Improving the Safety of Rapid Tranquilisation in Delirious Elderly In-patients through Pharmacological Education

Delirium is a neuropsychiatric condition commonly affecting hospitalised elderly individuals. It is characterised by acute cognitive disturbance and can present with agitation and aggression putting patients and staff at risk. Sedatives for rapid tranquilisation of agitation are not without risk in elderly populations and should be given as a last resort, at the lowest effective dose and with clear documentation of justification. This study aims to optimise these critical factors for safe rapid tranquilisation in elderly agitated patients.

This study used the electronic patient record system to retrospectively identify all rapid tranquilisation events over a 2-month period on an Elderly Medicine and a General Medicine ward in a UK-based District General Hospital. Following baseline data collection, it was found that most rapid tranquilisation sedatives were prescribed out-of-hours (66.7%) when resident doctors alone staff the wards. A well-promoted educational intervention was performed targeting resident doctors, focusing on the pharmacology and evidence base of sedatives in the context of rapid tranquilisation and discussing up-to-date literature. Data were then recollected from the same two wards over a 2-month period.

The mean age pre-intervention was 73, and post-intervention was 81. The results found that the number of patients given rapid tranquilisation fell significantly from 34 to 17 (p=0.02), even despite the total admitted patients increasing from 509 to 546. Post-intervention, documentation of justification improved with the indication documented for all patients. Furthermore, the mean and highest doses of both lorazepam and haloperidol fell and sedative side effects reduced in frequency.

This study identifies an intervention which improved the safety of rapid tranquilisation in the elderly with a post-intervention reduction in the number of elderly patients being sedated, the dosing of sedatives given and post-sedation side effects. Given the high incidence of delirium in the elderly, this intervention has potential for significant real world impact.