What medication is recommended for nocturnal agitation in a hospital setting?

From the Guidelines

For nightly agitation in the hospital, haloperidol 0.5-1mg is the recommended first-line option, as it has been shown to be effective in managing agitation with a relatively favorable safety profile, as indicated in the most recent guideline 1. When considering medication for nightly agitation, it's essential to start with the lowest effective dose and use it for the shortest duration possible, typically beginning 1-2 hours before bedtime. Non-pharmacological approaches, such as reorientation, maintaining day-night cycles with appropriate lighting, ensuring comfort, and addressing pain or other physical needs, should be tried first. Benzodiazepines like lorazepam 0.5-1mg can be considered but should be used cautiously, especially in elderly patients, due to risks of falls, respiratory depression, and paradoxical agitation, as suggested by 1. The choice of medication should be individualized based on the patient's age, comorbidities, and potential drug interactions. Key considerations include:

• Starting with a low dose of haloperidol, such as 0.5-1mg, and increasing as needed, with a maximum of 10mg daily or 5mg daily in elderly patients, as recommended by 1.
• Considering the addition of a benzodiazepine if the patient remains agitated, under close monitoring for potential adverse effects.
• Prioritizing the management of underlying causes of agitation, such as pain, delirium, or anxiety, to ensure effective and sustainable management of symptoms.

From the FDA Drug Label

The efficacy of intramuscular olanzapine for injection for the treatment of agitation was established in 3 short-term (24 hours of IM treatment) placebo-controlled trials in agitated adult inpatients from 2 diagnostic groups: schizophrenia and bipolar I disorder (manic or mixed episodes)

For nightly agitation in the hospital, olanzapine may be considered, specifically the intramuscular formulation, as it has been shown to be effective in treating agitation in adult inpatients with schizophrenia and bipolar I disorder 2. However, it is essential to note that the provided information does not explicitly mention "nightly" agitation, and the studies mentioned were short-term (24 hours of IM treatment).

• The primary efficacy measure used for assessing agitation signs and symptoms in these trials was the change from baseline in the PANSS Excited Component at 2 hours post-injection.
• Patients enrolled in the trials needed to be judged by the clinical investigators as clinically agitated and clinically appropriate candidates for treatment with intramuscular medication.

From the Research

Medication Options for Nightly Agitation in the Hospital

• The choice of medication for nightly agitation in the hospital depends on various factors, including the patient's underlying condition, medical history, and the severity of agitation 3, 4.
• Pharmacological treatment options include neuroleptics, benzodiazepines, and α2 agonists, which can be used alone or in combination 3, 5.
• For rapid tranquilization, intramuscular sedative agents such as antipsychotics, benzodiazepines, and ketamine can be used 5.
• A study comparing the combination of intramuscular droperidol/midazolam to haloperidol/lorazepam found that droperidol/midazolam was superior in achieving adequate sedation at 10 minutes 6.
• Atypical antipsychotics may be a suitable option for certain patients, with the added benefit of easier conversion to maintenance therapy 7.

Considerations for Specific Patient Populations

• Elderly patients with delirium and/or dementia require special consideration, and management should be guided by etiology and patient characteristics 7.
• Patients with sleep deprivation, brain injury, or underlying disease require individualized treatment plans 3, 4.
• The risk of medication-related adverse events, such as QT prolongation and torsades de pointes, should be considered when selecting a medication 5.

Comparison of Medication Options

• Droperidol (5-10 mg IM) and midazolam (5-10 mg IM) have been shown to have a faster onset of sedation compared to other agents 5, 6.
• Ketamine (5 mg/kg IM) is often reserved as a second-line agent due to the risk of airway compromise, but a lower dose (2 mg/kg IM) may reduce this risk while providing adequate sedation 5.