thank god for ativan...

[phillyfornia]

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or any other drug that helps sedate agitated patients.

does anyone know what docs used to do before these types of drugs came out? did they just tie patients up to their beds?

 

[sdn1977]

oh gosh - you dont' want to know!

haldol, diazepam (lasted a loooooong time), thioridazine, thorazine, stelazine - all sorts of not so nice stuff!

Years & years ago - we used nembutal, seconal suppos just to put them to sleep. Also used pheobarb - but, in the 50's mom's were given phenobarb syrup to rub on babies gums to decrease teething "fussiness" - funny, huh? Its actually in my older sister's baby book!

Then - there was & is always spirtus fermentii - a shot or two of something sometimes would quiet everyone down (you know - based on the dosing...the bottle went faster than predicted! Oh well - its tough being on all night!🙄).

 

[docB]

That's why they used to do lobotomies.

 

[spumoni620]

ativan seemed to be the wonder drug around here....so my intern and i decided to write for it when our pt was agitated/delirious overnight (of course, after ruling out treatable/reversible medical causes, etc. etc.) - and bad delirium, i mean singing and rocking the bed and climbing out and yelling. but it actually made her worse (my attending gave us flack for it the next day, stating that giving ativan is like making someone drunker and it should never have been prescribed). turns out risperdal was the way to go. who knew?

 

[GatorMedMan]

does anyone know what docs used to do before these types of drugs came out?

As opposed to just "treating" the nursing staff by giving a patient ativan, haldol, atypicals, etc., perhaps they treated the underlying cause.

 

[deleted87716]

does anyone know what docs used to do before these types of drugs came out? did they just tie patients up to their beds?

Straitjackets. And Thorazine.

 

[Trifling Jester]

oh gosh - you dont' want to know!

haldol, diazepam (lasted a loooooong time), thioridazine, thorazine, stelazine - all sorts of not so nice stuff!

I guess I must be a not so nice MD. I still use haldol...

-The Trifling Jester

 

[Faebinder]

Back then I am sure patient hand and foot restrains were given out like candy.

 

[Tired]

ativan seemed to be the wonder drug around here....so my intern and i decided to write for it when our pt was agitated/delirious overnight (of course, after ruling out treatable/reversible medical causes, etc. etc.) - and bad delirium, i mean singing and rocking the bed and climbing out and yelling. but it actually made her worse (my attending gave us flack for it the next day, stating that giving ativan is like making someone drunker and it should never have been prescribed). turns out risperdal was the way to go. who knew?

You just didn't give enough. Paradoxical agitation from benzos is uncommon, and to imply that it is an expected outcome is just stupid.

And there's nothing to indicate that risperidone is any better than haldol, just a lot more expensive.

 

[phillyfornia]

As opposed to just "treating" the nursing staff by giving a patient ativan, haldol, atypicals, etc., perhaps they treated the underlying cause.

how cute. what year in school are you?

 

[GatorMedMan]

how cute. what year in school are you?

I stayed at a holiday inn express last night.

 

[swpm]

or any other drug that helps sedate agitated patients.

Vecuronium?

 

[Mman]

You just didn't give enough. Paradoxical agitation from benzos is uncommon, and to imply that it is an expected outcome is just stupid.

And there's nothing to indicate that risperidone is any better than haldol, just a lot more expensive.

giving benzos to elderly people that are delirious is a good way to get them more delirious. I wouldn't just give more of it to fix the problem.

 

[spumoni620]

You just didn't give enough. Paradoxical agitation from benzos is uncommon, and to imply that it is an expected outcome is just stupid.

And there's nothing to indicate that risperidone is any better than haldol, just a lot more expensive.

Actually, she was a tiny thing, and got 3 x 2 mg doses of Ativan overnight....still didn't work, and neither my intern or I were comfortable giving any more.

Between haldol and risperdone, my attending preferred risperdone - less side effects in the younger population, more "PC" according to him, whatever that means. It worked pretty well (a lot better than the benzo...).

 

[NotAProgDirector]

Of course, there is that pesky problem of antipsychotics causing death in elderly patients. Kinda makes you want to try the benzo's again, doesn't it?

 

[spumoni620]

Of course, there is that pesky problem of antipsychotics causing death in elderly patients. Kinda makes you want to try the benzo's again, doesn't it?

it would if she were an elderly pt....this pt was a teenager.

(Btw - thanks for the article - I know I'll be quoting that on rounds one day given how many delirious elderly pts it seems are summarily zonked with ativan 🙂

 

[Puffle]

You just didn't give enough. Paradoxical agitation from benzos is uncommon, and to imply that it is an expected outcome is just stupid.

Ehh, not so fast. Benzos are well known for causing disinhibition in the elderly.

 

[BADMD]

giving benzos to elderly people that are delirious is a good way to get them more delirious. I wouldn't just give more of it to fix the problem.

Benzos = "clean" ie - they only hit one receptor.

Other drugs = multiple receptors with some unpredictability in effect
Atypical antipsychotics = all the receptors...and will worsen delirium too.

There isn't a perfect drug. The benzo are targeted and have a high therapeutic index. Thus they are my drugs of choice in the undifferentiate delirium. I might be talked into a smidge of haloperidol, but it isn't going to be the main sedative.

 

[Hurricane]

Benzos = "clean" ie - they only hit one receptor.

Other drugs = multiple receptors with some unpredictability in effect
Atypical antipsychotics = all the receptors...and will worsen delirium too.

There isn't a perfect drug. The benzo are targeted and have a high therapeutic index. Thus they are my drugs of choice in the undifferentiate delirium. I might be talked into a smidge of haloperidol, but it isn't going to be the main sedative.

So what if benzos hit only one receptor? It's the wrong receptor for delirium. High potency antipsychotics (haldol) + the avoidance of benzos and anticholinergics are the standard of care for delirium.

 

[Aubrey]

Do folks still use Seroquel for sundowning elderly patients? That used to be big around here.

 

[BADMD]

High potency antipsychotics (haldol) + the avoidance of benzos and anticholinergics are the standard of care for delirium.

I'd be really careful throwing around the words "standard of care." The management of acute delirium in the eldery isn't quite as cut and dry as you are making it out to be.

If you rely on haloperidol, you are going to give half your patients EPS symptoms which need treatment with...? Not to mention that you are going to prolong the QT is a population that is on multiple medications that cause QT prolongation. Throw in some electrolyte abnormalities and this only gets worse. Toss in haloperidol's tendancy to reduce the seizure threshold and there is more to be concerned about. Finally, haloperidol is known to cause, what else, delirium in the elderly.

Basically, you don't want to use anything. Lots of drugs have been tried because they all have significant problems.

 

[Puffle]

Benzos, antipsychotics, fairydust, what have you.... the treatment for delerium to fix the underlying cause. On my last geriatric psych rotation, my attending often joked that his favorite antipsychotic in the elderly was Bactrim.

And BADMD, you're right, a lot of the time you don't need to use anything. I've gotten into my share of micturition contests with nursing staff over orders like, "Watch patient constantly, don't let them hurt themselves, and try to keep them happy."

 

[Tired]

Ehh, not so fast. Benzos are well known for causing disinhibition in the elderly.

Yeah, in the same way that metformin is "well known" for causing lactic acidosis.

Just because a lot of people know about a rare side effect, it doesn't mean it happens all that often.

 

[Puffle]

Yeah, in the same way that metformin is "well known" for causing lactic acidosis.

Just because a lot of people know about a rare side effect, it doesn't mean it happens all that often.

Seems I need to clarify... Disinhibition isn't rare, look it up. And from my residency experience, I get paged from a nursing home, or a rehab unit, or the wards just about every weekend I'm on-call for a patient that responded poorly to a benzo which was given alone for agitation. It works through GABA, much like EtOH; another substance "well known" for causing disinhibition.

Often, it often just goes unrecognized, and a physician mistakenly believes that they simply didn't give enough in the first place. Remember, "you can't diagnosis it if you don't think of it; let alone treat it."

 

[cchoukal]

Vecuronium?

works every time. Makes the affect a little flat, though..

 

[carrigallen]

Whoever wrote about bactrim treating delirium hit the nail on the head. I don't know how many residents have ordered stat CT heads on patients with dirty U/As, or called in neuro consults for the same.
And IMHO, ativan/benadryl/ambien are basically contraindicated in any patients over 80. They are a good example where treatment is worse than the disease.

 

[fang]

Benzos, antipsychotics, fairydust, what have you.... the treatment for delerium to fix the underlying cause. On my last geriatric psych rotation, my attending often joked that his favorite antipsychotic in the elderly was Bactrim.

And BADMD, you're right, a lot of the time you don't need to use anything. I've gotten into my share of micturition contests with nursing staff over orders like, "Watch patient constantly, don't let them hurt themselves, and try to keep them happy."

Dude, the underlying cause seems to be (>85 y/o) + (being in the hospital) + (2:00 AM) = delerium. How do you treat that? Also, perhaps we ARE treating the infection, hyponatremia, etc, but how does that help you when it's 2:30 and you're admitting 3 patients at one but getting paged every 30 minutes because Ms. L is screaming and trying to climb out of bed? Nurses can't be there every moment, and sitters are for the most part useless. Any data about which antipsychotic is best?