Hot off the presses for
@RustedFox
Clinical question: The nurse comes to you about the elderly nursing home resident who's awaiting admission for a hip fracture. She's getting agitated, can we give her some ativan?
Answer: PLEASE DON'T
In residency I was taught that ativan is a very safe drug. Used alone it is hemodynamically stable and doesn't cause respiratory depression. Conversely, opioids kill people and you can only give little old ladies baby doses or else you'll totally zonk them out. THIS IS BACKWARDS. But, in the ED we don't see why. We see opioid OD's all the time, but fail to appreciate that none of those were people in acute pain who got weight-based morphine in a monitored setting. Contrariwise, when we give a dose or two of ativan in the ED, the nurse stops bothering us, and the patient goes upstairs - works for me!
What we don't see is that the elderly patient we gave ativan to often goes on to be in hypoactive delirium for 3 days, and then goes into agitated delirium until their pain gets adequately addressed.
Clinical pearl:
Untreated pain is a leading cause of agitation and delirium in the elderly AND doses of 0.05-0.1mg/kg of IV morphine are well tolerated in elderly folks with OK to not-so-great renal function who are in acute pain. In the above-linked article the authors found ZERO increase in delirium (OR = 1.00) in patients who received opioids (but no benzos) while significant increases in delirium were observed in those who got benzos or benzos + opioids.
In summary: Benzodiazepines are a terrible analgesic. Do your hospitalists a favor - if you have an agitated elderly patient in the ED, make sure to treat pain before reaching for the benzos. By avoiding delirium you might shave a couple days off of their LoS, which may even decrease your ED boarding.