From the Guidelines
For acute sedation in the elderly, lorazepam is generally preferred over haloperidol, starting with a low dose of 0.25-0.5 mg orally or intravenously, as it has a more favorable safety profile and is less likely to cause extrapyramidal symptoms, QT prolongation, and anticholinergic effects 1. This recommendation is based on the most recent and highest quality study available, which suggests that benzodiazepines, such as lorazepam, are the treatment of choice for acute sedation in the elderly, due to their anxiolytic and sedative effects with a moderate onset of action and intermediate duration 1. Some key points to consider when using lorazepam in the elderly include:
- Starting with a low dose and titrating gradually to minimize the risk of adverse effects, such as respiratory depression and paradoxical reactions 1
- Monitoring closely for adverse effects, including falls and cognitive impairment 1
- Considering non-pharmacological approaches, such as reorientation and maintaining day-night cycles, alongside medication when possible 1 In contrast, haloperidol, an antipsychotic, should be reserved for patients with delirium or psychosis, starting at 0.25-0.5 mg orally or intramuscularly, due to its higher risk of extrapyramidal symptoms, QT prolongation, and anticholinergic effects 1. It is essential to note that elderly patients are more sensitive to medication effects and have altered pharmacokinetics, so the "start low, go slow" approach is crucial when using either lorazepam or haloperidol 1.
From the Research
Acute Sedation in Elderly Patients
Comparison of Lorazepam and Haloperidol
- The choice of sedative for elderly patients should be based on their medical condition, comorbidities, and potential adverse effects 2, 3.
- Lorazepam is a commonly used benzodiazepine for sedation in elderly patients, particularly for agitation, anxiety, and dyspnea 4.
- Haloperidol is an antipsychotic that can be used for sedation, but its use should be cautious due to the risk of adverse effects, especially in elderly patients with comorbidities 3.
- Elderly patients require lower doses of sedatives due to their increased sensitivity and slower metabolism 2, 5.
- The administration of sedatives should be done by trained personnel with close monitoring of vital signs and level of consciousness to prevent complications such as respiratory depression 2, 6.
Safety Considerations
- Procedural sedation analgesia (PSA) is generally safe in older adults, but undertreating pain or inadequately sedating a stable patient is not acceptable 2.
- Elderly patients are at higher risk for oxygen desaturation, but they usually respond quickly to supplemental oxygen 2.
- The use of sedatives in elderly patients requires careful consideration of their age-related changes in physiology and pharmacokinetics 2, 5.
- Quality pre-oxygenation, careful dosing, and a robust training and governance framework are essential for safe sedation practice in elderly patients 6.