Geriatric Quick Consult       Delirium       Do #7

Think twice before using neuroleptics and sedatives

Knowledge Action
Before you sedate an agitated patient, go through the prior 6 steps in evaluating delirium.

If you don't have the time or experience to do this properly, ask for help.

Hospital routines do not allow for patients with disruptive behaviors like yelling, hitting staff, or pulling out various medical tubes.

Such behavior can interfere with the patient's medical care (IV lines, nutrition).

It can affect the staff or other patients on the unit.

Physicians are often asked to give medications to reduce or control disruptive behaviors.

Sedation, though sometimes necessary, often starts a cascade of events that leads to disaster.

Think twice before using neuroleptics and sedatives!

  • Before sedating an agitated patient, evaluate for delirium and if you need help doing this correctly, please ask!
Assuming that you have been through the evaluation and see no alternative, there are preferred approaches to drug treatments.

Unfortunately, most drugs used for this purpose will cause some undesired effects.

  • Use drugs that cause as few side effects as possible.

Anti-psychotic drugs are useful for hallucinations or violent agitation.

Haldol (haloperidol) is a potent neuroleptic (anti-psychotic) with few anti-cholinergic properties.

It is useful for acute agitation because it is potent, rapid acting, and injectable.

However, it makes patients less interactive and produces Parkinsonian motor effects.

In older patients we recommend starting with a low dose (0.25 or 0.5 mg) given twice daily.

We have seen orders for truly enormous doses (5 or 10 mg) of IV haloperidol "prn" in older patients. This sort of dosage is rarely if ever needed.

Some older patients ultimately require a little more Haldol, if we have to use this agent, but we usually give 1 or at most 2 mg. per dose.
  • If you use Haldol for agitation, start with a low dose ( 0.5 MG. BID).

  • Rarely or never order more than 2 mg. of Haldol (total) in 24 hours for an elderly patient.
Preferred are newer anti-psychotic drugs like risperidone (Risperdal), olanzapine (Zyprexa), or quetiapine (Seroquel).

They cause fewer Parkinsonian effects.

Recommended doses are low (0.5 mg BID for risperidone, 25 mg. for olanzapine, 2.5 mg. for quetiapine).
  • Preferably, try an alternative anti-psychotic like risperidone, olanzapine, or quetiapine.
Benzodiapezepines may be useful in selected situations, when patients appear anxious, but less often when signs suggest hallucinations, or for acute agitation.

Again, choosing the right drug, the right situation, and the right dose are key.

Long-acting agents like Valium (diazepam) should rarely be used.

Ativan (lorazepam) can be effective in low doses (0.5 - 1 mg.) and for short-term use.

Its effect lasts 8-12 hours in older patients.

  • Try Ativan if patients seem anxious but not hallucinating.
Benadryl is unfortunately used far too often in older patients, both for sleep and for agitation.

It is highly anti-cholinergic, has many side effects and should not be used in these situations.
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