What is the next step in managing a 78-year-old female patient with verbally and physically aggressive tendencies who is already taking hydroxyzine (an antihistamine) three times daily?

Management of Verbally and Physically Aggressive Behaviors in an Elderly Patient

For a 78-year-old female with verbally and physically aggressive tendencies who is already taking hydroxyzine three times daily, the next step should be to add a low-dose atypical antipsychotic such as risperidone, starting at 0.25-0.5 mg daily.

Assessment of Current Situation

Before implementing medication changes, it's important to understand:

• Hydroxyzine (an antihistamine) has limited efficacy for severe aggression in elderly patients
• At age 78, the patient is at higher risk for medication side effects, particularly anticholinergic effects from hydroxyzine
• Physical and verbal aggression in elderly patients often indicates underlying conditions requiring targeted treatment

Medication Management Algorithm

First-line approach:

1. Add low-dose atypical antipsychotic
   • Risperidone starting at 0.25-0.5 mg daily 1
   • Titrate slowly by 0.25 mg increments at intervals of >2 weeks
   • Target dose: 0.5-1 mg daily (not to exceed 3 mg daily in elderly)
   • Monitor for extrapyramidal symptoms, sedation, and orthostatic hypotension

If risperidone is ineffective or poorly tolerated:

1. Consider benzodiazepine alternative
   • Lorazepam 0.5 mg once or twice daily 2
   • Use with caution due to risk of falls, cognitive impairment, and paradoxical agitation
   • Limited duration of use (ideally <4 weeks)

For acute episodes of severe agitation:

1. Chemical restraint protocol
   • Offer oral medication before considering parenteral routes 3
   • Lorazepam 0.5-1 mg orally or IM for acute episodes
   • Document rationale and monitor continuously for adverse effects

Non-Pharmacological Interventions

Implement alongside medication changes:

• De-escalation techniques:

  • Calm, non-confrontational approach
  • Reduced sensory stimulation in environment
  • Removal of potential triggers 3

• Environmental modifications:

  • Consistent daily routine
  • Adequate lighting to reduce confusion
  • Familiar objects and photos 4

• Staff/caregiver training:

  • Recognition of early warning signs
  • Techniques to prevent escalation
  • Proper response to aggressive episodes

Monitoring and Follow-up

• Assess response to medication within 1-2 weeks
• Monitor for:
  • Sedation and falls
  • Extrapyramidal symptoms (with antipsychotics)
  • Cognitive changes
  • Cardiovascular effects (QT prolongation)

Important Caveats and Pitfalls

• Avoid using multiple sedating medications simultaneously - hydroxyzine plus high-dose antipsychotics can lead to excessive sedation
• Beware of anticholinergic burden - hydroxyzine has significant anticholinergic effects that can worsen cognition
• Consider underlying causes - rule out delirium, pain, urinary tract infection, or other medical conditions that may present as aggression
• Avoid PRN chemical restraint - this practice is prohibited and considered dangerous 3
• Document decision-making carefully - include rationale for medication choice and monitoring plan

Evidence Quality Considerations

The guidelines for managing aggression in elderly patients are primarily based on expert consensus rather than high-quality randomized controlled trials. The American College of Emergency Physicians guidelines 3 provide recommendations for acute agitation, while the American Academy of Child and Adolescent Psychiatry guidelines 3 offer insights on chemical restraint that can be extrapolated to elderly care with appropriate dose adjustments.