What are the best Pro Re Nata (PRN) medications to order for an elderly patient exhibiting aggression and agitation?

From the Guidelines

For elderly patients with agitation and aggression, the best PRN medications typically include low-dose antipsychotics like haloperidol 0.5-1 mg or benzodiazepines such as lorazepam, with the goal of using the lowest effective dose for the shortest duration possible, as recommended by the most recent guidelines 1. When managing agitation and aggression in elderly patients, it is essential to consider the potential risks and benefits of medication use. Non-pharmacological approaches should always be tried first, including:

• Reorientation
• Addressing unmet needs (pain, hunger, toileting)
• Creating a calm environment If medications are necessary, consider the patient's medical history and current medications to avoid harmful interactions. Some key points to consider when using medications for agitation and aggression in elderly patients include:
• Antipsychotics, such as haloperidol, carry black box warnings for increased mortality in elderly patients with dementia, so use them at the lowest effective dose for the shortest duration possible 1
• Benzodiazepines, such as lorazepam, can increase fall risk and cause paradoxical agitation in the elderly 1
• Document the specific behaviors prompting medication use, the patient's response, and any side effects
• Regular reassessment of the need for these medications is essential, with the goal of discontinuing them when possible In terms of specific medication doses, the most recent guidelines recommend:
• Haloperidol 0.5-1 mg orally at night and every 2 hours when required, with a maximum dose of 5 mg daily in elderly patients 1
• Lorazepam, with the dose depending on the specific clinical situation and the patient's response to treatment 1

From the FDA Drug Label

1.4 Olanzapine for Injection: Agitation Associated with Schizophrenia and Bipolar I Mania 2.4 Olanzapine for Injection: Agitation Associated with Schizophrenia and Bipolar I Mania 5.1 Elderly Patients with Dementia-Related Psychosis 5.8 Falls

The best PRNs (pro re nata) to order for an elderly aggressive and agitated patient are not explicitly stated in the provided drug label. However, considering the warnings and precautions for elderly patients with dementia-related psychosis and the potential for falls, it is crucial to exercise caution when selecting a medication.

• Olanzapine for Injection is indicated for agitation associated with schizophrenia and bipolar I mania.
• The label does not provide a direct comparison or recommendation for other PRNs. Given the potential risks, a conservative approach would be to consider olanzapine as a potential option, but with careful monitoring and consideration of the patient's overall health status 2.

From the Research

PRNs for Elderly Aggressive and Agitated Patients

The following are some PRNs that can be considered for elderly aggressive and agitated patients:

• Antipsychotics:
  • Olanzapine 3, 4, 5
  • Risperidone 4, 6
  • Aripiprazole 4, 5
  • Quetiapine 4
  • Haloperidol 3, 4, 5
• Benzodiazepines:
  • Lorazepam 3, 4, 5
  • Midazolam 4, 5
  • Diazepam 5
• Other options:
  • Ketamine 3, 7
  • Combination agents 3

Administration Routes

The route of administration may vary depending on the patient's condition and the medication used:

• Oral administration: olanzapine, risperidone, aripiprazole, quetiapine, haloperidol, lorazepam 4
• Intramuscular administration: olanzapine, lorazepam, ziprasidone, haloperidol, aripiprazole, midazolam, droperidol 4
• Intravenous administration: droperidol, lorazepam 4

Considerations

When choosing a PRN for an elderly aggressive and agitated patient, consider the following:

• Geriatric-specific dosing and contraindications 3
• Common adverse effects of the medication 3
• Patient's medical history and current condition 3, 7
• Non-pharmacologic modalities for mild to moderate agitation and aggression 3