What are the causes of altered mental status (AMS) in a 70-year-old female and how to treat Ativan (lorazepam)-induced AMS?

From the Guidelines

Altered Mental Status (AMS) in a 70-year-old female is most likely caused by delirium, which is a medical emergency that requires early detection and accurate diagnosis. The causes of AMS are diverse and can be attributed to various underlying medical conditions, substance use, and mental disorders 1. In elderly patients, delirium is a common cause of AMS, and its diagnosis can be missed if not properly screened for 1.

Common Causes of Altered Mental Status

• Underlying medical conditions such as infections, metabolic derangements, and neurological diseases
• Substance use or withdrawal
• Mental disorders such as dementia, depression, and psychosis
• Medications such as anticholinergic drugs, sedatives, and narcotics
• Environmental factors such as restraints, stress, and pain

Treatment of Ativan (Lorazepam)-induced AMS

• Discontinue the use of lorazepam, as it can exacerbate delirium and worsen AMS 1
• Identify and treat the underlying cause of delirium, such as infection, metabolic derangement, or substance withdrawal
• Use nonpharmacological approaches to control symptoms, such as reorientation, relaxation techniques, and environmental modifications
• Medications may be used to control symptoms, but should be used with caution and under close monitoring, as they can worsen delirium

Evaluation and Management of AMS

• Use validated assessment scales, such as the Richmond Agitation Sedation Scale and Glasgow Coma Scale, to objectively quantify the severity of symptoms 1
• Coordinate care to direct interventions towards improving reversible causes and limiting factors that extend or cause delirium 1
• Limit the use of chemical and physical restraints to only those situations in which they are absolutely necessary, and instead use alternative safety measures to manage the agitated patient 1

From the Research

Causes of Altered Mental Status (AMS) in a 70-year-old Female

• AMS can be caused by various factors, including benzodiazepine overdose, as seen in a case where a 70-year-old woman was found unresponsive due to high doses of alprazolam and lorazepam 2
• Other potential causes of AMS in elderly individuals include epidural steroid injections, which can lead to mania and psychosis, as reported in a case of a 76-year-old female with no prior psychiatric history 3
• Catatonia is another rare neuropsychiatric condition that can cause AMS, characterized by mutism, negativism, rigidity, and stupor, and can be treated with high doses of lorazepam or electroconvulsive therapy 4
• Neuroleptic malignant syndrome (NMS) is a life-threatening condition that can cause AMS, and can be treated with electroconvulsive therapy, as seen in a case of a 52-year-old female with schizoaffective disorder bipolar type 5

Treatment of Ativan (Lorazepam)-Induced AMS

• Flumazenil, a benzodiazepine antagonist, can be used to reverse the effects of lorazepam overdose, as seen in the case of the 70-year-old woman who improved dramatically after receiving 0.25 mg of intravenous flumazenil 2
• High doses of lorazepam can be used to treat catatonia, as reported in the case of a 59-year-old patient with bipolar disorder who had a complete clinical remission after receiving high doses of lorazepam 4
• However, long-term use of lorazepam can have adverse effects on cognitive performance, especially memory, in elderly individuals, as reported in a study of 37 cognitively intact elderly individuals on long-term daily treatment with lorazepam 6