What is the recommended treatment for agitation in elderly patients?

Treatment of Agitation in Elderly Patients

The recommended first-line approach for agitation in elderly patients is to identify and address reversible causes through non-pharmacological interventions, with pharmacological treatment reserved for severe cases where benzodiazepines should be avoided as first-line treatment and antipsychotics used only at the lowest effective dose for the shortest duration when necessary. 1, 2

Assessment and Non-Pharmacological Management

Identify and Treat Underlying Causes

• Address reversible causes of agitation first:
  • Explore patient concerns and anxieties
  • Ensure effective communication and orientation
  • Ensure adequate lighting
  • Treat medical causes: hypoxia, urinary retention, constipation, pain 1
  • Perform comprehensive medical evaluation 1

Non-Pharmacological Interventions

• Establish predictable daily routines with consistent meals, exercise, and bedtime schedules 2
• Implement environmental modifications:
  • Reduce excessive stimulation
  • Ensure adequate lighting during daytime to regulate circadian rhythm
  • Maintain comfortable room temperature 2
• Use distraction and redirection techniques when agitation begins 2
• Break complex activities into simple steps 2
• Consider simulated presence therapy using audio/video recordings from family members 2
• Animal-assisted interventions or pet robot therapy may be effective 2

Pharmacological Management

For Anxiety or Agitation (Patient Able to Swallow)

1. Lorazepam 0.25-0.5 mg orally four times a day as needed (maximum 2 mg in 24 hours for elderly patients) 1
   • Oral tablets can be used sublingually (off-label use)
   • CAUTION: Benzodiazepines should not be used as first-line treatment of agitation associated with delirium 1

For Anxiety or Agitation (Patient Unable to Swallow)

1. Midazolam 2.5-5 mg subcutaneously every 2-4 hours as needed 1
   • If needed frequently, consider subcutaneous infusion via syringe driver starting with 10 mg over 24 hours
   • Reduce dose to 5 mg over 24 hours if eGFR <30 mL/minute
   • CAUTION: Same concerns as with oral benzodiazepines

For Delirium with Agitation (Patient Able to Swallow)

1. Haloperidol 0.5-1 mg orally at night and every 2 hours when required 1
   • Increase dose in 0.5-1 mg increments as required (maximum 5 mg daily in elderly patients)
   • Consider higher starting dose (1.5-3 mg) only if patient is severely distressed or causing immediate danger
   • Use antipsychotics only at the lowest effective dose for the shortest possible duration 2

For Delirium with Agitation (Patient Unable to Swallow)

1. Levomepromazine 6.25-12.5 mg subcutaneously as starting dose in elderly patients 1
   • Can be given hourly as required
   • Maintain with subcutaneous infusion of 50-200 mg over 24 hours

Special Considerations

Medication Cautions

• Avoid medications with high risk for precipitating delirium 1
• Antipsychotics and benzodiazepines should be avoided for hypoactive delirium 1
• Patients with Parkinson's Disease or Lewy Body Dementia have increased sensitivity to antipsychotics like risperidone, with manifestations including confusion, postural instability, falls, extrapyramidal symptoms, and features consistent with neuroleptic malignant syndrome 3
• Antipsychotics in dementia patients increase mortality risk and cognitive decline 2

Pain Management

• Optimize pain management, preferably with non-opioid medications, to prevent delirium 1
• Acetaminophen is the preferred first-line pharmacological option for pain management 2

Monitoring

• Monitor for improvement in agitation behaviors, sleep quality, and potential side effects
• Regularly reassess agitation using quantitative measures like Neuropsychiatric Inventory Questionnaire (NPI-Q) 2
• For patients on antipsychotics, monitor for extrapyramidal symptoms, sedation, orthostatic hypotension, and falls 2, 3

Common Pitfalls to Avoid

• Overreliance on antipsychotics without addressing underlying causes 4
• Using physical restraints before exhausting non-pharmacological approaches 4
• Inadequate trial of non-pharmacological interventions before medications 2
• Continuing ineffective medications without reassessment 2
• Not involving caregivers in treatment planning 2

By following this structured approach to managing agitation in elderly patients, clinicians can provide effective care while minimizing risks associated with pharmacological interventions.