Sedation In The Elderly Guidelines

[Kay Hamling]

Thisguideline does not cover the management of acutely disturbed young people or adolescents (contact your local adolescent psychiatry liaison team for advice). For management of alcohol withdrawal, see guideline here.

Delirium is characterised by an acute and fluctuating change in alertness and cognition, usually with evidence of an underlying trigger. If the patient is more confused or drowsy than normal, "THINK DELIRIUM".

Delirium is a clinical syndrome indicative of 'brain failure' and is a medical emergency. It is essential that a thorough assessment is carried out to look for all potential causes of delirium and that these are treated as a matter of urgency. The 4AT tool and TIME checklist can be used to aid the diagnosis and management of delirium. These are found on purple paper on all wards. Detailed guidance is contained in the Delirium Diagnosis, Risk Reduction, and Management in Acute Services guideline.

Delirium may be a symptom at presentation and/or during the management of COVID-19. It may make management, including delivery of care and prevention of cross-infection, more challenging. For information see the Resources section on the British Geriatric Society website for 'Coronavirus: managing delirium in confirmed and suspect cases' guidance.

This should only be used when non-pharmacological management is unsuccessful and symptoms are causing significant distress to the patient, or symptoms threaten the safety of the patient or others (including their ability to accept necessary medical or nursing care).

Outwith the emergency situation it is very important that the patient, or more usually the Power of Attorney or next of kin, is made aware of the potential risks described above and agrees that the treatment is of benefit to the patient, is the least restrictive option and the benefit outweighs the risk. This discussion should be recorded as part of the treatment plan attached to the Section 47 form.

Before prescribing read all the information above and below for cautions, contraindications and dose administration advice (take into account frailty when considering total daily dose). Ensure patients are closely monitored following administration of sedative medication. Emergency sedation should always be discussed with a registrar or consultant.

Prior to treatment (or as soon as possible afterwards if the patient is too agitated) record an ECG to check QT interval. Ensure modifiable risk factors for QTc prolongation are minimised e.g. electrolyte abnormalities (hypokalaemia, hypomagnesaemia, hypocalcaemia) and discontinue other drugs known to prolong QTc if possible. A list of drugs that can prolong QT interval can be found at Further information can also be found in the Medicines Update Extra (MUE 08) drug induced prolongation article available at www.ggcmedicines.org.uk.

Start with the lowest clinically appropriate dose and titrate according to symptoms. Use the lower dose range in frail or elderly patients. Always use oral medication wherever possible and wait a minimum of 1 hour before repeat dosing.

If haloperidol is contraindicated because the patient is already on drugs that can prolong the QT interval which cannot be stopped, consider risperidone but be aware that caution is still required and an ECG should be recorded and monitored during treatment.

If antipsychotic medication is contraindicated e.g. in Parkinson's disease, MSA, PSP or Lewy body dementia, consider benzodiazepines and contact the local movement disorder team as soon as possible for further advice. Use with caution in patients with respiratory impairment and be aware that benzodiazepines can have a paradoxical effect in delirium. If the patient does not improve or the disturbed behaviour gets worse, discuss with a senior or seek specialist advice before giving any further doses.

After administration of sedative medication, monitor observations and conscious level and check for side effects. If there is any deterioration seek senior help immediately. Once the acute situation has been stabilised, perform a thorough clinical assessment to ensure all potential underlying causes of delirium and acutely disturbed behaviour have been addressed. Ensure you handover to the patient's regular team if sedation is prescribed out of hours to ensure early review and follow-up.

The above is a guide to initial management. If these measures do not result in an improvement in the disturbed behaviour, speak to senior medical staff to discuss alternatives. Other drug options are available and specialist advice from psychiatry may be required.

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As the number of elderly patients undergoing surgery continues to rise, it is important to consider anaesthetic options that minimize physiological stress in these patients. Monitored anaesthesia care (MAC), or sedation and monitoring during surgery, is an attractive option for certain common procedures. However, those administering MAC must consider the normal decline in functional reserve in patients aged >70 years. This includes loss of normal compensation for the stress of hypovolaemia, decreased peripheral vascular resistance, altered mental status and reduced response to hypoxia and hypercarbia associated with the perioperative and sedated state in this population. In addition, vigilance is necessary to identify co-morbid states, which increase in incidence with age and often present atypically. Elderly patients have increased sensitivity to all sedatives and opioids (doubled by age 80 years, quadrupled by age 90 years with benzodiazepines). As a result of changes in body composition, as well as senescence of renal and hepatic function, the time to onset and offset of even short-acting sedatives will be prolonged. There is also extreme variability in the response to sedatives among these patients. Anaesthetic dosing should be in smaller increments in the elderly, boluses reduced by half and infusions reduced by as much as two-thirds. Caution must be exercised through full monitoring of intra-operative and postoperative mental status, oxygenation and perfusion states. Pain is best treated using smaller doses in a multimodal regimen, the aim being to reduce adverse effects while ensuring adequate pain relief. In this way, a huge range of procedures can be safely performed in our aging population with expectations for a full and early return to baseline functional status.

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Intravenous sedation is used as a behavior modification technique during the dental treatment of patients with severe dementia who offer resistance or refuse to undergo dental treatment. Midazolam (MID), dexmedetomidine (DEX) and propofol are often used for intravenous sedation during dental treatment1. MID is classified as a benzodiazepine sedative and, like the other benzodiazepines, is a gamma-aminobutyric acid (GABA) receptor agonist that is thought to induce cognitive impairment, such as postoperative delirium (POD)2,3,4. Propofol, another GABA receptor agonist, is thought to exert similar effects2,3,4. On the other hand, unlike GABA receptor agonists, such as propofol and benzodiazepine sedatives, DEX acts on central α2-adrenergic receptors. Sedation with DEX has a minimal effect on respiratory rate and percutaneous arterial oxygen saturation (SpO2), and is known for the associated fast recovery from sedation with physical stimulation if needed5,6,7,8,9. It might be an appropriate sedative for elderly patients with dementia since it is less likely to inhibit the gag reflex, and animal studies have shown that it has cerebral protective effects, such as maintenance of cerebral blood flow (CBF) during hypoxia and focal cerebral ischemia, and causes reduction of brain cell damage5,6,7,8,9.

Cognitive impairments that develop after surgery are classified as POD and postoperative cognitive dysfunction (POCD). Many studies have found that preoperative cognitive decline, in particular, has an effect on the onset of POD and POCD2,3,4. One of the factors that might trigger POD and POCD is surgery-induced inflammation that spreads to the central nervous system2,3,4. DEX has an anti-inflammatory effect, and studies have shown that it has a low incidence rate of POD and POCD after cardiac and non-cardiac surgeries5,6,7,8,9.

It is generally believed that maintaining neuronal activity (brain waves and CBF) under anesthesia is important for maintaining perioperative cognitive function2,3,4. During intravenous sedation with midazolam in elderly patients with severe dementia, dose titration to a lower than the usual dose is needed, and respiratory complications (apnea) have occasionally been reported in this population. These conditions are different from those with other sedatives, such as propofol and dexmedetomidine10. In our previous prospective study, we found that CBF in elderly patients with no cognitive decline remained stable after intravenous sedation with 0.035 mg/kg of MID. However, when 0.027 mg/kg of MID was administered to elderly patients with severe dementia, CBF decreased by approximately 10%11. As the majority of dental treatments are conducted over the course of multiple visits, notable cognitive decline is possible from repetitive use of intravenous sedation. Hence, we need to identify sedatives that do not affect cerebral function, and DEX seems to potentially be one such drug.

This study prospectively registered elderly patients with severe dementia who were scheduled to undergo behavior modification with intravenous sedation for dental treatment. The objective of the present study was to investigate and compare the effects of intravenous sedation with two types of drugs, MID and DEX, on brain waves, assessed as the bispectral index (BIS) value, and CBF in each subject.

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