What medication helps with pacing due to anxiety or agitation?

Medications for Managing Pacing Due to Anxiety or Agitation

For patients with anxiety or agitation causing pacing behavior, benzodiazepines like lorazepam are the first-line pharmacological treatment, with antipsychotics such as haloperidol as alternatives for severe agitation, particularly when associated with delirium. 1

First-Line Medications

Benzodiazepines

• Lorazepam (Ativan):

  • Dosing for patients able to swallow: 0.5-1 mg orally four times a day as needed (maximum 4 mg/24 hours) 1
  • For elderly/debilitated patients: Reduced dose of 0.25-0.5 mg (maximum 2 mg/24 hours) 1
  • Oral tablets can be used sublingually (off-label) for faster onset 1
  • For patients unable to swallow: Consider midazolam 2.5-5 mg subcutaneously every 2-4 hours 1

• Other benzodiazepine options:

  • Oxazepam (Serax)
  • Temazepam (Restoril)
  • Zolpidem (Ambien)
  • Triazolam (Halcion) 1

Non-Benzodiazepine Anxiolytics

• Buspirone (BuSpar):
  • Initial dosage: 5 mg twice daily
  • Maximum: 20 mg three times daily
  • Only effective for mild to moderate agitation
  • Takes 2-4 weeks to become effective 1
  • Lacks dependence/abuse potential and has minimal sedative effects 2, 3
  • Safe for long-term use up to one year 4

Second-Line Medications

Antipsychotics (for severe agitation or delirium)

• Haloperidol (Haldol):

  • For delirium with agitation: 0.5-1 mg orally at night and every 2 hours as needed 1
  • Increase in 0.5-1 mg increments as needed (maximum 10 mg daily, or 5 mg in elderly) 1
  • Consider higher starting dose (1.5-3 mg) for severely distressed patients 1
  • Monitor for extrapyramidal symptoms 1, 5

• Second-generation antipsychotics:

  • Quetiapine: Initial 12.5-25 mg orally twice daily, maximum 200 mg twice daily 5
  • Risperidone: Initial 0.25-0.5 mg orally at bedtime, maximum 2-3 mg/day 5
  • Olanzapine: 5-10 mg IM for acute agitation requiring sedation 5
  • Aripiprazole: Initial 5 mg orally daily 5

Mood Stabilizers/Antiagitation Medications

• Trazodone (Desyrel):

  • Initial dosage: 25 mg daily
  • Maximum: 200-400 mg daily in divided doses
  • Use with caution in patients with premature ventricular contractions 1, 5

• Divalproex sodium (Depakote):

  • Initial dosage: 125 mg twice daily
  • Titrate to therapeutic blood level (40-90 mcg/mL)
  • Generally better tolerated than other mood stabilizers
  • Monitor liver enzymes and blood clotting parameters 1

• Carbamazepine (Tegretol):

  • Initial dosage: 100 mg twice daily
  • Titrate to therapeutic blood level (4-8 mcg/mL)
  • Has problematic side effects
  • Monitor complete blood count and liver enzymes regularly 1

Algorithm for Treatment Selection

1. Assess severity of agitation/pacing:

   • Mild to moderate: Start with non-pharmacological approaches
   • Moderate to severe: Consider pharmacological intervention

2. For anxiety-driven pacing:

   • First choice: Lorazepam (if immediate relief needed)
   • Alternative: Buspirone (if long-term treatment with less sedation desired)

3. For agitation with delirium:

   • First choice: Haloperidol (unless contraindicated)
   • Alternative: Second-generation antipsychotics (quetiapine, risperidone)

4. For chronic agitation without delirium:

   • First choice: SSRIs (sertraline 25-100 mg daily) 5
   • Alternative: Trazodone (especially if sleep disturbance is present)

Important Considerations and Cautions

• Benzodiazepines:

  • Regular use can lead to tolerance, addiction, depression, and cognitive impairment
  • Paradoxical agitation occurs in about 10% of patients
  • Use infrequent, low doses of short half-life agents when possible 1

• Antipsychotics:

  • FDA black box warning regarding increased mortality risk in dementia patients
  • Monitor for QTc prolongation, especially with haloperidol
  • Watch for extrapyramidal symptoms 5
  • Should be avoided or used at lowest effective dose for shortest duration possible 5

• Monitoring:

  • Schedule follow-up within 2 weeks to assess response
  • Monitor for side effects, cognitive function, falls risk, and therapeutic response 5
  • Regularly reassess the need for continued treatment 5

• Non-pharmacological approaches should be attempted first when possible, including:

  • Environmental modifications to reduce stimulation
  • De-escalation techniques
  • Addressing underlying causes (pain, discomfort, environmental triggers) 5

By following this structured approach, clinicians can effectively manage pacing behavior while minimizing risks associated with pharmacological interventions.