Benzodiazepine & Antipsychotic Medication
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Pharmacokinetics and Pharmacodynamics
A patient from my clinical experience is described as a Mr. X a 75 year male with a right hip fracture from a
fall. He had a known history new onset dementia and COPD. The patient arrived to the unit post-operative R
ORIF. He became increasingly confused over the course of his stay. He made several attempts to get out of
the bed, fought staff with care, pulled his oxygen off and lines and tubes out. He was not getting any sleep.
He had to eventually be restrained to prevent self-injury. However he aggressively attempted to get out of
his soft bilateral wrist restraints. This caused stress on his heart and increased his oxygen demand. He was
given a one-time dose of Ativan 2mg IV. The Ativan calmed him down for hours and then the cycle would
start over again. The confusion / delirium became worse. However, the IV Ativan was then scheduled and
after a few doses the patient became difficult to arouse. The patient became hypotensive and oxygen
demand required the need for intubation. Chest x-ray indicated pneumonia.
The relationship between the body and drugs is referred to as and Pharmacodynamics.
Pharmacokinetics is the study of the movement of drugs through the body. The Pharmacokinetic processes
are absorption, distribution, metabolism and excretion (Rosenthal and Burchum, 2018). Pharmacodynamics is how drugs affects the body(Rosenthal and Burchum, 2018).
Mr. X experienced a long course of recovery. The use of Ativan, his age and
co- morbidities influenced the Pharmacokinetic and Pharmacodynamic processes the patient Benzodiazepine & Antipsychotic Medication
experienced. The elderly have a decreased metabolism and excretion of benzodiazepines ( Neft, Oetther, Halloway& Hanneman, 2019). Distribution plays a significant role in age related changes including decreased fluid volume, decreased muscle mass, organ perfusion and serum albumin concentration. The effects are altered serum concentration, drugs are in the system longer, stronger drug effects at lower doses. Resulting in increased side effects and toxicity (Kratz and Diefenbacher, 2019).
The American Geriatrics Society (AGS) placed Benzodiazepines on a list of medication to avoid in
patients over the age of 65. ( Neft, Oetther, Halloway& Hanneman, 2019). Benzodiazepines are known to
cause respiratory depression and cognitive deficits in the elderly for the reasons aforementioned (Markota et al. 2016).
I would develop a plan for Mr. X, first off I would request a sitter and ask family to come in and be with
the patient. There are many different medications he could have been given. I would try a precedex gtt and go
from there. Bradycardia is a side effect but I have seen patients do well on this medication.
Mr. X is not an uncommon patient in the ICU. However, if there is an understanding of Pharmacokinetics
with drug therapy this may increase beneficial effects and minimize unnecessary patient harm. Benzodiazepine & Antipsychotic Medication
References
Kratz, T., & Diefenbacher, A. (2019). Psychopharmacological treatment in older people: Avoiding drug interactions and polypharmacy. Deutsches Aerzteblatt International, 116(29/30), 508–518. https://doi-org.ezp.waldenulibrary.org/10.3238/arztebl.2019.0508
Markota, M., Rummans, T. A., Bostwick, J. M., & Lapid, M. I. (2016). Benzodiazepine use in older adults: Dangers, management, and alternative therapies. Mayo Clinic Proceedings, 91(11), 1632–1639
Neft, M. W., Oerther, S., Halloway, S., Hanneman, S. K., & Mitchell, A. M. (2019). Benzodiazepine and antipsychotic medication use in older adults. Nursing open, 7(1), 4–6.
Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier
4 hours ago
RE: advanced Pharm
Hi Beth
Thank you for the informative post.As effective as Ativan is, it is very risky in the elderly population like it can cause sedation, confusion, sleepiness, and so on. The American Geriatrics Society added Ativan a benzodiazepine on a medication list that should be avoided to adults 65 years and older(Markota, et al., 2016). Several significant psychiatric associations also advise against using benzodiazepines for the elderly as they are always risky (Tannenbaum, 2015). In your scenario, I would be interested in knowing whether the patient’s size was considered in relation to the needed body surface for the 2mg Ativan given, also thinking of other medications or treatments that could work safely for this older patient. However, your individualized plan of care ensures that all precautions have been addressed for the patient’s safety. Thank you for your post.
References
Markota, M., Rummans, T., Bostwick, M., & Lapid, M. (2016). Benzodiazepine is in older adults:
dangers, management, and alternative therapies. Psychiatric and Psychology. (11), 1632-
1639. Benzodiazepine & Antipsychotic Medication
Tannenbaum, C. (2015). Inappropriate benzodiazepine use in elderly patients and their reduction.