What is the first line treatment for a geriatric patient demonstrating agitation?

From the Guidelines

The first-line treatment for agitation in geriatric patients should begin with non-pharmacological approaches, as recommended by the American Psychiatric Association practice guideline 1. These approaches include identifying and addressing underlying causes such as pain, hunger, thirst, need for toileting, or environmental factors like noise or unfamiliar surroundings. Creating a calm environment, using redirection, validation therapy, and maintaining consistent routines are essential strategies, as outlined in the guidelines for managing Alzheimer's disease 1. Some key non-pharmacological interventions include:

• Providing a predictable routine
• Allowing the patient to dress in their own clothing and keep possessions
• Explaining procedures and activities in simple language
• Simplifying tasks and providing instructions for each step
• Using distraction and redirection of activities to divert the patient from problematic situations
• Ensuring that comorbid conditions are optimally treated
• Providing a safe environment, such as removing sharp-edged furniture and installing grab bars If medication becomes necessary after non-pharmacological approaches have been exhausted, low-dose antipsychotics may be considered for short-term use, such as risperidone 0.25-0.5mg or quetiapine 12.5-25mg, starting at the lowest possible dose, as suggested by the American Psychiatric Association practice guideline 1 and the guidelines for managing Alzheimer's disease 1. However, these medications carry black box warnings for increased mortality in elderly patients with dementia and should be used cautiously. Benzodiazepines like lorazepam 0.25-0.5mg should generally be avoided due to increased fall risk, confusion, and paradoxical agitation in older adults. The "start low, go slow" principle is crucial when medicating geriatric patients, with close monitoring for side effects, as emphasized by the American Psychiatric Association practice guideline 1. This approach prioritizes patient safety while addressing the immediate need to manage agitation, recognizing that behavioral symptoms often represent unmet needs or medical issues rather than psychiatric conditions requiring medication.

From the Research

First Line Treatment for Agitated Behavior in Geriatric Patients

The first line treatment for agitated behavior in geriatric patients involves a combination of non-pharmacologic and pharmacologic approaches.

• Non-pharmacologic modalities are effective for managing mild to moderate agitation and aggression in patients with dementia 2.
• Pharmacologic management is indicated for agitation related to a psychiatric condition, severe agitation where a patient is at risk to harm self or others, and to facilitate time-sensitive diagnostic imaging, procedures, and treatment 2.
• Antipsychotics, benzodiazepines, and other agents can be used to manage agitation in geriatric patients, but their use requires careful consideration of geriatric-specific dosing, contraindications, and common adverse effects 2, 3.

Common Causes of Agitation in Geriatric Patients

Agitation in geriatric patients can be caused by various factors, including:

• Primary psychiatric disorders 2
• Substance use 2
• Hyperactive delirium 2
• Symptoms of dementia 2
• Medical illness, substance intoxication/withdrawal, or medication effect 3

Pharmacologic Options for Agitation Management

Pharmacologic options for managing agitation in geriatric patients include:

• Typical and atypical antipsychotic agents 3
• Benzodiazepines 3
• However, the use of these agents can be associated with adverse effects, such as extrapyramidal symptoms 4, 5 and orthostatic hypotension 6.