Management of Seizures and Anxiety in Elderly Patients

Introduction

The management of seizures and anxiety in elderly patients requires careful consideration of the patient's sensitivity to benzodiazepines, as recommended by the British Medical Journal and the American Geriatrics Society 1, 2, 3

For elderly patients with active seizures, administer lorazepam subcutaneously at a reduced dose of 0.5-1 mg every hour as needed, with a maximum of 2 mg in 24 hours due to increased sensitivity in this population 1, 2
The starting dose for elderly patients is 0.5-1 mg subcutaneously, and the maximum daily dose for elderly or debilitated patients is 2 mg in 24 hours 2
If seizures require frequent dosing, consider a subcutaneous infusion via syringe driver, starting with a dose that is adjusted based on renal function, with a reduction to 5 mg over 24 hours if eGFR <30 mL/minute 2

Subcutaneous injection of lorazepam may cause local irritation, and benzodiazepines can cause increased agitation and delirium in elderly patients 1
There is an increased risk of falls in elderly patients, and lorazepam may cause paradoxical agitation, especially in elderly patients 1, 2
Use lorazepam with caution in patients with severe pulmonary insufficiency, severe liver disease, or myasthenia gravis, and monitor patients for respiratory depression, especially those with pulmonary insufficiency, and adjust the dose accordingly 2

The standard starting dose of midazolam subcutaneous infusion is 10 mg over 24 hours, with adjustments for patients with renal impairment (eGFR <30 mL/minute) to 5 mg over 24 hours, as recommended by the British Medical Journal 2
For elderly or debilitated patients, consider starting at 5 mg over 24 hours, according to the British Medical Journal 2
If immediate symptom control is needed, administer midazolam 2.5-5 mg subcutaneously every 2-4 hours as required, and consider initiating the continuous infusion if PRN doses are needed more than twice daily, as suggested by the British Medical Journal 2

For delirium with agitation, consider combining midazolam with an antipsychotic such as haloperidol, as recommended by the British Medical Journal 2
For patients with delirium who are unable to swallow, midazolam can be used alone or in combination with levomepromazine, according to the British Medical Journal 2
When used for anxiety or agitation, ensure pain is adequately controlled first with opioids, and consider combining with an antipsychotic like haloperidol for delirium with agitation, as recommended by 3
For patients with renal impairment, use a reduced dose of 5 mg/24 hours, and consider dose reduction for patients with hepatic impairment due to decreased metabolism, as recommended by the British Medical Journal 2

Monitor patient response every 4-6 hours after starting infusion, and adjust the dose as needed to achieve symptom control, according to 3
There is no specified upper limit for the dose during end-of-life care, but titrate to symptom control, as recommended by 3
If symptoms persist, give a bolus dose equal to or double the hourly infusion rate, and consider doubling the infusion rate if two bolus doses are required within an hour, as recommended by 3