From the Guidelines
The best approach is to assess pain, ensure sleep-wake cycles are maintained, and ask family to visit daily. This patient is experiencing postoperative delirium, a common complication in elderly patients, especially those with pre-existing cognitive impairment. Rather than immediately starting antipsychotics like haloperidol or benzodiazepines like lorazepam, which can worsen confusion and have significant side effects in elderly patients, non-pharmacological interventions should be tried first. Discontinuing opioids is not appropriate as untreated pain can exacerbate delirium, as noted in the study by 1. The patient's vital signs are relatively stable with only mild tachycardia, and lab values show only mild hyponatremia and baseline anemia.
The recommended approach addresses the multifactorial nature of delirium by ensuring adequate pain control, promoting normal sleep patterns, and providing familiar faces (family) for reorientation. These interventions help reduce confusion while avoiding unnecessary medications that could potentially worsen the patient's condition. According to the study by 1, high-quality peri-operative care reduces the incidence of delirium, and non-pharmacological interventions are preferred. If delirium persists or worsens despite these measures, then pharmacological interventions might be considered, but they should not be the first-line approach in this non-aggressive, medically stable patient. The study by 1 also emphasizes the importance of systematic delirium screening and early detection to determine the underlying cause and initiate appropriate treatment.
Key considerations in managing this patient's delirium include:
- Ensuring adequate pain control with minimal use of opioids, as suggested by 1
- Promoting normal sleep-wake cycles
- Providing familiar faces for reorientation
- Avoiding unnecessary medications that could worsen confusion
- Monitoring for potential underlying causes of delirium, such as infection, hypoxia, or medication side effects, as noted in the study by 1.
From the FDA Drug Label
WARNINGS Risks from Concomitant Use with Opioids Concomitant use of benzodiazepines, including lorazepam, and opioids may result in profound sedation, respiratory depression, coma, and death. The patient is already receiving oxycodone, an opioid. Administering lorazepam in this scenario may increase the risk of respiratory depression and sedation. Given the patient's confusion and the potential risks associated with concomitant use of opioids and benzodiazepines, the best course of action would be to avoid administering lorazepam. Instead, consider alternative approaches to address the patient's confusion, such as:
- Assessing pain and ensuring it is adequately managed
- Ensuring sleep-wake cycles are maintained
- Asking family to visit daily to provide emotional support Discontinuing opioids for pain may not be necessary, but it is essential to monitor the patient closely for signs of respiratory depression and sedation 2.
From the Research
Assessment and Management of Delirium
The patient's presentation of confusion and disorientation suggests delirium, a common condition in hospitalized older adults 3. The causes of delirium are multifactorial and can include physiologic, psychosocial, and environmental alterations.
Non-Pharmacologic Interventions
Before considering pharmacologic interventions, it is essential to assess and address potential underlying causes of delirium, such as:
- Pain: Assess the patient's pain level and ensure adequate pain management 3
- Sleep-wake cycles: Maintain a normal sleep-wake cycle to reduce confusion
- Family support: Encourage family members to visit and provide emotional support
- Environmental factors: Ensure the patient's environment is calm and quiet
Pharmacologic Interventions
If non-pharmacologic interventions are insufficient, pharmacologic treatment may be necessary. The use of antipsychotics, such as haloperidol, is common in the management of delirium 4, 5, 6. However, the evidence for their effectiveness is limited, and they should be used with caution due to potential side effects.
Options for Management
Considering the patient's presentation and the available evidence, the following options can be considered:
- Assess pain, ensure sleep-wake cycles are maintained, and ask family to visit daily (Option D)
- Begin scheduled haloperidol, 0.5 mg intravenously every 8 hours (Option A)
- Give one dose of lorazepam, 1 mg intravenously (Option B)
- Discontinue opioids for pain (Option C)
It is essential to weigh the potential benefits and risks of each option and consider the patient's individual needs and circumstances. The use of haloperidol or lorazepam should be carefully monitored, and the patient's response to treatment should be regularly assessed.