A 76-year-old man is brought to the office by his daughter due to disruptive behavior. Last night he behaved normally, took his regular medications, and retired to his bedroom shortly after dinner. When the patient emerged an hour later, he was agitated, irritable, and confused. When asked what was wrong, he became belligerent and seemed unable to recognize some family members. The daughter describes similar episodes over the past 3 evenings. Although the patient seems calmer and less confused this morning, the daughter worries that he will have another episode. His medical history is significant for essential hypertension, benign prostatic hyperplasia, mild neurocognitive disorder, insomnia, and a recent increase in anxiety related to stock market losses. Medications include terazosin and alprazolam. A thorough physical examination is unremarkable, with no focal neurologic findings. Laboratory evaluation, including complete blood count and serum electrolytes, is normal. Which of the following is the most appropriate next step in management of this patient?

Question

A 76-year-old man is brought to the office by his daughter due to disruptive behavior.  Last night he behaved normally, took his regular medications, and retired to his bedroom shortly after dinner.  When the patient emerged an hour later, he was agitated, irritable, and confused.  When asked what was wrong, he became belligerent and seemed unable to recognize some family members.  The daughter describes similar episodes over the past 3 evenings.  Although the patient seems calmer and less confused this morning, the daughter worries that he will have another episode.  His medical history is significant for essential hypertension, benign prostatic hyperplasia, mild neurocognitive disorder, insomnia, and a recent increase in anxiety related to stock market losses.  Medications include terazosin and alprazolam.  A thorough physical examination is unremarkable, with no focal neurologic findings.  Laboratory evaluation, including complete blood count and serum electrolytes, is normal.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Although benzodiazepines are often prescribed for patients with insomnia and/or anxiety, they should be used sparingly in the elderly due to increased risk of adverse effects. As people age, they metabolize benzodiazepines more slowly and are more likely to experience confusion and increased risk of falls. In addition, patients with baseline cognitive impairment are even more vulnerable to the adverse effects of benzodiazepines. Another adverse effect of benzodiazepines is paradoxical agitation, which is suggested by this patient's recurrent episodes of confusion and agitation shortly after taking his alprazolam dose. Paradoxical agitation is characterized by increased agitation, confusion, aggression, and disinhibition, typically within an hour of administration. Although paradoxical reactions to benzodiazepines are relatively uncommon (<1%), they are important to recognize as increasing the benzodiazepine dose will only worsen the patient's condition (Choice A). Taper and eventual discontinuation of this patient's alprazolam is the most appropriate next step in management. (Choice B) CT scan of the head should not precede a decrease in alprazolam dose in a patient who develops mental status changes following repeated benzodiazepine administration and who has no focal neurologic findings. CT scan of the brain should be considered in individuals with focal neurologic findings, recent head injury, or no clear precipitant for an acute-onset episode of confusion. (Choice C) Donepezil is an acetylcholinesterase inhibitor used to slow cognitive decline in patients with Alzheimer disease, but there is no data to support its use in mild cognitive impairment. It would not be of help in patients with acute-onset cognitive impairment due to medication-induced delirium. (Choice D) Quetiapine would be appropriate only in a patient with persistent psychosis or uncontrolled agitation. This patient's alprazolam dose should be tapered before considering quetiapine. (Choice F) Terazosin, an alpha blocker, may cause orthostatic hypotension or syncope, especially with the first dose. Therefore, it should be used with caution in the elderly. Terazosin is not known to cause cognitive impairment or agitation, and there is no indication to discontinue it in this patient at this time. Educational objective: Benzodiazepines should be used with extreme caution in the elderly due to increased risk of cognitive impairment, falls, and paradoxical agitation. References: Paradoxical reaction to alprazolam in an elderly woman with a history of anxiety, mood disorders, and hypothyroidism. (http://www.ncbi.nlm.nih.gov/pubmed/27092285) What is the point of guidelines? Benzodiazepine and z-hypnotic use by an elderly population. (http://www.ncbi.nlm.nih.gov/pubmed/22704401)

A 76-Year-Old Man Is Brought to the Office by His