What can be given to an 81-year-old patient, allergic to Ativan (lorazepam), who is agitated, consistently trying to get out of bed, and unable to relax?

From the Guidelines

For an 81-year-old patient who is confused and attempting to get out of bed, with a noted allergy to Ativan, I strongly recommend considering alternative medications such as haloperidol (Haldol) 0.5-1mg orally or intramuscularly, or quetiapine (Seroquel) 25mg orally, as suggested by the most recent and highest quality study 1. These medications can help manage agitation while avoiding the allergic reaction risk. Non-pharmacological approaches should be tried first, including:

• Reorientation techniques
• Ensuring a calm environment with adequate lighting
• Having familiar objects nearby
• Maintaining a consistent caregiver presence Physical restraints should be avoided if possible as they can increase agitation. It's essential to identify and address underlying causes of confusion such as:
• Pain
• Urinary retention
• Constipation
• Infection
• Medication side effects If the patient has dementia, consider whether this represents sundowning (increased confusion in late afternoon/evening). Ensure patient safety with bed alarms or a low bed position while respecting dignity, as recommended by 1. These approaches balance the need to keep the patient safe while treating the underlying causes of agitation and confusion. The use of haloperidol or quetiapine is supported by the guidelines for managing Alzheimer's disease 1, which suggests that antipsychotic drugs can be used to control problematic delusions, hallucinations, severe psychomotor agitation, and combativeness. However, the most recent study 1 provides more specific guidance on the management of delirium, which is a critical consideration in this patient's care. By following this approach, we can prioritize the patient's morbidity, mortality, and quality of life, while also ensuring their safety and dignity.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment Options for Agitation

• The patient is experiencing agitation and is unable to relax, and is allergic to Ativan.
• According to 2, a variety of psychotropic drugs and combinations can be used to treat agitation, including typical antipsychotics like haloperidol, benzodiazepines like lorazepam, and atypical antipsychotics like olanzapine and aripiprazole.
• The combination of haloperidol and promethazine may be a good option, as it combines the sedative properties of the antihistamine with the calming action of haloperidol, with a reduced risk of extrapyramidal effects 2.

Alternative Treatment Options

• Other studies have compared the effectiveness of different treatment options for agitation, including oral risperidone, olanzapine, and quetiapine versus haloperidol 3, and oral treatment with risperidone and lorazepam versus intramuscular treatment with haloperidol and lorazepam 4.
• These studies found that atypical antipsychotics like olanzapine, risperidone, and quetiapine are as effective as haloperidol and better tolerated, with fewer extrapyramidal symptoms 3, 4.
• Lorazepam has also been found to be effective in treating agitation, either alone or in combination with haloperidol, although it may have a higher risk of sedation and other adverse effects 5, 6.

Considerations for the Patient

• Given the patient's age (81 years) and allergy to Ativan, it may be necessary to consider alternative treatment options that are safer and more effective for this population.
• The patient's daughter is present and can provide support, which may be beneficial in reducing the patient's agitation and improving their overall well-being.