What can be given to calm a confused, agitated, and impulsive patient with a history of seizures, hypertension (HTN), transient ischemic attack (TIA), chronic obstructive pulmonary disease (COPD), and asthma, presenting with a rib fracture and rotator cuff tear?

From the Guidelines

For an elderly patient with fall injuries, confusion, and increasing agitation, I recommend starting with low-dose lorazepam 0.5-1mg orally or IV for acute management, as it is a more recent and higher quality recommendation compared to haloperidol 1. Alternatives include quetiapine 25-50mg orally, but benzodiazepines like lorazepam are preferred in this scenario due to their rapid onset of action. Before administering any medication, first try non-pharmacological approaches like:

• Reorientation
• Ensuring pain control
• Checking for infection or metabolic disturbances
• Maintaining a calm environment with familiar objects and people Given the patient's history of seizures, COPD, and asthma, use benzodiazepines cautiously as they may worsen respiratory status or lower seizure threshold 1. Antipsychotics carry risks including QT prolongation and increased stroke risk in elderly patients. Start with the lowest effective dose, monitor vital signs and mental status closely, and discontinue as soon as possible. The goal is to ensure patient safety while identifying and treating the underlying cause of agitation, which could be pain, hypoxia, infection, or medication side effects. It is also important to note that sedation should only be used with close monitoring, especially in patients with respiratory conditions like COPD and asthma 1.

From the FDA Drug Label

Lorazepam Oral Concentrate is a prescription medicine used: to treat anxiety disorders for the short-term relief of the symptoms of anxiety or anxiety that can happen with symptoms of depression Parenteral medication, administered intramuscularly in doses of 2 to 5 mg, is utilized for prompt control of the acutely agitated schizophrenic patient with moderately severe to very severe symptoms

Lorazepam or haloperidol may be considered to calm the patient down.

• Lorazepam is used for the short-term relief of anxiety symptoms, which may be beneficial in this case.
• Haloperidol is used for prompt control of the acutely agitated patient, which may also be applicable. However, it is crucial to consider the patient's medical history, including seizures, HTN, TIA, COPD, and asthma, before administering any medication. The patient's confusion and agitation should be carefully evaluated, and the chosen medication should be used with caution, as both lorazepam 2 and haloperidol 3 can have significant side effects.

From the Research

Patient Assessment

The patient has a complex medical history, including:

• Rib fracture and rotator cuff tear
• History of seizures
• Hypertension (HTN)
• Transient ischemic attack (TIA)
• Chronic obstructive pulmonary disease (COPD)
• Asthma
• Confusion and increasing agitation and impulsivity

Considerations for Calming the Patient

When considering medications to calm the patient, the following points should be taken into account:

• Benzodiazepines are commonly prescribed for anxiety and insomnia, but their use in patients with COPD is associated with increased risk of adverse respiratory events 4, 5, 6, 7, 8
• Opioids may also be used to relieve dyspnea, but their use in patients with COPD is also associated with increased risk of adverse respiratory events 6, 7, 8
• The patient's history of seizures is a concern when considering medications that may lower the seizure threshold

Potential Risks and Benefits

The potential risks and benefits of using benzodiazepines or opioids in this patient should be carefully weighed:

• Benzodiazepines may provide short-term relief from anxiety and agitation, but their use may be associated with increased risk of respiratory depression, exacerbations of COPD, and respiratory tract infections 4, 5
• Opioids may provide relief from dyspnea, but their use may be associated with increased risk of respiratory depression, especially when used in combination with benzodiazepines 6, 7, 8

Alternative Options

Alternative options for calming the patient should be considered, such as:

• Non-pharmacological interventions, such as reassurance, relaxation techniques, and environmental modifications
• Other medications, such as antipsychotics or anti-anxiety medications, that may be safer in patients with COPD and a history of seizures