depressants 1
  • Anterograde amnesia 4

Contraindications and Special Considerations

• Use with extreme caution in patients with:

  • Severe pulmonary insufficiency 1
  • Severe liver disease 1
  • Myasthenia gravis 1
  • History of substance abuse 2
  • Concomitant use of other CNS depressants 1

• Avoid combining with high-dose olanzapine due to risk of respiratory depression 1

Monitoring and Follow-up

• Assess response within 1-2 hours after administration 1
• Monitor for excessive sedation, confusion, and respiratory status 4
• Reassess the need for continued therapy regularly 2
• When discontinuing, taper gradually to avoid withdrawal symptoms 2, 5

Potential Adverse Effects to Watch For

• Rebound anxiety or insomnia may occur upon discontinuation 5, 4
• Increased risk of falls and fractures 1
• Memory impairment and confusion are common in elderly patients 5
• Paradoxical reactions including increased agitation 1