What is the best treatment plan for an elderly patient with agitation who is on comfort measures, able to take oral medications, and currently being treated with PRN trazodone BID?

Management of Agitation in an Elderly Patient on Comfort Measures

For an elderly patient with agitation who is on comfort measures and able to take oral medications, haloperidol 0.5-1 mg orally at night and every 2 hours as needed is the most appropriate treatment, with consideration of adding lorazepam if agitation persists despite adequate haloperidol dosing. 1

First-Line Pharmacological Management

Antipsychotics

• Haloperidol is the preferred first-line agent for delirium with agitation in patients on comfort measures:

  • Starting dose: 0.5-1 mg orally at night and every 2 hours when required 1
  • Maximum dose: 5 mg daily in elderly patients 1
  • Can be increased in 0.5-1 mg increments as required based on response 1
  • Consider a higher starting dose (1.5-3 mg) if the patient is severely distressed or causing immediate danger to others 1

• Alternative antipsychotic options if haloperidol is not effective or tolerated:

  • Risperidone 0.5-1 mg twice daily 1
  • Olanzapine 2.5-15 mg daily 1
  • Quetiapine 50-100 mg PO twice daily 1

Benzodiazepines

• If agitation is refractory to antipsychotics, add lorazepam:
  • 0.5-1 mg orally four times a day as required (maximum 4 mg in 24 hours) 1
  • Reduce dose to 0.25-0.5 mg in elderly patients (maximum 2 mg in 24 hours) 1
  • Oral tablets can be used sublingually if needed (off-label use) 1

Non-Pharmacological Interventions (to be used concurrently)

• Address reversible causes of agitation first:
  • Explore patient's concerns and anxieties 1
  • Ensure effective communication and orientation 1
  • Provide adequate lighting 1
  • Treat underlying causes such as pain, constipation, or urinary retention 1
  • Orient patient with family presence 1

Monitoring and Dose Adjustment

• Titrate starting dose to optimal effect 1
• Monitor for symptom control and adjust medication as needed 1
• If needed frequently (more than twice daily), consider scheduled dosing 1
• Decrease doses if hepatic or renal failure is present 1

Important Considerations and Cautions

Trazodone Considerations

• Current PRN trazodone BID may not be the optimal choice for managing agitation in this population 2, 3
• Trazodone has shown limited efficacy for agitation in controlled trials compared to placebo 2, 3
• While trazodone has sedative properties, it carries risks in elderly patients:
  • Orthostatic hypotension increasing fall risk 4
  • Drowsiness/sedation 4
  • QTc prolongation with risk of ventricular arrhythmias 4

Antipsychotic Cautions

• Monitor for extrapyramidal symptoms with haloperidol 1
• Atypical antipsychotics may have fewer extrapyramidal side effects but can cause:
  • Sedation (especially quetiapine) 1
  • Orthostatic hypotension 1
  • Metabolic effects with long-term use 1

Benzodiazepine Cautions

• Increased risk of falls 1
• May cause paradoxical agitation, especially in elderly 1
• Use lower doses in frail elderly patients 1

Treatment Algorithm for Agitation in Elderly on Comfort Measures

1. First step: Discontinue trazodone and initiate haloperidol 0.5-1 mg orally at night and every 2 hours PRN 1
2. If inadequate response after 24-48 hours: Increase haloperidol dose in 0.5-1 mg increments 1
3. If still inadequate response: Add lorazepam 0.25-0.5 mg orally up to four times daily PRN 1
4. If severe, refractory agitation: Consider higher doses of haloperidol (up to 5 mg daily in elderly) or switch to an atypical antipsychotic such as quetiapine 25 mg twice daily 1

The goal of treatment should be adequate symptom control with minimal side effects, focusing on the patient's comfort and quality of life while on comfort measures 1.