Confusion lorazepam

Benzodiazepines are preferred by many for the management of agitation in nonpsychotic bipolar patients, though antipsychotics are effective as well. The most widely used benzodiazepines for this purpose are lorazepam and clonazepam. Lorazepam is perhaps the most versatile of the benzodiazepines. It has an intermediate duration of action, does not tend to accumulate and thereby cause confusion or excessive drowsiness, and can be administered by mouth, intramuscular injection, or intravenous injection. Lorazepam should be administered on an as-needed basis several times daily at 0.5-2mg per dose. The calming effects of lorazepam are usually evident within 20-30 minutes and will last for several hours. 

At equipotent doses, all benzodiazepines have similar effects. The choice of benzodiazepine is generally based on half-life, rapidity of onset, metabolism, and potency. In patients with moderate to severe hepatic dysfunction, it may be useful to avoid benzodiazepines. All benzodiazepines are metabolized at various levels by the liver, which leads to an increased risk of sedation and confusion in hepatic failure. If it is necessary to prescribe this class of medication, lorazepam and oxazepam are reasonable choices because they are predominantly eliminated by renal excretion. 

Long half-life BZDs may increase the risk of daytime sedation, lethargy, cognitive impairment, and delirium, as well as falls and hip fractures ( 309, 310 and 311). Long-term use of flurazepam (30 mg per day) has been associated with an increased incidence of ataxia and hallucinations ( 312). However, short half-life BZDs also may cause serious adverse effects. Ataxia, depression, confusion, amnestic syndromes, and oversedation have been reported in elderly lorazepam users, and there is some evidence that short-acting BZDs may also increase the risk of falls (313, 314, 315, 316 and 317). 

In the management of anxiety, the cumulative effects of longer half-life BZDs often result in excessive sleepiness, apathetic states, and confusion (with or without paradoxical agitation). Thus, short- and intermediate-acting agents such as oxazepam, lorazepam, and alprazolam are preferable. Lower doses (e g., 0.5 to 1.0 mg of lorazepam 0.25 to 0.5 mg of alprazolam) are preferable. Agents with very short half-lives, such as midazolam and triazolam, are not well tolerated, especially in those with more severe neurocognitive disruption. In this context, low-dose antipsychotics were found more effective than lorazepam in the treatment of AIDS-related delirium (495). 

Benzodiazepine (BZ) intoxication is manifested as slurred speech, poor coordination, swaying, drowsiness, hypotension, nystagmus, and confusion. Signs and symptoms of BZ withdrawal are similar to those of alcohol withdrawal, including muscle pain, anxiety, restlessness, confusion, irritability, haJlucinations, delirium, seizures, and cardiovascular collapse. Withdrawal from short-acting BZs (e.g., oxazepam, lorazepam, alprazolam) has an onset within 12 to 24 hours of the last dose. Diazepam, chlordiazep-oxide, and clorazepate have elimination half-lives (or active metabolites with elimination half-lives) of 24 to greater than 100 hours. So, withdrawal may be delayed for several days after their discontinuation. Sedative-hypnotic dependence is summarized in Table 73-2. 

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