What is the management approach for restlessness or agitation in patients with acute stroke?

Management of Restlessness and Agitation in Acute Stroke Patients

The most effective approach for managing restlessness or agitation in acute stroke patients is to first identify and treat underlying causes, then use benzodiazepines (lorazepam) or antipsychotics (haloperidol) for pharmacological management when necessary. 1

Initial Assessment and Non-Pharmacological Management

• Identify and treat potential underlying causes of agitation, including:

  • Hypoxia, increased intracranial pressure, seizures, or hypoglycemia 1
  • Infections such as pneumonia or urinary tract infections 1
  • Pain, full bladder, or other physical discomfort 1
  • Fever (temperature >37.5°C) 1

• Monitor vital signs, including temperature, every 4 hours for the first 48 hours, then as per ward routine 1

• Implement non-pharmacological interventions:

  • Early mobilization within 24 hours of stroke onset if no contraindications exist 1
  • Frequent, brief, out-of-bed activity involving active sitting, standing, and walking 1
  • Adequate hydration 1
  • Orientation strategies and environmental modifications to reduce confusion 1

Pharmacological Management

First-Line Medications

• For mild to moderate agitation:

  • Lorazepam (benzodiazepine): 1-2 mg IV/IM, may repeat as needed 1, 2
  • Can be used alone or in combination with an antipsychotic for enhanced effect 2

• For moderate to severe agitation:

  • Haloperidol: 5-10 mg IV/IM as initial dose, may repeat or adjust based on response 1, 2
  • Preferred neuroleptic for rapid control of delirium and agitation in critically ill patients 2

Alternative Medications

• Olanzapine: 5-10 mg IM, shown to be comparable to haloperidol or lorazepam in managing acute agitation with fewer extrapyramidal side effects 3, 4

• Droperidol: Consider when rapid sedation is required, as it acts faster than haloperidol 1

• For agitation associated with hypertension, consider labetalol (10-20 mg IV over 1-2 minutes) which can address both issues simultaneously 1, 5

Special Considerations

• New-onset seizures should be treated with appropriate short-acting medications (e.g., lorazepam IV) if they are not self-limiting 1

• Prophylactic use of anticonvulsant medications is not recommended in patients with ischemic stroke 1

• When managing agitated patients eligible for thrombolytic therapy, maintain blood pressure <185/110 mmHg before initiating thrombolysis 1, 6

• Monitor for potential side effects:

  • Haloperidol can cause extrapyramidal symptoms and rarely cardiac arrhythmias 3
  • Benzodiazepines may cause respiratory depression, especially in patients with compromised respiratory function 2, 3
  • Olanzapine should not be used simultaneously with other CNS depressants due to risk of adverse events 3

Treatment Algorithm

1. Assess for and treat underlying causes (infection, pain, hypoxia, etc.) 1
2. Implement non-pharmacological interventions 1
3. If agitation persists:
   • For mild-moderate agitation: Lorazepam 1-2 mg IV/IM 1, 2
   • For severe agitation: Haloperidol 5-10 mg IV/IM 1, 2
   • For agitation with hypertension: Consider labetalol 1, 5
4. Reassess frequently and titrate medication as needed 2
5. Once stabilized, transition to oral medications if long-term management is required 3

Pitfalls and Caveats

• Avoid rapid or excessive sedation which may mask neurological symptoms or impede neurological assessment 1

• Benzodiazepines and antipsychotics may lower seizure threshold in some patients 2

• Beta-blockers may be particularly helpful in cases where traditional antipsychotics and benzodiazepines fail to control agitation 5

• Post-stroke mania or mood disorders can present as restlessness and may require specific psychiatric management 7

• Carefully monitor blood pressure when using sedative medications, especially in patients eligible for thrombolysis 1