Agitation: Ativan Is Not the Answer—Is it Delirium?

So what is agitation? The answer to that question can vary greatly. It depends on the observer, and the observer’s frame reference.

It could be a person, sitting in the comfort of his own living room, asking again and again to “go home.” Or, it might be endlessly asking, “When is dinner?” Sometimes agitation wears the cloak of paranoia. An elder may become convinced that her spouse is a robber holding her hostage or poisoning her food. She may become convinced that she needs to escape.

These thoughts may lead to aggression or combative behavior. These delusions may result in fear so extreme that the elder refuses to eat or to bathe. The elder may become furious at small, unimportant incidents. He may walk nonstop. He may become impossible to console.

Some of these behaviors may sound extreme, but they are very, very common. Approximately 50 to 70 percent of elders with dementia experience agitation.

But delirium is different. To an inexperienced eye, it may seem like agitation, but it’s not. Being able to tell the difference between agitation and delirium can be a matter of life and death.

Agitation often can be difficult, but delirium can be deadly. Delirium can signal serious illness. Delirium has a 22- to 76-percent mortality rate. Very often in elders, delirium signals a bladder infection. However, it can result from many other problems: constipation, dehydration, new medications, heart attack, stroke, head injury, and many other problems. In addition, stopping alcohol or benzodiazepine tranquilizers—“Benzos,”  Xanax/Alprazolam, Ativan/Lorazepam, Klonopin/Clonazepam—abruptly may lead to a delirium.

Here are some ways to differentiate agitation and delirium:

• Agitation often is cyclical or situational. Delirium comes on suddenly. Its symptoms are usually not situational.

• Certain stressors or events often trigger agitation. Delirium fluctuates; its course is unpredictable.

• Agitated elders usually exhibit their normal level of attention and cognition. Elders who are delirious often exhibit an altered level of consciousness. They may be inattentive.

Delirium requires immediate medical care.

A work-up should check for all the medical conditions listed above, including risk of infection (bladder infection or pneumonia), kidney or liver abnormalities, worsening chronic illness such as emphysema, renal failure and hypertension. Don’t forget possible dental abscesses. Urinary retention may result from constipation, new anticholinergic medications

Delirium requires immediate medical care.  A work up should look at the possibility of injury, new altered level of consciousness may be from a head injury.  Evaluation of infection (bladder infection and pneumonia most common), falls or fractures, kidney and liver abnormalities, new medications, worsening chronic illness such as emphysema, renal failure, hypertension.  Do not forget possible dental abscesses, or urinary retention resulting from constipation, new anticholinergic medications, sleeping pills or prostate obstruction.

I have found that treating delirium with tranquilizers, “Benzos,” is not helpful, unless there is an immediate need to calm a patient to get a test or a procedure completed.

This area of medicine is controversial, but some practitioners have suggested that antipsychotic drugs—Haldol, Risperdal and Serquel—can be helpful in cases of delirium, once the underlying causes of the delirium have been addressed.

Elizabeth Landsverk MD                                                                                                                                                                                                                                                     elandsverk@elderconsult.com

Elizabeth Landsverk MD

Geriatrician, House calls doctor for Marin, Burlingame, San Francisco, San Jose, Walnut Creek

On call 24/7, working to avoid trips to the ER

Working to reduce medications, and improve enjoyment of every day