If a rapid response is needed, use short acting midazolam or lorazapam. All the benzos have an anticonvulsant effect if this is needed. Clonazepam has more anticonvulsant action than midazolam. Clonazepam helps with neuropathic pain if that is an associated problem. Use low doses in the elderly or frail patient particularly if there is liver and renal failure, low serum albumin or respiratory insufficiency.
Care is needed to prevent falls and fractures in the frail and elderly on benzos.
Beware of the problems of abrupt withdrawal of long term benzos, particularly if short acting - fits, confusion, tremors etc. Benzos have NO analgesic effect and concurrent analgesics need to be continued even in a semicomatose or comatose patient. For the more severely disturbed and confused patient neuroleptics are often needed, sometimes in conjunction with benzos. Also if there is an adverse reaction to benzos neuroleptics may be needed. The following table shows the most commonly used neuroleptics.