From the Research
For catatonia in patients 65 years and older, lorazepam (Ativan) is the preferred benzodiazepine for intramuscular administration, typically starting at 1 mg IM every 4-6 hours as needed, as it has been shown to be effective in treating catatonia with a rapid onset of action 1. In elderly patients, it's prudent to start at the lower end of the dosing range and titrate up cautiously based on response and tolerability. The onset of action is relatively quick, within 15-30 minutes after IM administration. Treatment should continue until catatonic symptoms resolve, typically requiring 24-72 hours of regular dosing, after which a gradual taper can be considered. Some key points to consider when treating catatonia in the elderly include:
- Close monitoring for respiratory depression, excessive sedation, and paradoxical reactions is essential in this age group.
- Benzodiazepines work in catatonia by enhancing GABA neurotransmission, which helps reduce the abnormal glutamatergic activity thought to underlie catatonic symptoms.
- If there is inadequate response after 48 hours of benzodiazepine treatment, electroconvulsive therapy should be considered as the next intervention, as suggested by 2.
- Vital signs and mental status should be monitored regularly during treatment. It's also important to note that chronic tolerance requiring higher doses was present in some patients, as reported in 3, and that some patients may need to continue benzodiazepines indefinitely for maintenance treatment of catatonia. However, the most recent and highest quality study 1 supports the use of lorazepam as the preferred benzodiazepine for treating catatonia, and its effectiveness has been consistently demonstrated across various studies, including 4.