What medications are used to manage aggressive behavior in geriatric patients?

Management of Aggressive Behavior in Geriatric Patients

For acute severe agitation with risk of harm, use low-dose haloperidol (0.5-1 mg orally or subcutaneously) only after non-pharmacological interventions have failed; for chronic agitation in dementia, SSRIs (citalopram or sertraline) are first-line pharmacological treatment. 1, 2

Immediate Assessment and Non-Pharmacological Management

Before any medication is considered, address reversible causes and implement behavioral strategies:

• Identify and treat underlying medical triggers: hypoxia, urinary retention, constipation, pain, urinary tract infections, and pneumonia 1
• Environmental modifications: reduce noise, ensure adequate lighting, maintain predictable daily routines for meals and bedtime 2
• Communication strategies: use the "three R's" approach (repeat instructions, reassure the patient, redirect attention) 2
• Structured activities: provide tailored activities individualized to current capabilities and previous interests 2

Pharmacological Management Algorithm

For Acute Severe Agitation (Immediate Threat of Harm)

Use antipsychotics only when:

• Patient is severely agitated or distressed AND threatening substantial harm to self or others 3
• Behavioral interventions have failed or are not possible 3, 1

Medication choice:

• Haloperidol 0.5-1 mg orally or subcutaneously, repeat every 2 hours as needed, maximum 5 mg daily in elderly patients 1
• Use the lowest effective dose for the shortest possible duration 3, 1
• Evaluate ongoing use daily with in-person examination 3

Critical warnings about antipsychotics:

• Patients over 75 years respond less well to antipsychotics, particularly olanzapine 3, 1
• Short-term treatment is associated with increased mortality 3
• Risk of QT prolongation, dysrhythmias, sudden death, hypotension, pneumonia, falls, and metabolic effects 3
• 47% of patients continue receiving antipsychotics after discharge without clear indication—avoid inadvertent chronic use 3

For Chronic Agitation in Dementia

First-line pharmacological treatment: SSRIs

• Citalopram or sertraline significantly reduce overall neuropsychiatric symptoms and agitation 2, 4
• Citalopram showed significant reduction in agitation on the Cohen-Mansfield Agitation Inventory (CMAI) compared to placebo 4
• Monitor for side effects: sweating, tremors, nervousness, insomnia/somnolence, dizziness, gastrointestinal disturbances 2, 5

Treatment protocol:

• Initiate at low dose and titrate to minimum effective dose 3
• Assess response with quantitative measures 3
• If no clinically significant response after 4 weeks of adequate dosing, taper and withdraw 3
• Even with positive response, periodically reassess need for continued medication 3, 2

What NOT to Use

Avoid benzodiazepines as first-line treatment:

• Should not be used except for specific indications (alcohol or benzodiazepine withdrawal) 3
• Can increase delirium incidence and duration 1
• May cause paradoxical agitation in approximately 10% of elderly patients 1
• If absolutely necessary: lorazepam 0.25-0.5 mg orally (maximum 2 mg in 24 hours) 1

Do not newly prescribe cholinesterase inhibitors:

• Not effective in preventing or treating delirium 3
• Associated with more adverse effects and increased mortality risk 3

Risk/Benefit Discussion Requirements

Before initiating antipsychotic treatment, discuss with patient (if feasible) and surrogate decision maker:

• Potential risks: increased mortality, cardiovascular effects, falls, metabolic changes 3
• Expected benefits and treatment goals 3
• Alternative non-pharmacological approaches 3
• Plan for ongoing monitoring and reassessment 3

Common Pitfalls to Avoid

• Do not continue antipsychotics indefinitely: Review need at every visit and taper if no longer indicated 3
• Do not use antipsychotics for mild agitation: Reserve for severe symptoms that are dangerous or cause significant distress 3
• Do not skip non-pharmacological interventions: These must be attempted first unless emergency situation 3
• Do not ignore the distinction between reactive and proactive aggression: Reactive aggression (due to lack of understanding) responds to improved communication and delayed treatment, while proactive aggression (from hallucinations/delusions) may require antipsychotic medication 6