What is the first line pharmacological therapy for acute agitation in elderly patients in the hospital?

First-Line Pharmacological Therapy for Acute Agitation in Elderly Hospitalized Patients

Antipsychotics at the lowest effective dose for the shortest possible duration should be used as first-line pharmacological therapy for acute agitation in elderly hospitalized patients, but only after behavioral interventions have failed or are not possible. 1

Decision Algorithm for Acute Agitation Management

Step 1: Non-Pharmacological Approaches (Try First)

• Environmental modifications to decrease sensory stimulation
• Verbal de-escalation techniques using calm communication
• Establish rapport and identify patient's wants/feelings

Step 2: Pharmacological Management (When Non-Pharmacological Approaches Fail)

First-Line Option:

• Low-dose antipsychotics for severely agitated elderly patients threatening harm to self/others 1
  • Risperidone: 0.5-2.0 mg/day (first-line choice) 2
  • Quetiapine: 50-150 mg/day (high second-line option) 2
  • Olanzapine: 5.0-7.5 mg/day (high second-line option) 2

Important Considerations:

• Use the lowest effective dose possible
• Prescribe for shortest duration necessary
• Evaluate daily with in-person examination
• Monitor for extrapyramidal symptoms, QT prolongation, sedation, and falls risk

Step 3: Special Situations

For Patients with Parkinson's Disease:

• Quetiapine is first-line 3

For Patients with Diabetes, Obesity, or Dyslipidemia:

• Avoid clozapine and olanzapine 3
• Consider risperidone (preferred) or quetiapine 3

For Patients with Cardiac Issues (QTc prolongation or CHF):

• Avoid clozapine, ziprasidone, and low-potency conventional antipsychotics 3

Medications to Avoid as First-Line

Benzodiazepines

• Not recommended as first-line treatment for agitated elderly patients 1
• Should only be used when specifically indicated (e.g., alcohol or benzodiazepine withdrawal) 1
• Associated with increased delirium risk, longer delirium duration, and possible transition to delirium in ICU patients 1

Cholinesterase Inhibitors

• Should not be newly prescribed to prevent or treat delirium 1
• May be associated with adverse effects and increased mortality risk 1

Monitoring and Follow-up

• Schedule follow-up within 2 weeks to assess response 2
• Monitor for:
  • Extrapyramidal symptoms
  • QT prolongation
  • Cognitive function
  • Falls risk
  • Therapeutic response

Important Caveats

• The quality of evidence for these recommendations is generally low 1
• Antipsychotics carry an FDA black box warning regarding increased mortality risk in dementia patients 2
• For hypoactive delirium (non-agitated), antipsychotics should not be prescribed 1
• Pharmacologic treatment has not been consistently shown to modify the duration or severity of postoperative delirium 1
• Regular reassessment is critical to minimize duration of antipsychotic use

Remember that all antipsychotics should be used cautiously in elderly patients, with close monitoring for adverse effects and with the goal of tapering and discontinuing as soon as clinically appropriate.