What is the best approach to manage acute agitation in a 91-year-old female patient with a history of dementia, diagnosed with acute metabolic encephalopathy, and currently experiencing no treatment for agitation?

From the Guidelines

I strongly recommend starting low-dose haloperidol 0.25-0.5mg orally or intramuscularly for acute agitation management in this 91-year-old female with UTI-induced metabolic encephalopathy. This patient is experiencing delirium secondary to her UTI, which is common in elderly patients with dementia 1. While treating the underlying UTI is the primary intervention, the acute agitation requires immediate management for patient safety. Haloperidol at low doses can help control agitation with minimal side effects. Alternative options include quetiapine 12.5-25mg or lorazepam 0.25-0.5mg, though benzodiazepines should be used cautiously in elderly patients with dementia.

Key Considerations

• Implement non-pharmacological approaches simultaneously:
  • maintain a calm environment
  • ensure adequate lighting
  • encourage family presence if possible
  • use reorientation techniques
• Monitor for extrapyramidal symptoms, QT prolongation, and sedation
• Once the UTI resolves, the encephalopathy and agitation should improve, allowing discontinuation of antipsychotics, which should be used short-term only
• Ensure adequate hydration and continue antibiotics for the UTI to address the underlying cause of her delirium

According to the American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia 1, expert consensus suggests that use of an antipsychotic medication in individuals with dementia can be appropriate, particularly in individuals with dangerous agitation or psychosis. However, it is crucial to balance the potential benefits and harms of a particular intervention as compared to other therapeutic options for the individual patient. The NCCN clinical practice guidelines in oncology: palliative care also provide guidance on managing delirium, including the use of haloperidol and other medications 1.

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 The optimal response in such patients is usually obtained with more gradual dosage adjustments and at lower dosage levels.

For a 91-year-old female patient with dementia and acute metabolic encephalopathy, caution is advised when using haloperidol due to her age and potential for adverse reactions.

• The patient's age and debilitated state may require a lower dosage of haloperidol.
• Gradual dosage adjustments are recommended to achieve optimum therapeutic control.
• The maximum dose is 20 mg per day. Given the patient's condition, it is recommended to start with a low dose and monitor closely for clinical efficacy, sedation, and adverse effects 2.

From the Research

Management of Agitation in Elderly Patients with Dementia

• The patient's agitation can be managed using a step-wise approach, starting with non-coercive de-escalation strategies and moving on to pharmacologic interventions as necessary 3.
• For elderly patients with dementia, low-dose haloperidol may be effective in treating acute agitation, with a recommended starting dose of 0.5 mg 4.
• However, higher doses of haloperidol may increase the risk of sedation and other complications, without providing additional benefits in reducing agitation or hospital stay 4.
• Alternative pharmacologic options, such as risperidone and lorazepam, may be considered for treating agitation in elderly patients with dementia, with similar efficacy and safety profiles to haloperidol and lorazepam 5, 6.
• The choice of pharmacologic agent should be tailored to the individual patient, taking into account their medical history, current condition, and potential risks and benefits of each medication 3, 7.

Pharmacologic Options for Agitation

• Haloperidol: low-dose (0.5 mg) may be effective in treating acute agitation, but higher doses may increase risk of sedation and complications 4.
• Risperidone: oral treatment with 2 mg of risperidone plus 2 mg of lorazepam may be an effective alternative to intramuscular haloperidol and lorazepam for treating agitation 5, 6.
• Lorazepam: may be used in combination with antipsychotics, such as haloperidol or risperidone, for treating agitation 5, 7, 6.
• Ketamine: may be considered as a second-line agent for treating agitation, but may be associated with a higher risk of airway compromise requiring endotracheal intubation 7.