Transdermal Scopolamine: Delirium Right Before Our Eyes
Juan N. Lessing, MD1 & Thuan D. Ong, MD, MPH1,2
Department of Internal Medicine,1 University of Washington, Seattle, Washington
Division of
Gerontology and Geriatric Medicine,2 University of Washington, Seattle, Washington
A 72 year-old woman underwent surgical revision of a total ankle replacement. Post-operative
day #1, a scopolamine 1.5 mg topical patch was placed retroaurticularly to treat nausea and
vomiting. Within hours, the patient became confused, disoriented, inattentive and pulled out her
intravenous line. Pain control was being managed appropriately. Exam revealed dilated pupils
with the pupil ipsilateral to the patch being two mm larger than the other. The rest of the exam
was normal, including a non-focal neurological exam. Basic labs, urine analysis and bladder scan
were normal. With removal of the scopolamine patch, washing underlying skin and
implementation of environmental interventions, by post-operative day #2 altered mental status
(AMS) and papillary abnormalities resolved, and the patient returned to her baseline level of
function.
Discussion
Scopolamine--an anticholinergic agent that competitively inhibits the action of acetylcholine on
muscarinic receptors--is used in the prevention of nausea and vomiting associated with motion
sickness and surgery. Use of oral preparation has been limited due to side effects, namely
anticholinergic toxicity. In 1981, a transdermal preparation became available that extends time of
drug coverage while decreasing dose exposure due to sustained release over three days. Although
this preparation is reported to be safer and have lower incidence of adverse effects (1), it is worth
noting that transdermal scopolamine has the same side effect profile as other preparations (2,3).
In 37 reported cases of transdermal scopolamine-induced AMS, most involved patients of
advanced age. Transdermal scopolamine is also reported to cause mydriasis and anisocoria
especially with eye rubbing after touching the patch (4). In 2012, scopolamine was added to the
Beers Criteria list.
Knowledge of the side effects of transdermal scopolamine will lead clinicians to consider this
medication as a possible cause of rapidly reversible delirium and a medication to avoid in the
elderly.
1. Transdermal scopolamine for motion sickness. Med Lett.1981;23:89-90.
2. Rozzini R, et al. Delirium from transdermal scopolamine in an elderly woman.
JAMA.1988;260:478.
3. Seo SW, et al. Mental confusion associated with scopolamine patch in elderly with mild
cognitive impairment. Arch Gerontol Geriatr.2009;49:204-7.
4. Riddick FA, et al. Cruise ship anisocoria. Ann Intern Med.1992;117:95.