Treatment of Agitation in the Elderly

Non-pharmacological interventions must be attempted first and documented as failed before any medication is considered, unless the patient is severely agitated with imminent risk of harm to self or others. 1

Step 1: Identify and Treat Reversible Causes

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

Pain assessment and management is the single most important contributor to behavioral disturbances and must be addressed immediately 1
Infections: Check for urinary tract infections and pneumonia, which are major triggers of agitation 1, 2
Metabolic derangements: Assess for hypoxia, dehydration, hyperglycemia, and electrolyte abnormalities 1, 2
Urinary retention and constipation: Both can significantly worsen agitation 1, 2
Medication review: Identify and eliminate anticholinergic medications (diphenhydramine, oxybutynin, cyclobenzaprine) that worsen agitation and cognitive function 1
Sensory impairments: Address hearing and vision problems that increase confusion and fear 1

Step 2: Implement Non-Pharmacological Interventions

These interventions have substantial evidence for efficacy without the mortality risks associated with medications 1:

Environmental Modifications

Ensure adequate lighting and reduce excessive noise 1, 2
Install safety equipment (grab bars, bath mats) to prevent injuries 1
Simplify the environment with clear labels and structured layouts 1
Provide structured daily routines 1

Communication Strategies

Use calm tones and simple one-step commands instead of complex multi-step instructions 1, 2
Allow adequate time for the patient to process information before expecting a response 1
Explain where the patient is, who you are, and your role 1

Specific Evidence-Based Interventions

Person-centred care with supervision reduces agitation both immediately and up to 6 months (effect size -1.4 to -0.3) 3
Music therapy reduces agitation during interventions (effect size -0.8 to -0.5) 3, 4
Sensory interventions (aromatherapy, massage) reduce both mean and clinically significant symptoms (effect size -1.3 to -0.6) 3, 5, 4
Structured activities reduce agitation during implementation (effect size -0.8 to -0.6) 3

Caregiver Education

Educate caregivers that behaviors are symptoms of dementia, not intentional actions 1

Step 3: Pharmacological Treatment (Only When Non-Pharmacological Approaches Fail)

Indications for Medication

Medications should only be used when 1:

The patient is severely agitated, threatening substantial harm to self or others
Behavioral interventions have been thoroughly attempted and documented as insufficient
Symptoms are dangerous or causing significant distress to the patient

Critical Safety Discussion Required Before Any Medication

You must discuss with the patient (if feasible) and surrogate decision maker 1:

Increased mortality risk (1.6-1.7 times higher than placebo) 1
Cardiovascular effects and cerebrovascular adverse reactions 1
Risk of QT prolongation, dysrhythmias, sudden death, hypotension, pneumonia, and falls 1
Expected benefits and treatment goals 1

Medication Selection Algorithm

For Chronic Agitation Without Psychotic Features (First-Line)

SSRIs are the preferred pharmacological option 1:

Citalopram: Start 10 mg/day, maximum 40 mg/day 1
- Well tolerated; some patients experience nausea and sleep disturbances 1
Sertraline: Start 25-50 mg/day, maximum 200 mg/day 1
- Well tolerated with less effect on metabolism of other medications 1

Monitoring: Evaluate response within 4 weeks using quantitative measures (Cohen-Mansfield Agitation Inventory or NPI-Q) 1. If no clinically significant response after 4 weeks at adequate dose, taper and withdraw 1.

For Acute Severe Agitation (Imminent Risk of Harm)

Haloperidol is first-line for acute severe agitation 1:

Haloperidol: 0.5-1 mg orally, subcutaneously, or IM 1
- Maximum 5 mg daily in elderly patients 1
- Can be given every 2 hours as required 1
- Monitor for extrapyramidal symptoms and QT prolongation 1

Alternative for acute agitation:

Risperidone: 0.5-1 mg orally 1

Critical caveat: Patients over 75 years respond less well to antipsychotics, particularly olanzapine 1. Use the lowest effective dose for the shortest possible duration with daily in-person examination 1.

For Severe Agitation With Psychotic Features (Second-Line)

Risperidone is preferred for chronic severe agitation with psychosis 1:

Risperidone: Start 0.25 mg at bedtime, maximum 2-3 mg/day in divided doses 1
- Risk of extrapyramidal symptoms at doses above 2 mg/day 1, 6
- In elderly patients, start at 0.5 mg twice daily and titrate slowly 6

Alternatives:

Quetiapine: Start 12.5 mg twice daily, maximum 200 mg twice daily 1
- More sedating with risk of orthostatic hypotension 1
Olanzapine: Start 2.5 mg at bedtime, maximum 10 mg/day 1
- Less effective in patients over 75 years 1

For Severe Agitation Without Psychotic Features (Alternative)

Divalproex sodium for mood stabilization 1:

Start 125 mg twice daily, titrate to therapeutic blood level 1
Monitor liver enzymes and coagulation parameters 1

Trazodone as a safer alternative to antipsychotics 1:

Start 25 mg/day, maximum 200-400 mg/day in divided doses 1
Use caution in patients with premature ventricular contractions due to orthostatic hypotension risk 1

What NOT to Use

Avoid Benzodiazepines as First-Line 1

Benzodiazepines increase delirium incidence and duration 1
Cause paradoxical agitation in approximately 10% of elderly patients 1
Risk of tolerance, addiction, cognitive impairment, and respiratory depression 1, 7
Exception: Alcohol or benzodiazepine withdrawal 1

Avoid Typical Antipsychotics as First-Line 1

Haloperidol, fluphenazine, and thiothixene carry a 50% risk of tardive dyskinesia after 2 years of continuous use in elderly patients 1
Reserve haloperidol only for acute severe agitation requiring immediate intervention 1

Avoid Anticholinergic Medications 1

Diphenhydramine, oxybutynin, and cyclobenzaprine worsen agitation and cognitive function 1

Do Not Newly Prescribe Cholinesterase Inhibitors 1

Associated with increased mortality when started to prevent or treat delirium or agitation 1

Monitoring and Reassessment

Daily Monitoring (While on Antipsychotics)

Evaluate ongoing need with daily in-person examination 1
Monitor for extrapyramidal symptoms, falls, sedation, metabolic changes, QT prolongation, and cognitive worsening 1
Review the need for continuation at every visit 1

4-Week Evaluation (For SSRIs and Chronic Treatment)

Use the same quantitative measure (NPI-Q or Cohen-Mansfield Agitation Inventory) used at baseline 1
If no clinically significant response after 4 weeks at adequate dose, taper and withdraw 1

Avoid Indefinite Continuation

Approximately 47% of patients continue receiving antipsychotics after discharge without clear indication 1
Taper if no longer indicated 1
Even with positive response, periodically reassess the need for continued medication 1

Common Pitfalls to Avoid

Starting medication without attempting non-pharmacological interventions unless in an emergency with imminent risk of harm 1
Using antipsychotics for mild agitation – reserve for severe, dangerous symptoms only 1
Continuing antipsychotics indefinitely without regular reassessment and tapering attempts 1
Using benzodiazepines as first-line for agitated delirium (worsens outcomes) 1
Failing to address pain before considering psychotropic medications 1
Not discussing mortality risks with surrogate decision makers before initiating antipsychotics 1
Using typical antipsychotics chronically due to high tardive dyskinesia risk 1

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