Oral drug regimens for acute behavioural disturbance in older people

Managing a patient with acute behavioural disturbance is a detailed flowchart for managing a patient with acute behavioural disturbance.

The indications for oral sedation for acute behavioural disturbance in older people are detailed here.

Behavioural disturbance in older people is most often associated with delirium or behavioural and psychological symptoms of dementia (BPSD), for which drug therapy is rarely required to manage symptoms. Clinicians who manage acute behavioural disturbance in older people require adequate training in the diagnosis and management of delirium and BPSD, and in nonpharmacological management of acute behavioural disturbance. Only use the drug recommendations for sedation in this topic if the acute behavioural disturbance is severe and there is an imminent risk of harm to the patient or others, and the required expertise and equipment is available.

The aim of pharmacological management is to calm the patient with a sufficient initial dose of a sedative drug. Repeated subtherapeutic doses that are inadequate to reduce the patient’s distress and calm their behaviour can prolong the risk of harm to the patient or others. This can also result in larger cumulative doses, or multiple drug administration, both of which increase the risk of adverse drug effects, especially in older people. If oral sedation is administered, monitor the patient closely for adverse effects of drugs, including increased risk of falls; see Principles of monitoring a patient with acute behavioural disturbance.

When selecting a dose and regimen of a sedative drug for an older person, consider patient factors, such as their level of agitation and distress (eg measured with a Sedation Assessment Tool [SAT] score), age, body size,  sex, comorbidities, drug history, previous response to sedative drugs and response to treatment. In older people with cognitive impairment or communication difficulties, consider the SAT score in the context of the patient’s baseline function and communication style (eg loud outbursts may be usual for individuals with dementia).

The most common drugs used in older people to manage acute behavioural disturbance are benzodiazepines and antipsychotics, which are used for their sedative effects. The sedative effects of antipsychotics occur much sooner than the antipsychotic effects. Although oral antipsychotics (eg haloperidol, olanzapine, risperidone) are sometimes used for delirium, and BPSD, oral benzodiazepines are preferred to oral antipsychotics to manage acute behavioural disturbance in older people. This is because relatively higher doses of oral antipsychotics than oral benzodiazepines are required to achieve sedation, and serious adverse effects are more likely to occur in an older person (eg hypotension, QT-interval prolongation).

For an older person, lower doses of benzodiazepines are recommended than for other adults; when a dose range is given in the drug recommendations below, it is advisable that clinicians consider choosing a dose at the lower end of the range initially. The pharmacodynamic response to benzodiazepines can be variable in older people. Suitable oral benzodiazepines for older patients are lorazepam or diazepam. Lorazepam may be safer than diazepam for older people, who often have medical comorbidities such as kidney or liver impairment, because lorazepam does not have active metabolites. Diazepam has active metabolites, which prolong its duration of action after a single dose. Clonazepam is generally not recommended for older people because of its very long half-life.

If oral sedation is indicatedfor an older adult with undifferentiated acute behavioural disturbance, in combination with nonpharmacological techniques, use:

Repeating the SAT score can be useful to determine whether sedation has been effective or if a repeat dose is needed. Individualise the target SAT score based on patient factors (eg response to nonpharmacological interventions, whether the patient needs to be sedated for investigations) and the ability to maintain patient and staff safety.

Always monitor the patient closely for potential adverse effects after administering a sedative drug for acute behavioural disturbance (especially in drug-naive patients). Older people who have been administered sedation are at increased risk of falls and require continuous clinical observation.