What to give for agitation in a patient?

Management of Agitation in Patients

For agitation in patients, first address reversible causes and use verbal de-escalation techniques, then proceed with benzodiazepines for anxiety-related agitation (lorazepam 0.5-1mg orally if able to swallow or midazolam 2.5-5mg subcutaneously if unable to swallow) or antipsychotics for delirium-related agitation (haloperidol 0.5-1mg orally/subcutaneously for patients able to swallow or levomepromazine 12.5-25mg subcutaneously for those unable to swallow). 1

Step 1: Address Reversible Causes

Before administering any medication, identify and treat potential underlying causes:

• Explore patient's concerns and anxieties
• Ensure effective communication and orientation
• Provide adequate lighting
• Treat medical causes such as:
  • Hypoxia
  • Urinary retention
  • Constipation
  • Pain

Step 2: Verbal De-escalation Techniques

Implement verbal de-escalation strategies:

• Respect personal space (maintain two arms' length distance)
• Use calm demeanor and unclenched hands
• Establish verbal contact with one designated staff member
• Use simple language and concise sentences
• Identify patient's goals and expectations
• Practice active listening
• Set clear limits and expectations
• Offer realistic choices 1, 2

Step 3: Pharmacological Management

For Anxiety or Agitation:

If patient can swallow:

• Lorazepam 0.5-1mg orally four times daily as needed (maximum 4mg/24 hours)
• Reduce dose to 0.25-0.5mg in elderly or debilitated patients (maximum 2mg/24 hours)
• Oral tablets can be used sublingually (off-label) 1

If patient cannot swallow:

• Midazolam 2.5-5mg subcutaneously every 2-4 hours as needed
• Consider subcutaneous infusion if needed frequently (more than twice daily), starting with midazolam 10mg over 24 hours
• Reduce dose to 5mg over 24 hours if eGFR <30 mL/minute 1

For Delirium with Agitation:

If patient can swallow:

• Haloperidol 0.5-1mg orally at night and every 2 hours when required
• Increase dose in 0.5-1mg increments as needed (maximum 10mg daily, or 5mg daily in elderly patients)
• Consider higher starting dose (1.5-3mg) if patient is severely distressed or causing immediate danger
• Consider adding benzodiazepine if patient remains agitated 1

If patient cannot swallow:

• Levomepromazine 12.5-25mg subcutaneously as starting dose, then hourly as needed (use 6.25-12.5mg in elderly patients)
• Maintain with subcutaneous infusion of 50-200mg over 24 hours
• Consider midazolam alone or in combination with levomepromazine if anxiety is also present 1

Special Considerations

Based on Suspected Etiology:

• Medical/intoxication-related agitation: Prefer benzodiazepines first; consider adding antipsychotic for severe cases
• Psychiatric-related agitation: Either benzodiazepine or antipsychotic for mild/moderate cases; prefer antipsychotic for severe cases
• Unknown etiology: Start with either medication class; consider adding the other if first dose ineffective 1

For Olanzapine (Alternative for Severe Agitation):

If using intramuscular olanzapine:

• Standard dose: 10mg
• Consider lower dose (5-7.5mg) when clinically warranted
• For elderly or debilitated patients: 5mg/injection
• For patients predisposed to hypotension: 2.5mg/injection
• Monitor for orthostatic hypotension before subsequent doses 3

Important Cautions

• Assess for orthostatic hypotension before administering subsequent doses of intramuscular medications
• Avoid using intramuscular olanzapine simultaneously with other CNS depressants
• Monitor respiratory status when using benzodiazepines
• Consider eGFR when dosing medications (reduce doses for impaired renal function)
• Physical restraints should only be used as a last resort when all other interventions have failed 1, 3, 4

Remember that the goal is to help the patient regain control while ensuring safety for all involved, using the least restrictive intervention necessary to manage the agitation effectively.