From the Guidelines
The first line treatment for agitation in the elderly is non-pharmacological intervention, as recommended by the most recent and highest quality study 1. This approach includes identifying and addressing underlying causes such as pain, hunger, thirst, need to use the bathroom, boredom, or environmental factors like excessive noise or unfamiliar surroundings. Techniques such as reorientation, distraction, validation therapy, and maintaining a calm, structured environment are essential. Some key points to consider in non-pharmacological intervention include:
- Structured and tailored activities that are individualized and aligned to current capabilities and take into account previous roles and interests may be considered 1
- Supporting the ability of the caregiver to provide care for their family member or friend, as well as their ability to be a partner in care may be appropriate 1 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, with careful monitoring for side effects, as suggested by older studies 1. However, these medications carry significant risks in the elderly, including increased mortality, falls, and cognitive decline. Benzodiazepines should generally be avoided due to their risk of paradoxical agitation, falls, and cognitive impairment. The underlying principle is to start with the least invasive approach that addresses the cause of agitation rather than simply sedating the patient, as medications often worsen outcomes in elderly patients with dementia or delirium. Other studies, such as 1 and 1, provide additional guidance on the management of agitation in the elderly, but the most recent and highest quality study 1 prioritizes non-pharmacological intervention as the first line treatment.
From the Research
First Line Treatment for Agitation in the Elderly
The first line treatment for agitation in the elderly can vary depending on the underlying cause of the agitation and the patient's medical history.
- Non-pharmacological interventions, such as verbal de-escalation and sensory interventions, are often recommended as the first line of treatment for agitation in the elderly 2, 3.
- Verbal de-escalation involves a 3-step approach, including verbal engagement, establishment of a collaborative relationship, and verbal de-escalation of the patient's agitated state 2.
- Sensory interventions, such as music therapy or aromatherapy, have been shown to be effective in reducing agitation in older adults with dementia 3.
- Pharmacological interventions, such as antipsychotics and benzodiazepines, may be used as a last resort or in situations where the patient is at risk of harming themselves or others 4, 5, 6.
- Intramuscular olanzapine has been shown to be effective in rapidly sedating agitated patients, including those with acute undifferentiated agitation and those with agitation secondary to organic medical conditions 4.
- Haloperidol and lorazepam are also commonly used to treat acute agitation, but may have more side effects and interactions than atypical antipsychotics like olanzapine 4, 5, 6.
Considerations for Treatment
When treating agitation in the elderly, it is essential to consider the patient's underlying medical conditions, medications, and potential interactions.
- The use of benzodiazepines, such as lorazepam, may be associated with an increased risk of falls, cognitive impairment, and other adverse effects in older adults 5, 6.
- Atypical antipsychotics, such as olanzapine, may have a lower risk of extrapyramidal symptoms and other side effects compared to typical antipsychotics like haloperidol 4, 6.
- The choice of treatment should be individualized based on the patient's specific needs and circumstances, and should involve a comprehensive assessment of the patient's medical, psychiatric, and social history 2, 4, 3, 5, 6.