Sedation in the Elderly: Recommended Approach
Benzodiazepines should be avoided in elderly patients for sedation due to increased risk of cognitive impairment, delirium, and respiratory depression; when sedation is necessary, use reduced doses of short-acting agents like midazolam with careful titration, or consider non-benzodiazepine alternatives such as propofol or antipsychotics depending on the clinical context. 1
Key Principles for Elderly Sedation
Avoid Benzodiazepines When Possible
- Benzodiazepines cause decreased cognitive performance and should be avoided in older patients and those with cognitive impairment 1
- Benzodiazepines should not be used as initial treatment for delirium in elderly patients 1
- The elderly are at greater risk for central nervous system depression, respiratory depression, hypoventilation, airway obstruction, and apnea with benzodiazepines 2, 3
When Benzodiazepines Are Necessary
Midazolam dosing for elderly patients (≥60 years):
- For procedural sedation: Start with no more than 1.5 mg given over at least 2 minutes (compared to 2.5 mg in younger adults) 2
- Wait an additional 2 or more minutes after each dose to fully evaluate sedative effect before giving more 2
- Total doses greater than 3.5 mg are not usually necessary in elderly patients 2
- If concomitant CNS depressants are used, elderly patients require at least 50% less midazolam than younger unpremedicated patients 2
- The peak effect may take longer in elderly patients, requiring smaller increments and slower injection rates 2
Lorazepam considerations:
- Age over 65 is associated with greater incidence of CNS depression and respiratory depression 3
- Start at the low end of the dosing range for elderly patients 3
- Greater sensitivity to sedation in older individuals cannot be ruled out 3
Alternative Sedation Strategies
For palliative sedation in elderly cancer patients:
- Midazolam remains the preferred agent for palliative sedation, with alternatives including levomepromazine, chlorpromazine, phenobarbital, and propofol 1
- Antipsychotics (haloperidol, risperidone, olanzapine, quetiapine) are preferred for delirium-related agitation rather than benzodiazepines 1
- For refractory insomnia, consider antipsychotics (chlorpromazine, quetiapine, olanzapine) or sedating antidepressants (trazodone, mirtazapine) over benzodiazepines 1
For ICU sedation:
- Propofol is suggested over benzodiazepines for mechanically ventilated adults after cardiac surgery 1
- Target light rather than deep sedation in critically ill elderly patients unless clinically indicated 1
Critical Safety Measures
Titration and monitoring:
- Always titrate slowly: administer over at least 2 minutes and allow an additional 2 or more minutes to evaluate sedative effect 2
- The danger of hypoventilation, airway obstruction, or apnea is greater in elderly patients 2
- Increments should be smaller and injection rate slower in patients age 60 or older 2
Special vulnerabilities:
- Elderly patients have friable skin prone to pressure necrosis during prolonged sedation 1
- Age-related pharmacokinetic and pharmacodynamic changes render elderly patients sensitive to relative overdose, causing myocardial depression and reduced blood pressure homeostasis 1
- Lower doses are necessary for sedation in older patients to avoid hemodynamic and respiratory side-effects 4
Common Pitfalls to Avoid
- Do not use standard adult doses - elderly patients require 30-50% dose reductions 2
- Do not rush titration - wait full 2+ minutes between doses to assess effect 2
- Avoid combining benzodiazepines with other sedating medications without significant dose reduction 2
- Do not use benzodiazepines for delirium management - use antipsychotics instead 1
- Paradoxical excitement can occur with phenobarbital in the elderly 1