What is the recommended intravenous (IV) medication for an elderly patient with agitation and confusion?

IV Medication for Agitated and Confused Elderly Patients

For an elderly patient with agitation and confusion, haloperidol 0.5-1 mg IV is the first-line IV medication, administered slowly after attempting non-pharmacological interventions and only when there is severe agitation with imminent risk of harm to self or others. 1

Critical First Steps Before Any Medication

Before administering any IV medication, you must:

• Identify and treat reversible causes immediately: Check for hypoxia, urinary retention, constipation, pain, urinary tract infections, and pneumonia—these are major drivers of agitation in elderly patients who cannot verbally communicate discomfort 1
• Attempt non-pharmacological interventions first: Use calm tones, simple one-step commands, ensure adequate lighting, provide effective communication about where the patient is and who you are 1
• Reserve IV medications only for severe agitation where the patient is threatening substantial harm to self or others and behavioral interventions have failed or are not possible 1

First-Line IV Medication: Haloperidol

Haloperidol 0.5-1 mg IV or subcutaneously is the preferred first-line IV antipsychotic for delirium with agitation in elderly patients, with a maximum dose of 5 mg daily. 1

Dosing specifics:

• Start with 0.5-1 mg IV, administered slowly (no faster than 2 mg/minute if using lorazepam protocols as reference) 1
• In frail elderly patients, start with 0.25-0.5 mg and titrate gradually 2
• Maximum 5 mg daily in elderly patients 1
• Can be given IV, subcutaneously, or intramuscularly 2, 1

Critical safety monitoring:

• Monitor ECG for QTc prolongation, as haloperidol carries risk of dysrhythmias and sudden death 1
• Watch for extrapyramidal symptoms (tremor, rigidity, bradykinesia) 1
• Higher than 1 mg initial doses provide no evidence of greater effectiveness and result in significantly greater risk of sedation and side effects 3

Alternative IV Option: Olanzapine

Olanzapine 2.5-5 mg IM is an alternative if haloperidol is contraindicated, with a reduced dose of 2.5 mg in elderly patients. 2

• Less likely to cause extrapyramidal symptoms than haloperidol 2
• Risk of oversedation and respiratory depression, especially if combined with benzodiazepines 2
• Patients over 75 years respond less well to olanzapine 1

What NOT to Use as First-Line

Benzodiazepines (Lorazepam, Midazolam)

Avoid benzodiazepines as first-line treatment for agitated delirium in elderly patients—they increase delirium incidence and duration, cause paradoxical agitation in approximately 10% of elderly patients, and carry significant risk of respiratory depression. 1

• Lorazepam 0.25-0.5 mg IV may be considered only for severe, dangerous agitation requiring immediate sedation when haloperidol would be too slow, or for alcohol/benzodiazepine withdrawal 2, 1
• Midazolam poses excessive risk to older adults—a 2025 systematic review found 53% adverse event rate with midazolam versus 16.8% overall, with 5.25 times higher odds of adverse events compared to haloperidol 4
• Use lower doses (0.5-1 mg lorazepam or 0.5-1 mg midazolam) in older or frail patients or if co-administered with an antipsychotic 2

Anticholinergic Medications

Avoid diphenhydramine, oxybutynin, and cyclobenzaprine—these worsen agitation and cognitive function in elderly patients. 1

Duration of Treatment

Evaluate ongoing need daily with in-person examination and use the lowest effective dose for the shortest possible duration. 1

• For delirium, attempt to taper within 1 week once agitation resolves 1
• Approximately 47% of patients continue receiving antipsychotics after discharge without clear indication—inadvertent chronic use must be avoided 1

Mandatory Risk Discussion

Before initiating any antipsychotic, discuss with the patient's surrogate decision maker the increased mortality risk (1.6-1.7 times higher than placebo), cardiovascular effects including QT prolongation and sudden death, cerebrovascular adverse reactions, falls, pneumonia, and hypotension. 1

Common Pitfalls to Avoid

• Do not use higher than recommended initial doses (>1 mg haloperidol)—they are not more effective and cause significantly more sedation and side effects 3
• Do not use benzodiazepines routinely—reserve only for alcohol/benzodiazepine withdrawal or as crisis medication when antipsychotics alone are insufficient 2, 1
• Do not continue antipsychotics indefinitely—review need at every visit and taper if no longer indicated 1
• Do not use antipsychotics for mild agitation—reserve for severe symptoms that are dangerous or cause significant distress 1