What is a good medication for a 66-year-old patient with agitation in the hospital?

Management of Acute Agitation in a 66-Year-Old Hospitalized Patient

For a 66-year-old hospitalized patient with acute agitation, low-dose haloperidol (0.5-1 mg orally or subcutaneously) is the first-line pharmacological treatment after behavioral interventions have failed or are not possible, with the critical caveat that you must first identify and treat reversible causes such as pain, infection, urinary retention, or medication side effects. 1

Initial Assessment: Rule Out Reversible Causes First

Before administering any medication, you must systematically investigate underlying causes that may be driving the agitation: 1

• Pain - a major contributor in patients who cannot verbally communicate discomfort 1
• Infections - especially urinary tract infections and pneumonia 1
• Metabolic derangements - hypoxia, dehydration, electrolyte imbalances 1
• Urinary retention or constipation 1
• Medication side effects - particularly anticholinergic medications that worsen agitation 1
• Sensory impairments - hearing or vision problems that increase confusion 1

Non-Pharmacological Interventions

Environmental and behavioral modifications must be attempted first unless there is imminent risk of harm: 1

• Use calm tones, simple one-step commands, and gentle touch for reassurance 1
• Ensure adequate lighting and reduce excessive noise 1
• Provide effective communication and orientation 1
• Allow adequate time for the patient to process information before expecting a response 1

Pharmacological Management

First-Line: Low-Dose Haloperidol

When the patient is severely agitated and threatening substantial harm to self or others, and behavioral interventions have failed, use haloperidol 0.5-1 mg orally or subcutaneously. 1 The maximum dose is 5 mg daily in elderly patients. 1

• Haloperidol can be given every 2 hours as required, with careful monitoring 1
• This provides targeted treatment for agitation with lower risk of respiratory depression compared to benzodiazepines 1
• Evaluate response daily with in-person examination 1

Alternative First-Line: Risperidone

Risperidone 0.5-2 mg/day orally is an alternative first-line option for severe agitation. 1 However, extrapyramidal symptoms increase at doses above 2 mg/day. 1

Second-Line: Olanzapine

Olanzapine 10 mg intramuscularly can be considered, particularly for acute undifferentiated agitation. 2, 3 In a 2023 study, IM olanzapine 10 mg effectively sedated 78.9% of patients with acute undifferentiated agitation within 20 minutes. 2 A 2018 comparative study found olanzapine provided more effective sedation than haloperidol at 15 minutes. 3

Critical caveat: Patients over 75 years respond less well to olanzapine, making it less ideal for older geriatric patients. 1

When NOT to Use Benzodiazepines

Avoid benzodiazepines as first-line treatment for agitated delirium except in cases of alcohol or benzodiazepine withdrawal. 1 Benzodiazepines can:

• Increase delirium incidence and duration 1
• Cause paradoxical agitation in approximately 10% of elderly patients 1
• Worsen cognitive function 1

However, if agitation is refractory to haloperidol, adding lorazepam 0.5-2 mg every 4-6 hours may be considered. 4 The combination of benzodiazepines and haloperidol may produce faster sedation than monotherapy. 4

Critical Safety Warnings

Before initiating any antipsychotic, you must discuss with the patient (if feasible) and surrogate decision maker: 1

• Increased mortality risk - all antipsychotics increase mortality in elderly patients with dementia 1
• Cardiovascular effects - QT prolongation, dysrhythmias, sudden death, hypotension 1
• Falls risk - pneumonia, metabolic effects 1
• Expected benefits and treatment goals 1

Dosing Strategy and Duration

Use the lowest effective dose for the shortest possible duration. 1 Key principles include:

• Evaluate ongoing need daily with in-person examination 1
• Monitor for extrapyramidal symptoms, falls, metabolic changes, and QT prolongation 1
• Taper and discontinue as soon as the acute episode resolves 1
• Avoid inadvertent chronic use - approximately 47% of patients continue receiving antipsychotics after discharge without clear indication 1

Common Pitfalls to Avoid

• Do not use typical antipsychotics like haloperidol as chronic therapy - 50% risk of tardive dyskinesia after 2 years of continuous use in elderly patients 1
• Do not use anticholinergic medications like diphenhydramine - these worsen agitation in elderly patients 1
• Do not start cholinesterase inhibitors to prevent or treat delirium - associated with increased mortality 1
• Do not use higher than recommended doses of haloperidol - a 2013 study found no evidence that higher dosages were more effective, but did increase sedation risk 5

For Refractory Agitation

If agitation persists despite initial haloperidol: 4

• Add lorazepam 0.5-2 mg every 4-6 hours as needed 4
• Titrate haloperidol upward in increments of 0.5-1 mg until adequate control, maximum 10 mg/day 4
• Consider haloperidol 0.5-2 mg IM/IV every 1 hour for severe unresponsive agitation 4
• Consult psychiatry or palliative care if agitation remains inadequately controlled 4