What is the best sedation option for an 80-year-old patient with dementia, delirium, and severe agitation, who has received oral Haldol (haloperidol) 2 mg six times and Lorazepam (lorazepam) 0.5 mg three times in the last 24 hours, with only 1 hour of sleep and persistent distress?

From the Guidelines

For an 80-year-old patient with dementia who remains severely agitated and delirious despite multiple doses of haloperidol and lorazepam, I would recommend a trial of low-dose quetiapine, starting at 25mg orally, with the option to repeat in 4-6 hours if needed, as suggested by the most recent guidelines 1. This approach is based on the patient's severe agitation and delirium, which have not responded to initial treatments. The use of quetiapine is supported by its potential benefits in managing delirium symptoms with a lower risk of extrapyramidal side effects compared to first-generation antipsychotics 1.

Key Considerations:

• The patient's severe sleep deprivation likely exacerbates her delirium, making sedation a critical component of her management plan to break this cycle.
• Simultaneously addressing underlying causes of delirium, such as pain, urinary retention, constipation, or infection, is essential.
• Non-pharmacological approaches, including reorientation techniques, ensuring adequate lighting, maintaining day-night cycles, and having familiar objects or family members present, should be implemented.
• Close monitoring for respiratory depression, hypotension, and paradoxical reactions is necessary with any sedative medication in elderly patients, with dose adjustments made accordingly 1.

Alternative Options:

• A dexmedetomidine infusion at 0.2-0.7 mcg/kg/hr could be considered if the patient is in a monitored setting, given its sedative properties without significant respiratory depression.
• Benzodiazepines like midazolam or lorazepam may be used as crisis interventions for severe agitation but with caution due to their potential to worsen delirium and increase the risk of falls 1.

Guiding Principles:

• The use of pharmacological interventions should be limited to patients with distressing delirium symptoms or safety concerns, and medications should be used in the lowest effective dose for the shortest period possible 1.
• Regular assessment and adjustment of the treatment plan are crucial to balance benefits and potential harms.

From the FDA Drug Label

Administration of theophylline or aminophylline may reduce the sedative effects of benzodiazepines, including lorazepam. Geriatric Use Clinical studies of lorazepam generally were not adequate to determine whether subjects aged 65 and over respond differently than younger subjects; however, the incidence of sedation and unsteadiness was observed to increase with age In general, dose selection for an elderly patient should be cautious, and lower doses may be sufficient in these patients DOSAGE AND ADMINISTRATION There is considerable variation from patient to patient in the amount of medication required for treatment. As with all antipsychotic drugs, dosage should be individualized according to the needs and response of each patient. Geriatric or Debilitated Patients - 0.5 mg to 2 mg b.i.d. or t.i.d.

The patient has already received high doses of haloperidol (2 mg 6 times in the last 24 hours) and lorazepam (3 doses of 0.5 mg). Considering the patient's age (80 years) and condition (dementia, delirious, and agitated), the best sedation option would be to avoid additional doses of lorazepam due to the risk of increased sedation and unsteadiness in the elderly. For haloperidol, the patient is already receiving a high dose, and increasing it further may not be necessary. The focus should be on monitoring the patient's response and adjusting the dosage as needed to achieve optimal therapeutic control while minimizing the risk of adverse effects. Non-pharmacological interventions should also be considered to help manage the patient's agitation and delirium. 2 2 3

From the Research

Sedation Options for Agitated Delirium

The patient's condition of agitated delirium, despite receiving oral Haldol and lorazepam, requires careful consideration of the best sedation options.

• The patient has already received multiple doses of oral Haldol (2 mg, 6 times in the last 24 hours) and lorazepam (0.5 mg, 3 doses), yet remains agitated and delirious 4, 5.
• The use of benzodiazepines, such as lorazepam, in combination with antipsychotics, like Haldol, may be beneficial in managing agitation in delirium, as evidenced by a study that showed a significant reduction in agitation with the addition of lorazepam to haloperidol 5.
• However, it is essential to consider the potential risks and benefits of continued benzodiazepine use, particularly in elderly patients with dementia, as they may be more susceptible to adverse effects 6, 7.
• Alternative sedation options, such as ketamine, may be considered, as they have been recommended for the treatment of hyperactive delirium with severe agitation 4.
• Non-pharmacologic interventions, such as promoting good sleep hygiene, early mobilization, and minimizing unnecessary noise and stimuli, may also be beneficial in reducing agitation and delirium 6, 8.

Considerations for Sedation

When selecting a sedation option, it is crucial to consider the patient's underlying medical condition, potential interactions with other medications, and the risk of adverse effects.

• The patient's sleep deprivation (only 1 hour of sleep in the last 24 hours) may be contributing to their agitation and delirium, and addressing this issue may be essential in managing their condition 6, 8.
• The use of antipsychotics, such as Haldol, may be effective in managing agitation, but their use should be carefully monitored due to the risk of adverse effects, particularly in elderly patients with dementia 6, 7.
• The patient's condition should be continuously assessed, and the sedation plan adjusted as needed to ensure their safety and comfort 4, 5.