What is the best approach to manage agitation in hospitalized older adults?

Management of Agitation in Hospitalized Older Adults

Implement multicomponent nonpharmacologic interventions as first-line treatment, delivered by an interdisciplinary team throughout hospitalization, and avoid routine use of antipsychotics—reserving haloperidol or atypical antipsychotics only for severe distress with hallucinations/delusions or when patients pose imminent harm to themselves or others. 1

Initial Assessment: Identify and Treat Underlying Causes

Before any intervention, aggressively search for and treat reversible medical causes, as delays prolong delirium and worsen outcomes including mortality: 1

• Pain (often undertreated and a primary driver of agitation) 2, 3
• Hypoxia requiring supplemental oxygen 2, 4
• Urinary retention or constipation 2, 4
• Infections (UTI, pneumonia, sepsis) 2
• Dehydration and electrolyte disturbances 2
• Medication side effects (anticholinergics, benzodiazepines, opioids) 2
• Sensory impairments (ensure glasses and hearing aids are available) 2

The American Geriatrics Society strongly recommends performing medical evaluation and making medication/environmental adjustments immediately upon diagnosing delirium, as treatment delays result in prolonged delirium, worse cognitive recovery, and higher mortality. 1

First-Line: Multicomponent Nonpharmacologic Interventions

These interventions have strong evidence for reducing delirium incidence, duration, and mortality with no harmful effects. 1

Core Components (implement as a bundle):

• Cognitive reorientation: Use clocks, calendars, familiar objects; provide frequent reorientation to time/place/person 1
• Sleep enhancement: Minimize nighttime noise and light; cluster care activities; avoid unnecessary vital signs 1
• Early mobilization: Get patients out of bed and walking as soon as medically safe 1
• Vision/hearing optimization: Ensure glasses and hearing aids are in place and functioning 1
• Hydration and nutrition: Proactive fluid repletion and nutritional support 1
• Pain management: Aggressive treatment with appropriate analgesics 1, 2
• Medication review: Discontinue or minimize deliriogenic medications 1

The ABCDEF bundle (Assessment of pain, Both spontaneous awakening and breathing trials, Choice of sedation, Delirium monitoring, Early mobility, Family engagement) showed reduced mortality and more delirium-free days in multicenter studies. 1

Environmental and Communication Strategies:

• Decrease sensory stimulation: Quiet room, dim lighting, minimize staff traffic 2
• Verbal de-escalation: Respect personal space, use calm demeanor, designate one staff member to interact, use simple language, set clear limits 2
• Avoid physical restraints: The American Geriatrics Society explicitly recommends against restraints as they exacerbate delirium 1

Pharmacologic Management: Use Sparingly and Only When Necessary

When to Consider Pharmacotherapy:

Reserve medications ONLY for: 1

• Patients with significant distress from hallucinations or delusions causing fearfulness
• Agitation severe enough that patient may harm themselves or others
• Agitation preventing essential diagnostic procedures or treatments

Critical Evidence on Antipsychotics:

The 2018 Critical Care Medicine guidelines conditionally recommend AGAINST routine use of haloperidol or atypical antipsychotics for delirium treatment, as they do not reduce delirium duration, mechanical ventilation time, ICU length of stay, or mortality. 1 This represents the most recent high-quality guideline evidence and should guide practice.

If Pharmacotherapy is Necessary:

For patients who can swallow: 2, 4, 5

• Haloperidol 0.5-1 mg PO at night and every 2 hours as needed (maximum 5 mg daily in elderly)
• Start at the lowest possible dose (0.5 mg) in geriatric patients 5
• Alternative: Lorazepam 0.25-0.5 mg PO four times daily as needed for anxiety (though benzodiazepines increase delirium risk and should not be first-line) 2, 4

For patients unable to swallow: 4, 6

• Haloperidol 0.5-1 mg subcutaneously every 2 hours as needed (maximum 5 mg daily)
• Can use subcutaneous infusion of 2.5-10 mg over 24 hours if needed frequently 4
• Alternative: Levomepromazine 6.25-12.5 mg subcutaneously 4

Critical Cautions with Pharmacotherapy:

• Monitor for extrapyramidal symptoms (occur frequently in elderly with haloperidol) 4, 5
• Discontinue immediately once agitation resolves—do not continue unnecessarily 1, 4
• Avoid benzodiazepines as first-line for delirium (increase delirium risk, prolong duration, higher adverse events) 4
• Atypical antipsychotics may be better tolerated than haloperidol but lack superior efficacy 4

Special Considerations for Dementia

For patients with underlying dementia, nonpharmacologic approaches are even more critical as first-line treatment. 2 A randomized trial showed that haloperidol, trazodone, and behavioral management techniques all produced comparable modest reductions in agitation—no better than placebo—with haloperidol causing more parkinsonian adverse effects. 7

Common Pitfalls to Avoid

• Failing to identify treatable medical causes before resorting to sedation 2
• Using standard adult doses without geriatric dose adjustments 2, 5
• Jumping to pharmacotherapy without attempting nonpharmacologic interventions first 2
• Continuing antipsychotics after hospital discharge when no longer needed 1
• Using physical restraints, which worsen delirium and outcomes 1