Is clonazepam (benzodiazepine) used in the management of organic delirium?

Clonazepam in Organic Delirium

Clonazepam should not be used for the treatment of organic delirium except in specific circumstances such as alcohol or benzodiazepine withdrawal delirium. 1

First-line Management Approach for Delirium

• Benzodiazepines, including clonazepam, are not recommended as initial treatment for delirium in patients not already taking them 1
• Benzodiazepines are sedating, have been identified as deliriogenic (can cause or worsen delirium), and increase the risk of falls 1
• Current guidelines recommend first addressing reversible causes and using non-pharmacological interventions (reorientation, cognitive stimulation, sleep hygiene) before considering medication 1, 2

Appropriate Pharmacological Management of Delirium

• Antipsychotics are the mainstay of pharmacological treatment for delirium with distressing symptoms 3
• For moderate delirium, oral haloperidol, risperidone, olanzapine, or quetiapine are recommended 1
• For severe delirium with agitation, antipsychotic medications such as haloperidol, olanzapine, or chlorpromazine are recommended 1
• Second-generation antipsychotics (olanzapine, quetiapine, aripiprazole) may offer benefit with fewer extrapyramidal side effects than first-generation agents 1

Specific Circumstances When Benzodiazepines May Be Used in Delirium

• Benzodiazepines are the treatment of choice as monotherapy for alcohol or benzodiazepine withdrawal delirium 1
• Benzodiazepines may be added for agitation that is refractory to high doses of neuroleptics 1
• Lorazepam is the benzodiazepine of choice when needed, as it has a rapid onset, shorter duration of action, low risk of accumulation, and more predictable bioavailability 3
• Midazolam or lorazepam may be used as crisis intervention in delirium management for severe agitation and distress 1

Risks and Cautions with Benzodiazepines in Delirium

• Benzodiazepines can worsen cognitive function and may precipitate or exacerbate delirium 4, 5
• They increase the risk of falls, confusion, and respiratory depression, particularly in older or frail patients 1
• A recent Cochrane review found insufficient evidence to determine whether benzodiazepines are effective for treating delirium in non-ICU settings 5
• When benzodiazepines are used with antipsychotics, there is risk of oversedation and respiratory depression 1

Clinical Decision-Making Algorithm

1. Identify and treat underlying causes of delirium 1, 2
2. Implement non-pharmacological interventions 1, 2
3. If pharmacological intervention is needed:
   • For most cases of delirium: Use antipsychotics (haloperidol, olanzapine, quetiapine, etc.) 1
   • For alcohol/benzodiazepine withdrawal delirium: Use benzodiazepines 1
   • For refractory agitation despite antipsychotics: Consider adding a benzodiazepine like lorazepam 1

Important Caveats

• Benzodiazepines should be used in the lowest effective dose and for the shortest time possible 1
• Patients receiving benzodiazepines require close monitoring for excessive sedation, confusion, or respiratory depression 6
• Older adults are particularly sensitive to the adverse effects of benzodiazepines 6
• The presence of therapeutic levels of neuroleptics usually prevents the paradoxical excitation sometimes seen when delirious patients are given benzodiazepines 1