What medications can be prescribed for agitation and psychosis in elderly nursing home residents?

Medication Management for Agitation and Psychosis in Elderly Nursing Home Residents

For elderly nursing home residents with agitation and psychosis, haloperidol 0.5-1 mg orally at night and every 2 hours as required (maximum 5 mg daily in elderly) is the first-line pharmacological treatment after addressing reversible causes. 1

Step 1: Address Reversible Causes First

Before initiating any medication:

• Explore patient's concerns and anxieties
• Ensure effective communication and orientation
• Ensure adequate lighting
• Treat underlying medical causes such as:
  • Pain
  • Hypoxia
  • Urinary retention
  • Constipation
  • Medication side effects
  • Sensory deficits
  • Undiagnosed medical conditions

Step 2: Non-Pharmacological Interventions

Always attempt these strategies before medication:

• Create a predictable daily routine
• Provide a dementia-friendly environment with:
  • Comfortable seating
  • Adequate access to food, drink, and toileting
  • Reduced sensory overload
  • Clear signage
  • Proper lighting
• Document triggers using ABC (antecedent-behavior-consequences) charting
• Train caregivers in effective communication techniques

Step 3: Pharmacological Management Algorithm

For Delirium with Agitation (able to swallow):

1. First-line: Haloperidol 0.5-1 mg orally at night and every 2 hours when required

   • Maximum 5 mg daily in elderly patients
   • Consider higher starting dose (1.5-3 mg) if severely distressed or causing immediate danger 1

2. If inadequate response: Add a benzodiazepine

   • Lorazepam 0.25-0.5 mg orally four times a day as required (maximum 2 mg in 24 hours) 1

For Delirium with Agitation (unable to swallow):

1. First-line: Levomepromazine 6.25-12.5 mg subcutaneously as starting dose in elderly patients

   • Maintain with subcutaneous infusion of 50-200 mg over 24 hours 1

2. If anxiety is prominent: Consider midazolam

   • 2.5-5 mg subcutaneously every 2-4 hours as required
   • Reduce dose to 5 mg over 24 hours if eGFR <30 mL/minute 1

For Psychosis in Dementia:

1. First-line (after non-pharmacological approaches):

   • Risperidone 0.5-2.0 mg/day 2
   • Start at lowest dose and titrate slowly

2. Second-line options:

   • Quetiapine 50-150 mg/day
   • Olanzapine 5.0-7.5 mg/day 2

Special Considerations

Medication Selection Based on Comorbidities:

• Parkinson's disease: Quetiapine preferred 2
• Diabetes/obesity/dyslipidemia: Avoid olanzapine and low-potency conventional antipsychotics 2
• Cardiac issues (QTc prolongation/CHF): Avoid ziprasidone and low-potency conventional antipsychotics 2

Duration of Treatment:

• For agitated dementia: Taper within 3-6 months to determine lowest effective maintenance dose 2
• For delirium: Approximately 1 week after resolution 2

Important Warnings:

1. Black Box Warning: Antipsychotics increase mortality risk in elderly patients with dementia-related psychosis 3

2. Monitor for adverse effects:

   • Extrapyramidal symptoms
   • Orthostatic hypotension
   • QT prolongation
   • Sedation
   • Falls
   • Metabolic effects

3. Avoid inadvertent chronic administration: Review necessity regularly and discontinue when possible 1

Monitoring Recommendations

• Assess effectiveness using quantitative measures like Neuropsychiatric Inventory Questionnaire (NPI-Q)
• Monitor for side effects at each visit
• Reassess at least every 6 months
• Document response to treatment and any adverse effects

Remember that antipsychotics should be used at the lowest effective dose for the shortest possible duration, and only when behavioral interventions have failed or are not possible 1. Regular in-person examinations are essential to evaluate ongoing need for medication.