A prospective observational cohort pilot study of the association between midazolam use and delirium in elderly endoscopy patients

Abstract

Background Midazolam is a benzodiazepine commonly used in procedural sedation and general anaesthesia. Current anaesthetic guidelines advise the avoidance of benzodiazepines in elderly patients due to concerns of an increased risk of delirium. Delirium is associated with significant patient morbidity and mortality, while also increasing health costs. Despite this, midazolam is often used in elderly patients undergoing low risk procedures due to the benefits of rapid onset, anxiolysis and haemodynamic stability compared to other sedatives. To date, studies describing the relationship between midazolam use and delirium in elderly patients undergoing low risk procedures, such as endoscopy, are limited. Method This was a prospective observational cohort pilot study identifying the prevalence of delirium pre-procedure and incidence of delirium post-procedure in elderly endoscopy patients receiving midazolam. The study population was elderly patients greater than 65 years of age, without underlying cognitive dysfunction, undergoing elective endoscopy. Electronic databases were used for collection of demographic and clinical information. Delirium was identified through the administration of the Family Confusion Assessment Method survey; this was administered to carers of the study population 24–48 h pre and post procedure to categorically identify the presence or absence of delirium. Results Fifty-eight participants were recruited for this study and eighteen were subsequently excluded based upon additional exclusion criteria. Forty patients were included in the final results. American Society of Anaesthesiology Classification (ASA) of patients were as follows: 1 (9 patients), 2 (12 Patients), 3 (16 Patients) and 4 (3 patients). Patients underwent gastroscopy, colonoscopy or combined gastroscopy and colonoscopy. This study identified no cases of delirium in elderly patients after administration of midazolam for elective endoscopy procedures 24–48 h post-procedure. Additionally, a high proportion of elderly patients were found to have received midazolam. Conclusion No episodes of delirium were identified in this study. This finding runs counter to current guideline recommendations regarding midazolam use in the elderly patient and that elderly patients undergoing elective endoscopy represent a significantly different patient population compared to those previously studied. This study suggests that in the study population that the risk of delirium in patients exposed to midazolam in elective endoscopy was not demonstrated and that it may be safe to perform experimental studies to elucidate the safety of midazolam in larger studies.

Comparison of 95% effective dose of remimazolam besylate and propofol for gastroscopy sedation on older patients: A single‐centre randomized controlled trial

“…Benzodiazepine was reported to be associated with abnormal mental symptoms in sedated patients, such as delirium 45 and paradoxical reactions 4,7 . For gastroscopy, delirium may have a lower risk (reported at <0.11%) for its short duration 37,46 . Paradoxical reactions occurred in 1.4–8.9% of patients undergoing endoscopy under midazolam sedation, 7–9 whereas no related data were available on remimazolam.…”

Efficacy and safety of midazolam combined with dezocine for sedation and analgesia in digestive endoscopy: A prospective open single-center study

“…Midazolam, a benzodiazepine with rapid onset, a short elimination half-life, small local irritation, a wide safety limit, a high therapeutic index, antianxiety effects, the ability to induce anterograde amnesia, and stable hemodynamics and without accumulation and residual effects, has been widely used for sedation, but its analgesic effect is unsatisfactory ( Lee et al, 2021 ). One study showed that compared with gastroscopy performed under anesthesia using only propofol and fentanyl, the amount of propofol decreased and the satisfaction of patients increased after the addition of midazolam ( das Neves et al, 2016 ).…”

Management of Post-nephrectomy Delirium in Patients with Traumatic Renal Rupture: A Case Report

“…Finally, it has been controversial whether antipsychotic treatment is effective for delirium. There was rare evidence to support the use of antipsychotics for agitation, and anesthesia guidelines recommend avoiding benzodiazepines in older patients [17,18]. However, in our report, a patient with POD was successfully cured with midazolam, and there was no postoperative cognitive decline in the patient at the 6month follow-up.…”