What medication should be used to manage agitation in an elderly patient?

Management of Agitation in Elderly Patients

For elderly patients with agitation, start immediately with non-pharmacological interventions and treatment of reversible causes; if pharmacological treatment becomes necessary due to severe agitation with imminent risk of harm after behavioral approaches have failed, use low-dose haloperidol (0.5-1 mg orally or subcutaneously) for acute situations or initiate an SSRI (citalopram 10 mg/day or sertraline 25-50 mg/day) for chronic agitation. 1, 2

Step 1: Identify and Treat Reversible Causes First

Before any medication, systematically investigate underlying medical triggers that commonly drive agitation in elderly patients who cannot verbally communicate discomfort 1, 2:

• Pain assessment and management is a major contributor to behavioral disturbances and must be addressed first 1, 2
• Infections, particularly urinary tract infections and pneumonia, should be identified and treated 1, 2
• Metabolic disturbances including hypoxia, dehydration, constipation, and urinary retention require correction 3, 2
• Medication review to identify anticholinergic medications (diphenhydramine, oxybutynin, cyclobenzaprine) that worsen agitation and cognitive function 1, 2
• Sensory impairments such as hearing or vision deficits that increase confusion and fear 1, 2

Step 2: Implement Non-Pharmacological Interventions

Environmental and behavioral modifications must be attempted and documented as failed before initiating medications 1, 2:

• Communication strategies: Use calm tones, simple one-step commands, and gentle touch for reassurance rather than complex instructions 3, 1
• Environmental modifications: Ensure adequate lighting, reduce excessive noise, and provide structured daily routines 3, 1
• Orientation support: Explain where the person is, who they are, and your role repeatedly 3
• Timing optimization: Schedule care activities when the patient is most calm and receptive 1
• Caregiver education: Explain that behaviors are symptoms of the underlying condition, not intentional actions 1

Step 3: Pharmacological Treatment Algorithm

For Chronic Mild-to-Moderate Agitation:

SSRIs are the preferred first-line pharmacological option 1, 2:

• Citalopram: Start at 10 mg/day, maximum 40 mg/day; well tolerated though some patients experience nausea and sleep disturbances 1
• Sertraline: Start at 25-50 mg/day, maximum 200 mg/day; well tolerated with less effect on metabolism of other medications 1
• Evaluate response within 4 weeks using quantitative measures (Cohen-Mansfield Agitation Inventory or NPI-Q) 1, 2
• Taper and discontinue if no clinically significant response after 4 weeks at adequate dose 1

For Severe Acute Agitation with Imminent Risk of Harm:

Low-dose haloperidol is the first-line medication when the patient is severely agitated, threatening substantial harm to self or others, and behavioral interventions have failed 3, 1:

• Haloperidol dosing: 0.5-1 mg orally at night and every 2 hours as required, with a maximum of 5 mg daily in elderly patients 3, 1
• Subcutaneous administration: The same dose may be given subcutaneously if unable to swallow 3
• Reduce starting dose to 0.5 mg in frail elderly or debilitated patients 3
• Daily reassessment required: Evaluate ongoing need with in-person examination and use the lowest effective dose for the shortest possible duration 1

Alternative Atypical Antipsychotics for Severe Agitation:

If haloperidol is contraindicated or not tolerated 1:

• Risperidone: Start at 0.25 mg at bedtime, maximum 2-3 mg/day in divided doses; risk of extrapyramidal symptoms at doses above 2 mg/day 1
• Quetiapine: Start at 12.5 mg twice daily, maximum 200 mg twice daily; more sedating with risk of transient orthostasis 1, 4
• Olanzapine: Start at 2.5 mg at bedtime, maximum 10 mg/day; generally well tolerated but less effective in patients over 75 years 1

If Agitation Persists Despite Haloperidol:

Consider adding a benzodiazepine only for severe, refractory agitation 3:

• Lorazepam: 0.25-0.5 mg orally (maximum 2 mg in 24 hours) in elderly patients; tablets can be used sublingually 3
• Midazolam: 2.5-5 mg subcutaneously every 2-4 hours if unable to swallow 3

Critical Safety Warnings

Before initiating any antipsychotic, discuss with the patient (if feasible) and surrogate decision maker 1, 2:

• Increased mortality risk: 1.6-1.7 times higher than placebo in elderly patients with dementia 1
• Cardiovascular effects: QT prolongation, dysrhythmias, sudden death, and hypotension 1
• Falls risk: Increased risk of falls and fractures 1
• Metabolic effects: Weight gain, diabetes, and dyslipidemia 1
• Cerebrovascular adverse events: Increased risk of stroke 1

What NOT to Use

Avoid benzodiazepines as first-line treatment for agitated delirium (except in alcohol or benzodiazepine withdrawal) because they increase delirium incidence and duration, and cause paradoxical agitation in approximately 10% of elderly patients 3, 1, 2

Avoid typical antipsychotics other than haloperidol as first-line therapy due to 50% risk of tardive dyskinesia after 2 years of continuous use in elderly patients 1

Avoid anticholinergic medications (diphenhydramine, oxybutynin, cyclobenzaprine) as they worsen agitation and cognitive function 1, 2

Monitoring and Reassessment

• Daily in-person examination to evaluate ongoing need when using antipsychotics 1, 2
• Monitor for side effects: Extrapyramidal symptoms, falls, sedation, metabolic changes, QT prolongation, and cognitive worsening 1
• Review need at every visit and taper if no longer indicated 1, 2
• Avoid inadvertent chronic use: Approximately 47% of patients continue receiving antipsychotics after discharge without clear indication 1

Common Pitfalls to Avoid

• Do not skip non-pharmacological interventions unless in an emergency situation with imminent risk of harm 1, 2
• Do not use antipsychotics for mild agitation or behaviors that are not dangerous (unfriendliness, poor self-care, repetitive questioning, wandering) 1
• Do not continue antipsychotics indefinitely without regular reassessment and attempts at tapering 1, 2
• Do not use medications before addressing pain, infections, and other reversible causes 1, 2