What are the recommended management strategies for geriatric aggression?

Management of Geriatric Aggression

Geriatric aggression requires a systematic approach beginning with immediate assessment for delirium and agitation, followed by non-pharmacological interventions as first-line therapy, with pharmacologic management reserved for severe cases where patients pose harm to themselves or others, or when agitation impedes time-sensitive diagnostic procedures. 1

Initial Assessment and Identification

Implement mandatory screening protocols for delirium and agitation in all geriatric patients presenting with behavioral disturbances. 1

• Assess for underlying medical causes including pain, infection, metabolic derangements, and medication effects, as these are the most common precipitants of aggression in elderly patients 2, 3
• Screen for hyperactive delirium, which is a primary driver of agitation in older emergency department patients and can impede diagnosis of life-threatening conditions 2
• Evaluate for pre-existing dementia or psychiatric disorders (schizophrenia, bipolar disorder), as these require different management strategies 1, 2
• Identify substance use or withdrawal as potential contributors to aggressive behavior 2
• Assess sensory impairments (hearing, vision) that may contribute to confusion and agitation 1

Non-Pharmacological Management (First-Line)

Deploy environmental and behavioral interventions before considering pharmacologic options, as these are effective for mild to moderate agitation and carry no adverse effects. 1, 2

Environmental Modifications

• Reduce noise levels and enhance acoustical privacy, as enhanced environments increase patient safety and reduce withholding of medical information 1
• Provide access to music programming that patients can control without disturbing others 1
• Simplify the environment and establish structured routines to reduce confusion 1
• Ensure adequate lighting and minimize overstimulation 1

Communication Strategies

• Use calmer tones, simpler single-step commands, and light touch for reassurance 1
• Avoid harsh tones, complex multi-step commands, open-ended questioning, and screaming 1
• Include family/caregivers in the triage and care process, as their presence improves outcomes 1

Pain Management

• Implement aggressive pain control using multimodal analgesic approaches, as effective pain management reduces unnecessary psychotropic prescriptions 1, 2
• Recognize that uncontrolled pain is a major contributor to agitation in geriatric patients 1

Caregiver Education

• Educate caregivers that aggressive behaviors in dementia are not intentional but represent unmet needs 1
• Train staff and caregivers in de-escalation techniques and communication strategies 1, 4

Pharmacological Management (Second-Line)

Reserve pharmacologic interventions for three specific scenarios: agitation related to primary psychiatric conditions, severe agitation where patients risk harming themselves or others, and when agitation prevents time-sensitive diagnostic imaging or procedures. 2

Indications for Pharmacotherapy

• Severe agitation with imminent risk of harm to self or others 2
• Agitation impeding critical diagnostic procedures or treatment 2
• Underlying psychiatric disorder requiring optimization of existing regimen 1
• Failure of non-pharmacological interventions in moderate to severe cases 2, 3

Medication Selection Principles

• Use geriatric-specific dosing with lower starting doses than younger adults 2
• Consider contraindications specific to elderly patients, including increased fall risk, cognitive impairment, and cardiovascular effects 2
• Monitor closely for adverse effects including oversedation, delirium worsening, and extrapyramidal symptoms 2, 3

Available Pharmacologic Agents

Emergency physicians have several options including antipsychotics, benzodiazepines, opioid and non-opioid analgesics, ketamine, and combination agents, though specific agent selection should be guided by the underlying cause and patient-specific factors 2

Restraint Policies and Safety

Establish clear restraint policies as part of comprehensive patient safety protocols, using physical restraints only as a last resort when all other interventions have failed. 1

• Implement restraint policies that prioritize patient dignity and safety 1
• Document all attempts at de-escalation before applying restraints 1
• Monitor restrained patients continuously for complications 1

Critical Pitfalls to Avoid

• Do not assume aggression is "just dementia" without ruling out delirium, pain, infection, or metabolic causes, as these are treatable and reversible 2, 3
• Do not skip non-pharmacological interventions in favor of immediate sedation, as this increases adverse outcomes and fails to address underlying causes 1, 4
• Do not use standard adult dosing of psychotropic medications, as elderly patients require geriatric-specific dosing to avoid toxicity 2
• Do not ignore caregiver distress, as caregiver burden is associated with increased aggression and predicts institutionalization 3, 5

Ongoing Monitoring and Follow-Up

Implement systematic evaluation protocols to assess intervention effectiveness and adjust management strategies accordingly. 1

• Assess whether recommended non-pharmacological strategies were implemented and if they reduced both the aggressive behavior and caregiver distress 1
• For patients on psychotropic medications, consider dose reduction or discontinuation trials to ensure continued necessity 1
• Recognize that behavioral symptoms fluctuate over the dementia course, requiring ongoing reassessment 1
• Refer high-risk patients to case management upon admission with documented risk assessment results 1