From the Guidelines
Treatment for agitation in elderly patients should prioritize non-pharmacological approaches and, when necessary, utilize selective serotonin reuptake inhibitors (SSRIs) as first-line pharmacological treatment, due to their efficacy in reducing overall neuropsychiatric symptoms and agitation, as supported by the most recent evidence 1.
Non-Pharmacological Approaches
Before considering medications, it's essential to identify and address underlying causes of agitation, such as pain, infection, medication side effects, or unmet needs. Creating a calm environment by reducing noise, maintaining consistent caregivers, and establishing regular routines can also help alleviate agitation. Other non-pharmacological interventions like simulated presence therapy, massage therapy, animal-assisted interventions, and personally tailored interventions have shown promise in reducing symptoms of agitation.
Pharmacological Management
For pharmacological management, SSRIs such as citalopram (10mg daily) or sertraline (25mg daily) are recommended as first-line treatments for agitation in elderly patients 1. Antipsychotics like risperidone, quetiapine, or haloperidol may be considered for severe agitation but should be used at the lowest effective dose for the shortest duration possible due to the increased risk of stroke and mortality in elderly patients with dementia. Benzodiazepines like lorazepam may be used for acute agitation but should be avoided for long-term use due to risks of falls, confusion, and dependence.
Key Considerations
- Regular monitoring for side effects is essential, with medication review every 1-2 weeks initially.
- The goal is to identify and treat the underlying cause while minimizing medication use, as elderly patients are more sensitive to medication effects due to altered pharmacokinetics, reduced hepatic and renal function, and increased blood-brain barrier permeability.
- The most recent and highest quality evidence supports the use of SSRIs as a preferred pharmacological option for managing agitation in elderly patients, emphasizing the importance of prioritizing treatments that balance efficacy with safety and quality of life considerations 1.
From the FDA Drug Label
2.3 Dose Modifications in Elderly Patients Consideration should be given to a slower rate of dose titration and a lower target dose in the elderly and in patients who are debilitated or who have a predisposition to hypotensive reactions [see Clinical Pharmacology (12.3)] . When indicated, dose escalation should be performed with caution in these patients. Elderly patients should be started on quetiapine fumarate tablets 50 mg/day and the dose can be increased in increments of 50 mg/day depending on the clinical response and tolerability of the individual patient.
For the treatment of agitation in elderly patients, quetiapine can be used with a recommended initial dose of 50 mg/day, with cautious dose escalation in increments of 50 mg/day.
- The dose should be adjusted based on the patient's clinical response and tolerability.
- It is essential to consider a slower rate of dose titration and a lower target dose in elderly patients due to the potential for hypotensive reactions 2.
- Similarly, risperidone can be used in elderly patients, but a lower starting dose is recommended, reflecting decreased pharmacokinetic clearance in the elderly 3.
- For risperidone, the initial dose should be limited to 0.5 mg twice daily, followed by careful titration, and monitoring of orthostatic vital signs should be considered.
From the Research
Treatment Options for Agitation in Elderly Patients
- Non-pharmacologic modalities are available for the management of mild to moderate agitation and aggression in patients with dementia 4.
- Environmental modifications and non-pharmacological strategies can be implemented to maximize the safety of the patient and others 5.
- Pharmacologic management is indicated for agitation related to a psychiatric condition, severe agitation where a patient is at risk to harm self or others, and to facilitate time-sensitive diagnostic imaging, procedures, and treatment 4.
- Emergency physicians have several pharmacologic agents at their disposal, including opioid and non-opioid analgesics, antipsychotics, benzodiazepines, ketamine, and combination agents 4.
Non-Pharmacological Interventions
- Massage therapy, animal-assisted intervention, and personally tailored intervention are associated with more substantial reductions in agitation compared with other interventions and controls 6.
- Non-pharmacological interventions can be effective in ameliorating agitation in people with dementia and should be encouraged in clinical practice 6.
Pharmacologic Management
- The choice of pharmacological options depends on patient comorbidities, specific behavioral and psychological symptoms of dementia (BPSD) presentation, and patient tolerance of medications 7.
- Low- to moderate-quality evidence supports the use of anti-depressants, anti-psychotics, or anti-epileptics in conjunction with cholinesterase inhibitors for the management of BPSD 7.
- It is advised to start with low doses and gradually increase as needed, using small increments of dose increase 5.
Prevention and Treatment Strategies
- Agitation can be precipitated by several factors, such as hospitalization, admission to nursing residencies, or changes in pharmacological regimens 8.
- Identifying and addressing these precipitating factors can help in preventing and managing agitation in dementia patients 8.
- A comprehensive approach to managing agitation in elderly patients should include a combination of non-pharmacological and pharmacological interventions, as well as strategies to prevent and address underlying causes of agitation 4, 5, 8.