What is the management of agitation in the elderly due to acute infection?

From the Guidelines

Managing agitation in elderly patients with acute infection requires a comprehensive approach that prioritizes non-pharmacological interventions and addresses the underlying infection. The first step is to treat the infection promptly with appropriate antibiotics based on the suspected source. For agitation management, start with non-pharmacological interventions such as maintaining a calm environment, ensuring adequate lighting, reorienting the patient frequently, and encouraging family presence, as recommended by the geriatric emergency department guidelines 1. Some key considerations include:

• Eliminating or minimizing identified risk factors
• Avoiding high-risk medications
• Preventing or promptly treating infections, dehydration, and electrolyte disturbances
• Providing adequate pain control and maximizing oxygen delivery
• Using sensory aids and fostering orientation and familiarity
• Minimizing the use of restraints and chemical restraint/sedation whenever possible, as stated in the policy of the geriatric ED 1. If medication is necessary, low-dose antipsychotics like haloperidol 0.25-0.5mg orally or IM every 4 hours as needed can be used short-term, with close monitoring for side effects, as recommended by the guidelines 1. It is essential to ensure adequate pain control, hydration, and correction of any electrolyte imbalances, and to monitor vital signs, oxygenation, and mental status regularly. This approach works because infections in the elderly often manifest as delirium rather than typical symptoms, and treating the underlying cause while providing supportive care addresses both the infection and resulting behavioral changes.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION ... Debilitated or geriatric patients, as well as those with a history of adverse reactions to antipsychotic drugs, may require less Haloperidol Injection, USP Parenteral medication, administered intramuscularly in doses of 2 to 5 mg, is utilized for prompt control of the acutely agitated schizophrenic patient with moderately severe to very severe symptoms

The management of agitation in the elderly from acute infection is not directly addressed in the provided drug label. However, for agitation in the elderly, lower dosage levels and more gradual dosage adjustments are recommended due to the patient's age and potential for adverse reactions.

• The initial dose for acute agitation can be 2 to 5 mg intramuscularly.
• The dose may be repeated as often as every hour, with a maximum dose of 20 mg per day.
• It is essential to monitor clinical signs and symptoms closely and adjust the dosage accordingly. 2

From the Research

Management of Agitation in the Elderly from Acute Infection

• Agitation in older adults can be caused by various factors, including primary psychiatric disorders, substance use, hyperactive delirium, and symptoms of dementia 3.
• Understanding the etiology of agitation is critical to proper management, and effective non-pharmacologic modalities are available for mild to moderate agitation and aggression in patients with dementia 3.
• Pharmacologic management is indicated for agitation related to a psychiatric condition, severe agitation where a patient is at risk to harm self or others, and to facilitate time-sensitive diagnostic imaging, procedures, and treatment 3, 4.

Non-Pharmacologic Management

• Non-pharmacologic approaches can help reduce the risk of agitation, and techniques such as frequent and sufficient reality orientation, validation therapy, and strategies that improve the individual's quality of life can be effective 5.
• Nurses should increase the use of validated techniques to manage agitation and prevent harm to the patient and personnel 5.

Pharmacologic Management

• Pharmacologic treatment of agitated patients can include neuroleptics, benzodiazepines, and α2 agonists, and the choice of medication should be based on the individual patient's needs and the underlying cause of agitation 6, 7.
• A single oral dose of risperidone plus lorazepam can be as effective as parenterally administered haloperidol plus lorazepam for the rapid control of agitation and psychosis 7.
• Ketamine, benzodiazepines, and antipsychotics can also be considered for the management of agitation, and the emergency physician should be familiar with multiple pharmaceutical options and geriatric-specific dosing, contraindications, and common adverse effects of these agents 3, 4.