What is a suitable medication to calm an agitated senior citizen (elderly patient) in an inpatient setting?

From the Guidelines

For managing agitation in elderly inpatients, olanzapine (2.5-5 mg orally or subcutaneously) is a recommended option, as it may cause less extrapyramidal side effects compared to typical antipsychotics, according to the most recent guidelines 1. When considering medication options, it's essential to weigh the potential benefits and risks, prioritizing the patient's morbidity, mortality, and quality of life.

• Atypical antipsychotics like olanzapine, quetiapine, and risperidone are generally preferred over typical antipsychotics due to their lower risk of extrapyramidal side effects (EPS) 1.
• Benzodiazepines, such as lorazepam, can be used cautiously, but their potential for increased fall risk, paradoxical reactions, and cognitive impairment should be carefully considered, especially in elderly patients 1.
• Non-pharmacological approaches, including reorientation, presence of family members, and addressing underlying causes like pain, constipation, or urinary retention, should be tried first when possible.
• The medication dosages should be started at the lowest possible dose and reassessed frequently, as elderly patients are more sensitive to medication effects and have altered metabolism.
• It's crucial to monitor patients closely for potential side effects, including sedation, orthostatic hypotension, and cognitive impairment, and adjust the treatment plan accordingly.
• The choice of medication should be individualized, taking into account the patient's medical history, current condition, and potential interactions with other medications.

From the FDA Drug Label

The efficacy of intramuscular olanzapine for injection for the treatment of agitation was established in 3 short-term (24 hours of IM treatment) placebo-controlled trials in agitated adult inpatients from 2 diagnostic groups: schizophrenia and bipolar I disorder (manic or mixed episodes) In the studies, the mean baseline PANSS Excited Component score was 18. 4, with scores ranging from 13 to 32 (out of a maximum score of 35), thus suggesting predominantly moderate levels of agitation with some patients experiencing mild or severe levels of agitation. All doses were statistically superior to placebo on the PANSS Excited Component at 2 hours post-injection. However, the effect was larger and more consistent for the 3 highest doses. Olanzapine for injection was statistically superior to placebo on the PANSS Excited Component at 2 hours post-injection

Olanzapine is a medication that can be used to calm down an agitated senior citizen inpatient. The recommended dose is not specified for senior citizens, but the study used doses of 2.5 mg, 5 mg, 7.5 mg, and 10 mg. The 10 mg dose was found to be effective in reducing agitation in adult inpatients with schizophrenia and bipolar I disorder. However, it is essential to note that the safety and efficacy of olanzapine in senior citizens have not been directly established in this study. 2

From the Research

Medication Options for Agitated Senior Citizens

• Antipsychotics are widely used in geriatric psychiatric disorders, and atypical antipsychotics such as risperidone, quetiapine, and olanzapine are commonly recommended for agitated dementia with delusions 3.
• For agitated dementia without delusions, an antipsychotic alone is considered a high second-line option, with risperidone and quetiapine being preferred choices 3.
• Benzodiazepines, such as lorazepam, can be effective in managing acute agitation in older adults, but may have a higher risk of adverse events, including respiratory depression and falls 4.
• A combination of an antipsychotic and a benzodiazepine, such as risperidone and lorazepam, can be an effective and safe alternative to traditional intramuscular treatments for acute psychotic agitation 5, 6.

Considerations for Medication Selection

• Patient-specific factors, such as medical comorbidities, cognitive impairment, and history of side effects, should be considered when selecting a medication for agitation in older adults 3, 4.
• The potential for adverse effects, such as extrapyramidal symptoms, QTc prolongation, and cognitive impairment, should be carefully weighed when choosing an antipsychotic or benzodiazepine 3, 4.
• The use of antipsychotics and benzodiazepines should be monitored closely, and treatment should be tailored to the individual patient's needs and response to therapy 3, 4.

Treatment Guidelines

• The expert panel recommends risperidone, quetiapine, and olanzapine as first-line or high second-line options for agitated dementia with delusions 3.
• For agitated dementia without delusions, the expert panel recommends an antipsychotic alone as a high second-line option, with risperidone and quetiapine being preferred choices 3.
• The American Journal of Emergency Medicine study recommends a combination of lorazepam and haloperidol as the treatment of choice for acute psychotic agitation 6.