Outside of very specific cases, there is little to no evidence supporting the treatment of agitation due to delirium or dementia with benzodiazepines (Defrancesco et al. 2015). In fact, benzodiazepines (benzos) can worsen delirium (Breitbart et al. 1996) and can actually turn nondelirious patients into delirious patients! That said, decades of clinical practice support the use of benzodiazepines in the acutely agitated patient. Allow us to use a simile. When approaching the agitated patient, think of lorazepam as a six-pack of your favorite beer. Sure, it is crisp, delicious, and will make you feel great on a hot summer day, but if you finish that six-pack in one sitting, there is going to be a price to pay. Benzos get the job done of calming the agitated patient, but the ease of use comes with the associated potential cost of worsening the patient’s condition and/or making their delirium last longer. Lorazepam is our benzodiazepine of choice for several reasons. It can be given PO, IM, and intravenously (IV). It does not require the P450 system for oxidation, as it undergoes glucuronidation, so it is not contraindicated in patients with liver dysfunction. Also, it has few drug-to-drug interactions. The added benefit of using a benzodiazepine in acute agitation is that if the patient’s agitation is due to alcohol or benzodiazepine withdrawal, you are treating the underlying problem in addition to the acute agitation. Benzodiazepines should be used judiciously in women who are or may be pregnant, as all of the commonly used benzodiazepines are pregnancy category D.

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