What are the recommended medications for managing agitation in a 90-year-old inpatient?

Management of Agitation in a 90-Year-Old Inpatient

For managing agitation in a 90-year-old inpatient, low-dose haloperidol (0.5-1 mg) should be used at the lowest effective dose for the shortest possible duration, and only after behavioral interventions have failed or are not possible.

First-Line Approach: Non-Pharmacological Interventions

Before considering medication:

• Address reversible causes of agitation/delirium:
  • Treat pain, hypoxia, urinary retention, constipation
  • Ensure adequate lighting and orientation
  • Explore patient's concerns and anxieties
  • Provide clear communication about location, identity, and staff roles
  • Explain to caregivers how they can help

Pharmacological Management Algorithm

For Severe Agitation Threatening Harm:

1. First-line medication (if able to swallow):

   • Haloperidol 0.5-1 mg orally at night and every 2 hours when required 1
   • Maximum 5 mg daily in elderly patients 1
   • Increase dose in 0.5-1 mg increments as required 1

2. First-line medication (if unable to swallow):

   • Haloperidol 0.5-1 mg subcutaneously as required 1
   • Consider subcutaneous infusion of 2.5-5 mg over 24 hours if needed frequently 1

3. For persistent agitation despite haloperidol:

   • Consider adding a low-dose benzodiazepine such as lorazepam 0.25-0.5 mg (maximum 2 mg in 24 hours) 1
   • Note: Benzodiazepines should NOT be used as first-line treatment except for alcohol/benzodiazepine withdrawal 1

4. Alternative for severe agitation if unable to swallow:

   • Levomepromazine 6.25-12.5 mg subcutaneously (lower dose for elderly patients) 1

Evidence Quality and Considerations

The American Geriatrics Society provides strong recommendations against using benzodiazepines as first-line treatment for agitation in elderly patients due to:

• Increased risk of delirium 1
• Longer delirium duration 1
• Possible transition to delirium in hospitalized patients 1

Research evidence supports using low-dose haloperidol (≤0.5 mg) as it has been shown to be:

• As effective as higher doses for controlling agitation 2
• Associated with lower risk of sedation 3
• Not requiring additional doses within 4 hours in most cases 2

Important Safety Considerations

1. Monitor for adverse effects:

   • Extrapyramidal symptoms (most common with haloperidol)
   • QT prolongation and cardiac arrhythmias
   • Excessive sedation
   • Orthostatic hypotension
   • Falls

2. Dosing cautions:

   • Start with half the usual adult dose
   • Titrate slowly
   • Use for shortest possible duration
   • Evaluate need daily with in-person examination 1

3. Contraindications:

   • Avoid antipsychotics in patients with Parkinson's disease or Lewy body dementia
   • Use with caution in patients with cardiac conditions due to QT prolongation risk

Special Situations

• Hypoactive delirium: Antipsychotics and benzodiazepines should NOT be prescribed for older adults with postoperative delirium who are not agitated and not threatening harm 1

• Alcohol/benzodiazepine withdrawal: Benzodiazepines are indicated and should be used instead of antipsychotics 1

• Dementia with agitation: Be aware of increased mortality risk with antipsychotics in elderly patients with dementia-related psychosis 4

Remember that all pharmacological interventions for agitation in the elderly carry significant risks. The goal should be to use the lowest effective dose for the shortest possible duration while continuing to address underlying causes of agitation.