What is the recommended oral medication and dosage for treating agitation?

Oral Medication for Treating Agitation

For oral treatment of agitation, lorazepam 0.5-1 mg orally four times daily as needed (maximum 4 mg in 24 hours) is recommended for anxiety or agitation in patients able to swallow, with reduced doses of 0.25-0.5 mg in elderly or debilitated patients (maximum 2 mg in 24 hours). 1

First-Line Oral Options by Clinical Context

For Anxiety or Agitation (Able to Swallow)

• Lorazepam 0.5-1 mg orally four times daily as needed is the guideline-recommended benzodiazepine, with a maximum of 4 mg in 24 hours 1
• In elderly or debilitated patients, reduce the dose to 0.25-0.5 mg with a maximum of 2 mg in 24 hours 1
• Oral tablets can be used sublingually as an off-label route 1

For Delirium with Agitation (Able to Swallow)

• Haloperidol 0.5-1 mg orally at night and every 2 hours when required is the preferred antipsychotic 1
• Increase dose in 0.5-1 mg increments as required, with a maximum of 5 mg daily in elderly patients (10 mg daily in younger adults) 1
• Consider a higher starting oral dose (1.5-3 mg) if the patient is severely distressed or causing immediate danger to others 1
• Consider adding a benzodiazepine such as lorazepam if the patient remains agitated despite haloperidol 1

For Agitated Psychosis (Cooperative Patients)

• Combination of oral lorazepam (2 mg) and oral risperidone is effective for agitated but cooperative patients 1
• The American Geriatrics Society recommends risperidone 0.5-2 mg/day orally as first-line for elderly patients with severe agitation after behavioral interventions have failed 2

Alternative Oral Antipsychotics

Olanzapine

• Starting dose: 2.5 mg orally at bedtime for elderly patients 2
• FDA-approved dosing for agitation associated with bipolar mania or schizophrenia starts at 5-10 mg once daily in adults 3
• The American Academy of Family Physicians notes olanzapine is generally well tolerated but less effective in patients over 75 years 2
• Maximum dose of 10 mg/day in divided doses 2

Quetiapine

• Starting dose: 25 mg (immediate release) orally 1
• Give every 12 hours if scheduled dosing required 1
• The American Academy of Family Physicians recommends starting at 12.5 mg twice daily with a maximum of 200 mg twice daily 2
• More sedating with risk of orthostatic hypotension and dizziness 1
• Less likely to cause extrapyramidal symptoms than other antipsychotics 1

Risperidone

• Starting dose: 0.5 mg orally 1
• Can be given up to every 12 hours if scheduled dosing required 1
• Increased risk of extrapyramidal symptoms if dose exceeds 6 mg/24 hours 1
• Available as orally disintegrating tablet 1

Critical Safety Considerations

When NOT to Use Benzodiazepines First-Line

• The American Geriatrics Society recommends avoiding benzodiazepines as first-line treatment for agitated delirium except in cases of alcohol or benzodiazepine withdrawal 2
• Benzodiazepines can increase delirium incidence and duration, and may cause paradoxical agitation in approximately 10% of elderly patients 2

Antipsychotic Warnings

• All antipsychotics carry an FDA black box warning for increased mortality risk in elderly patients with dementia-related psychosis 3
• The American Geriatrics Society requires discussing potential risks including increased mortality, cardiovascular effects, falls, and metabolic changes with the patient and surrogate decision maker before initiating treatment 2
• Patients over 75 years respond less well to antipsychotics, particularly olanzapine 2

Dosing Strategy

• Start with the lowest effective dose and evaluate response daily with in-person examination 2
• Use antipsychotics for the shortest duration possible with daily reassessment 2
• Evaluate response within 4 weeks using quantitative measures, and taper if no clinically significant response 2

Common Pitfalls to Avoid

• Never use typical antipsychotics (haloperidol, fluphenazine, thiothixene) as first-line therapy in elderly patients due to 50% risk of tardive dyskinesia after 2 years of continuous use 2
• Avoid anticholinergic medications (diphenhydramine, oxybutynin, cyclobenzaprine) as they worsen agitation and cognitive function 2
• Do not continue antipsychotics indefinitely - review the need at every visit and taper if no longer indicated 2
• Reserve antipsychotics for severe symptoms that are dangerous or cause significant distress, not for mild agitation 2