Sedation/Agitation Management in an 80-Year-Old with Trochanteric Fracture + Delirium + Dementia

Step 1 - Rule Out Reversible Causes FIRST (Before Any Sedation)

"Serious underlying conditions must be excluded as the cause of agitation before empirically treating patients with pain medications, sedatives, or physical restraints." - Sabiston Textbook of Surgery

Step 2 - Non-Pharmacological Measures (Always First)

• Re-orientation: Calm reassurance, familiar faces, family at bedside
• Minimise room/staff changes
• Ensure glasses and hearing aids are in place (sensory deprivation worsens delirium)
• Adequate lighting - not too bright or too dark
• Clock and calendar in view
• Reduce unnecessary procedures and monitoring interruptions at night
• Verbal de-escalation techniques (see below)
• Avoid physical restraints if possible - they worsen agitation and can cause injury

Step 3 - Analgesia (Often the Key Intervention)

• Paracetamol 500-1000 mg oral/IV every 6 hours (safe, first-line)
• Femoral nerve block / fascia iliaca block - highly effective for hip fracture, reduces need for systemic opioids and delirium risk
• Avoid NSAIDs (renal risk, GI risk in elderly)
• Low-dose opioids (oral morphine 1-2 mg) can be considered cautiously if pain is severe, but they too can worsen delirium - titrate carefully

Step 4 - Pharmacological Sedation (If Non-Pharmacological Fails)

⚠️ Key Principles for This Patient

• Use the lowest effective dose
• Avoid anticholinergic drugs (diphenhydramine, promethazine) - they prolong and worsen delirium
• Avoid benzodiazepines as first-line - they cause oversedation and exacerbate confusion in elderly; reserve for withdrawal states
• The goal is an awake but manageable patient - not deep sedation
• All antipsychotics carry a black-box warning for increased mortality in elderly patients with dementia-related psychosis - this must be discussed with family/documented

Drug Options (Evidence-Based)

1. Haloperidol (First-Line for Non-Parkinson Delirium)

"The recommended starting dose is 0.25-0.5 mg haloperidol orally or intramuscularly, repeated every 30 minutes after vital signs have been rechecked... the average elderly patient should receive no more than 3-5 mg in 24 hours." - Goldman-Cecil Medicine

"Low doses of haloperidol (0.5-1 mg orally or intramuscularly) are usually used as first-line. Elderly patients can be very sensitive and may require lower doses." - Textbook of Family Medicine

2. Quetiapine (Atypical - Good Choice if Parkinsonism Suspected or Tolerated)

3. Olanzapine (Atypical - IM Available)

4. Benzodiazepines (Use Cautiously - NOT First-Line Here)

"Benzodiazepines are not recommended as first-line treatment of delirium because of their tendency to cause oversedation and to exacerbate the confusional state." - Goldman-Cecil Medicine

5. Melatonin / Ramelteon (Adjunct - Circadian)

• Melatonin 0.5-3 mg at night helps regulate sleep-wake cycle and may reduce nocturnal agitation
• Very safe in elderly; no significant drug interactions
• Not a sedative per se, but helps restore circadian rhythm disrupted by hospitalisation

⚠️ Drugs to Actively AVOID

Summary Algorithm

RESTLESS ELDERLY WITH HIP FRACTURE + DELIRIUM
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1. TREAT PAIN FIRST (Paracetamol + Fascia Iliaca Block)
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2. CHECK REVERSIBLE CAUSES (SpO2, glucose, Na, retention)
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3. NON-PHARMACOLOGICAL (re-orient, family, quiet environment)
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4. If still agitated → HALOPERIDOL 0.25-0.5 mg IM/PO
   (repeat up to max 3-5 mg/24 hrs in elderly)
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5. If antipsychotic partial response → add LORAZEPAM 0.5-1 mg
   (combination more effective than monotherapy)
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6. Nocturnal agitation → QUETIAPINE 12.5-25 mg PO at night
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7. AVOID: anticholinergics, benzodiazepine monotherapy

Special Note: Dementia + Delirium ("Delirium Superimposed on Dementia")

• Rosen's Emergency Medicine, p. 981
• Goldman-Cecil Medicine, p. 3751
• Tintinalli's Emergency Medicine, Chapter 287/288
• Textbook of Family Medicine 9e