What medications are recommended for managing agitation in elderly patients?

From the Guidelines

For agitated elderly patients, a stepped approach is recommended starting with non-pharmacological interventions before considering medications, with low-dose antipsychotics like risperidone 0.25-0.5mg being a preferred option for acute agitation, as suggested by the most recent guidelines 1. When medications are necessary, it is crucial to consider the potential side effects and interactions.

• Low-dose antipsychotics like haloperidol 0.25-0.5mg or risperidone 0.25-0.5mg can be used for acute agitation, with risperidone being preferred due to its lower risk of extrapyramidal symptoms (EPS) 1.
• Benzodiazepines such as lorazepam 0.5mg should be used cautiously due to increased fall risk and confusion, and are generally recommended for alcohol or benzodiazepine withdrawal 1.
• For ongoing agitation, consider trazodone 25-50mg at bedtime or mirtazapine 7.5-15mg, as these medications have a more favorable side effect profile compared to antipsychotics 1.
• SSRIs like sertraline 25-50mg daily may help if depression contributes to agitation, but should be used with caution in elderly patients due to potential interactions and side effects 1. Always start with the lowest possible dose ("start low, go slow") and monitor closely for side effects, as elderly patients metabolize medications more slowly and are more sensitive to adverse effects 1. Regularly reassess the need for continued medication, as many can be tapered after the acute situation resolves, and identify and address underlying causes of agitation such as pain, infection, medication side effects, or unmet needs before relying on pharmacological approaches 1.

From the FDA Drug Label

Consideration should be given to a slower rate of dose titration and a lower target dose in the elderly and in patients who are debilitated or who have a predisposition to hypotensive reactions Elderly patients should be started on quetiapine fumarate tablets 50 mg/day and the dose can be increased in increments of 50 mg/day depending on the clinical response and tolerability of the individual patient.

For agitated elderly patients, quetiapine can be considered as a treatment option, starting with a dose of 50 mg/day and increasing in increments of 50 mg/day as needed and tolerated.

• The dose should be titrated slowly and cautiously in elderly patients.
• It is essential to monitor the patient's response and tolerability to the medication.
• Lorazepam may also be considered for acute agitation, but its use should be cautious due to the risk of respiratory depression and excessive sedation, especially in elderly patients 2 3.

From the Research

Medications for Agitated Elderly Patients

• Antipsychotics are widely used in geriatric psychiatric disorders, including agitation in elderly patients 4
• For agitated dementia with delusions, antipsychotic drugs such as risperidone (0.5-2.0 mg/day), quetiapine (50-150 mg/day), and olanzapine (5.0-7.5 mg/day) are recommended 4
• Risperidone appears effective in controlling agitation in patients with dementia and has a relatively benign adverse-effect profile 5
• In cases of acute psychotic agitation, oral treatment with risperidone plus lorazepam is as effective as intramuscular treatment with haloperidol plus lorazepam 6
• Other medications that may be used to treat agitation in elderly patients include benzodiazepines, such as lorazepam, and other antipsychotics, such as aripiprazole and haloperidol 7, 8

Considerations for Medication Selection

• The choice of medication should be based on individual patient needs and medical history 4, 8
• Geriatric-specific dosing and contraindications should be considered when selecting a medication 7
• The potential for adverse effects, such as extrapyramidal symptoms and cognitive impairment, should be taken into account when choosing a medication 4, 5
• Combination therapy, such as the use of an antipsychotic and a benzodiazepine, may be necessary in some cases 6