What are the medication options for agitation in the elderly population?

From the Guidelines

For elderly patients experiencing agitation, low-dose atypical antipsychotics such as risperidone (Risperdal) with an initial dosage of 0.25 mg per day at bedtime, are recommended as a first-line treatment option. This approach is based on the guidelines for managing Alzheimer's disease, which suggest that atypical antipsychotic agents are preferred over typical antipsychotic agents due to their diminished risk of developing extrapyramidal symptoms and tardive dyskinesia 1.

Key Considerations

• Atypical antipsychotics like risperidone, olanzapine (Zyprexa), and quetiapine (Seroquel) are recommended for control of problematic delusions, hallucinations, severe psychomotor agitation, and combativeness 1.
• Typical antipsychotic agents, such as haloperidol (Haldol) and fluphenazine (Prolixin), should be avoided if possible due to their significant side effects involving the cholinergic, cardiovascular, and extrapyramidal systems 1.
• Mood-stabilizing drugs like trazodone (Desyrel) and divalproex sodium (Depakote) may be useful alternatives to antipsychotic agents for control of severe agitated, repetitive, and combative behaviors 1.
• Benzodiazepines, such as lorazepam (Ativan), should be used with caution and only for acute situations due to the risk of tolerance, addiction, depression, and cognitive impairment 1.

Treatment Approach

• Start with non-pharmacological interventions before considering medications.
• When medications are necessary, use low-dose atypical antipsychotics like risperidone (0.25-0.5mg once or twice daily) for short-term use (generally 1-2 weeks).
• Monitor for side effects and titrate slowly while addressing underlying causes of agitation such as pain, infection, or environmental factors.
• Regular reassessment is crucial, with the goal of using medications temporarily while addressing underlying causes of agitation.

From the Research

Medication Options for Elderly Agitation

• Antipsychotics are widely used in geriatric psychiatric disorders, including agitation in elderly patients 2.
• Risperidone is a commonly recommended antipsychotic for agitation in dementia patients, with a low initial dosage that is gradually adjusted upward 3, 4.
• Other antipsychotics, such as quetiapine and olanzapine, may also be used to manage agitation in elderly patients 2.
• Benzodiazepines, such as lorazepam and diazepam, may be used to manage acute agitation, but their use should be cautious due to the risk of adverse effects 5, 6.

Dosage and Administration

• The dosage of antipsychotics for agitation in elderly patients should be individualized, with a low initial dosage that is gradually adjusted upward 2, 4.
• Risperidone oral solution has been shown to be effective and well-tolerated in elderly patients with agitation associated with dementia, at doses ranging from 0.5 to 1.25 mg 4.
• The combination of haloperidol and promethazine may be a good choice for acute agitation, due to its sedative properties and reduced risk of extrapyramidal effects 6.

Safety and Efficacy

• Antipsychotics, particularly atypical antipsychotics, have a relatively benign adverse-effect profile compared to traditional neuroleptics 2, 3.
• Risperidone has been shown to be effective in controlling agitation in patients with dementia, with a low frequency of extrapyramidal symptoms 3, 4.
• The efficacy and safety of antipsychotics for agitation in elderly patients should be carefully monitored, with regular assessments of cognitive function, behavioral symptoms, and extrapyramidal symptoms 2, 4.