What is the recommended pharmacological treatment for agitation in the elderly?

Management of Agitation in the Elderly

For agitation in elderly patients, attempt non-pharmacological interventions first, then initiate an SSRI (citalopram 10 mg/day or sertraline 25-50 mg/day) as first-line pharmacological treatment for chronic agitation, reserving low-dose atypical antipsychotics (risperidone 0.25-0.5 mg/day) only for severe acute agitation with imminent risk of harm to self or others after behavioral approaches have failed. 1

Step 1: Rule Out Reversible Causes

Before any pharmacological intervention, systematically investigate and treat underlying medical causes:

• Pain is a major contributor to behavioral disturbances in patients who cannot verbally communicate discomfort 1
• Infections, especially urinary tract infections and pneumonia 1
• Metabolic disturbances including hypoxia, dehydration, constipation, and urinary retention 1
• Medication toxicity, particularly anticholinergic medications that worsen agitation 2, 1
• Sensory impairments such as hearing or vision deficits that increase confusion and fear 1

Step 2: Non-Pharmacological Interventions (Required First)

Environmental and behavioral modifications must be attempted and documented as failed before initiating medications 1:

• Use calm tones, simple one-step commands, and gentle touch for reassurance 1
• Ensure adequate lighting and effective communication to maintain orientation 1
• Establish consistent routines and simplify tasks 1
• Provide adequate supervision and ensure environmental safety 1
• Time care activities when the patient is most calm and receptive 1

Step 3: Pharmacological Treatment Algorithm

For Chronic Mild-to-Moderate Agitation

SSRIs are the preferred first-line pharmacological option 1:

• Citalopram: Start 10 mg/day, maximum 40 mg/day 1
• Sertraline: Start 25-50 mg/day, maximum 200 mg/day 2, 1
• Assess response with quantitative measures after 4 weeks of adequate dosing 1
• If no clinically significant response after 4 weeks, taper and withdraw 1
• Even with positive response, periodically reassess the need for continued medication 1

For Severe Acute Agitation with Imminent Risk of Harm

Only when the patient is severely agitated, threatening substantial harm to self or others, and behavioral interventions have failed 1:

First-line atypical antipsychotics 1, 3:

• Risperidone: Start 0.25 mg at bedtime, maximum 2-3 mg/day in divided doses 2, 1
  • Extrapyramidal symptoms may occur at doses ≥2 mg/day 2
  • Patients over 75 years respond less well 1
• Quetiapine: Start 12.5 mg twice daily, maximum 200 mg twice daily 2
  • More sedating with risk of transient orthostasis 2
  • Preferred for patients with Parkinson's disease 3
• Olanzapine: Start 2.5 mg at bedtime, maximum 10 mg/day 2
  • Generally well tolerated but less effective in patients over 75 years 1

For acute agitation requiring rapid intervention:

• Haloperidol: 0.5-1 mg orally or subcutaneously, maximum 5 mg daily 1
  • Use only for shortest duration possible with daily reassessment 1

Alternative Mood Stabilizers (Second-Line)

For severe agitation without psychotic features when SSRIs and antipsychotics are not appropriate 2:

• Divalproex sodium: Start 125 mg twice daily, titrate to therapeutic blood level (40-90 mcg/mL) 2
  • Monitor liver enzymes and coagulation parameters 2
• Trazodone: Start 25 mg/day, maximum 200-400 mg/day in divided doses 2
  • Use with caution in patients with premature ventricular contractions 2

Critical Safety Warnings

Mandatory Risk Discussion Before Antipsychotic Use

Discuss with patient and surrogate decision maker 1:

• Increased mortality risk in elderly patients with dementia 1
• Cardiovascular effects including QT prolongation, dysrhythmias, sudden death, and hypotension 1
• Falls risk and pneumonia 1
• Metabolic effects 1

What NOT to Use

• Avoid typical antipsychotics (haloperidol, fluphenazine, thiothixene) as first-line therapy due to 50% risk of tardive dyskinesia after 2 years of continuous use 2, 1
• Avoid benzodiazepines for routine use due to risk of tolerance, addiction, cognitive impairment, and paradoxical agitation in 10% of elderly patients 2, 1
• Do not use cholinesterase inhibitors to prevent or treat agitation, as they are associated with increased mortality 1

Duration of Treatment and Monitoring

• Evaluate response daily with in-person examination when using antipsychotics 1
• Use the lowest effective dose for the shortest possible duration 1
• Review the need for antipsychotics at every visit and taper if no longer indicated 1
• Approximately 47% of patients continue receiving antipsychotics after discharge without clear indication—avoid inadvertent chronic use 1

Recommended Duration Before Attempting Taper:

• Acute agitation/delirium: 1 week 3
• Agitated dementia: Taper within 3-6 months to determine lowest effective maintenance dose 3

Common Pitfalls to Avoid

• Do not continue antipsychotics indefinitely without regular reassessment 1
• Do not use antipsychotics for mild agitation—reserve for severe symptoms that are dangerous or cause significant distress 1
• Do not skip non-pharmacological interventions unless in an emergency situation 1
• Do not use anticholinergic medications (diphenhydramine, benztropine) as they worsen agitation in dementia 2, 1