From the Guidelines
Yes, you can give this 88-year-old male patient medication to help with his restlessness, confusion, and agitation. Since he can take oral medications, consider starting with oral haloperidol (Haldol) 0.5-1 mg orally at night and every 2 hours when required, as recommended by the most recent guideline 1. Alternatively, oral lorazepam (Ativan) 0.5-1 mg every 4-6 hours as needed could be used, given his previous response to IV Ativan. Before administering any medication, assess for underlying causes of his agitation such as pain from rib fractures, urinary retention, constipation, or delirium. Start with the lowest effective dose to minimize side effects like excessive sedation or falls, which are particularly concerning given his recent fall history. Monitor vital signs, mental status, and respiratory function after administration. If oral medications are ineffective, you may need to consider returning to parenteral options. The goal is to provide comfort while maintaining safety and addressing the underlying cause of his agitation, as suggested by the guideline 1. Some key points to consider when managing agitation in this patient include:
- Using the lowest effective dose of medication to minimize side effects
- Monitoring for underlying causes of agitation, such as pain or delirium
- Considering non-benzodiazepine options, such as trazodone, for sleep disturbances
- Prioritizing the patient's safety and comfort above all else, as recommended by the guideline 1.
From the FDA Drug Label
For elderly or debilitated patients, an initial dosage of 1 mg/day to 2 mg/day in divided doses is recommended, to be adjusted as needed and tolerated For anxiety, most patients require an initial dose of 2 mg/day to 3 mg/day given twice daily or three times daily. For insomnia due to anxiety or transient situational stress, a single daily dose of 2 mg to 4 mg may be given, usually at bedtime.
The patient is an 88-year-old male who is restless, confused, and agitated. Given his age and condition, an initial dose of 1 mg to 2 mg of lorazepam orally may be considered, as per the recommended dosage for elderly or debilitated patients 2. However, it is crucial to start with a low dose and monitor the patient's response closely, as benzodiazepines can lead to respiratory depression and other adverse effects, especially in elderly patients 2.
- Key considerations:
- Dose: 1 mg to 2 mg orally
- Frequency: As needed, but cautiously
- Monitoring: Close observation for adverse effects and response to treatment
- Important warnings:
- Respiratory depression
- Dependence and withdrawal reactions
- Concomitant use with other CNS depressants 2
From the Research
Patient Assessment
The patient is an 88-year-old male who is restless, confused, and agitated. He was admitted for falling at home with rib fractures. Yesterday, he was given Ativan IV to manage his agitation.
Treatment Options
- Lorazepam is a benzodiazepine that can be used to manage acute agitation, as shown in a systematic review of 11 studies 3.
- The use of lorazepam has been found to be effective in improving outcomes related to agitation, although it may have some adverse effects such as dizziness, sedation, and somnolence 3.
- Another study found that lorazepam may be an alternative to antipsychotic drugs for controlling agitation without compromising spontaneous recovery in patients with traumatic brain injury 4.
Pain Management
- The patient has multiple rib fractures, which can be associated with a high risk of morbidity and mortality.
- Regional analgesia (RA) techniques, such as thoracic epidural or paravertebral catheter, have been found to be effective in reducing the risk of delirium in older adults with multiple rib fractures 5, 6.
- A multicenter study found that RA use was associated with a 35% lower risk of delirium in older adults with multiple rib fractures 6.
Considerations
- The patient is able to take oral medications, which may be an option for managing his agitation and pain.
- However, the use of opioids for pain management may increase the risk of delirium in older adults, and RA techniques may be a safer alternative 5, 6.
- A multidisciplinary approach, including allied health, nursing, medical, and surgical intervention, may be effective in improving patient outcomes 7.