Management of Agitation in Elderly Patients

Introduction

Agitation in elderly patients is a complex condition that requires a comprehensive approach, including non-pharmacological interventions and pharmacological treatment, as recommended by the American Geriatrics Society and the American Academy of Family Physicians 1, 2

The American Geriatrics Society recommends attempting non-pharmacological interventions first, including creating a dementia-friendly environment, providing predictable daily routines, identifying and addressing triggers, and caregiver education and support 2
Creating a dementia-friendly environment can be achieved by providing comfortable seating arrangements, ensuring adequate access to food, drink, and toileting facilities, and reducing sensory overload by creating quieter spaces, implementing color-coding, and installing clear signage 3, 4, 5
Providing a predictable daily routine, creating a safe environment, and using proper lighting can reduce agitation 6, 1
Documenting triggers and patterns using the ABC (antecedent-behavior-consequences) charting approach can help identify environmental triggers and develop effective interventions 6
Educating caregivers about neurotic syndrome and behavior management, training them in effective communication techniques, and providing support to reduce caregiver stress can be beneficial, as recommended by the American Geriatrics Society 7

The American Geriatrics Society suggests that antipsychotics may be considered at the lowest effective dose for the shortest possible duration for severe agitation where the patient is threatening harm to self or others 2
The following atypical antipsychotics may be used for agitation in dementia:
Medication Indication Dosage
Quetiapine Agitation in LBD Lowest effective dose for shortest duration
Brexpiprazole Agitation in Alzheimer's dementia As recommended by the manufacturer
Cholinesterase inhibitors may be considered as a first-line pharmacological treatment for agitation in dementia, as they may improve behavioral symptoms, according to the Alzheimer's Association 1
The British Medical Journal recommends low-dose haloperidol (0.5-1 mg orally at night) as first-line pharmacological treatment for elderly patients with agitation and nocturnal hallucinations, with careful monitoring for extrapyramidal side effects 8
The Annals of Oncology recommends quetiapine 25 mg (immediate release) orally at bedtime as an alternative to haloperidol, which can be increased gradually if needed, with a reduced dose in hepatic impairment 9

Medication	Indication	Dosage
Quetiapine	Agitation in LBD	Lowest effective dose for shortest duration
Brexpiprazole	Agitation in Alzheimer's dementia	As recommended by the manufacturer

The following anxiolytic and sedative medications may be used for agitation in dementia:

Medication	Indication	Dosage
Lorazepam	Agitation in dementia	0.25-0.5 mg orally four times a day as required, with a maximum dose of 2 mg in 24 hours
Midazolam	Agitation in dementia	2.5-5 mg subcutaneously every 2-4 hours as required, with a reduced dose to 5 mg over 24 hours if eGFR <30 mL/minute

The American Academy of Family Physicians recommends divalproex sodium (Depakote) as a mood stabilizer, with an initial dosage of 125 mg twice daily, and titration to a therapeutic blood level of 40-90 mcg/mL, with regular monitoring of liver enzyme levels, platelets, prothrombin time, and partial thromboplastin time as indicated 1
The American Academy of Family Physicians suggests carbamazepine (Tegretol) as an alternative to divalproex sodium, with an initial dosage of 100 mg twice daily, and titration to a therapeutic blood level of 4-8 mcg/mL, requiring regular monitoring of complete blood cell count and liver enzyme levels 1

Regularly reevaluating the need for continued medication, determining if recommended strategies were implemented and effective, and assessing symptom improvement and caregiver distress can help guide treatment, as suggested by the American Geriatrics Society 7
Regular monitoring is necessary, including assessing effectiveness using quantitative measures, monitoring for side effects, and reassessing at least every 6 months, as recommended by the American Medical Association and the American Geriatrics Society 6, 7
Evaluate patients for pain-related behaviors rather than relying solely on self-reporting, assessing for underlying medical conditions, reviewing current medications, and considering comorbid conditions like arthritis that may contribute to pain, as recommended by the American Geriatrics Society 7
Regularly reassess agitation in dementia patients using quantitative measures like Neuropsychiatric Inventory Questionnaire (NPI-Q) to evaluate the effectiveness of treatment, as recommended by the American Geriatrics Society and the American Psychiatric Association 7, 10, 11

Side effects like somnolence, dizziness, and mental clouding are especially problematic in older adults, according to the American Geriatrics Society 12
Medications with high risk for precipitating delirium should be avoided, according to the American Geriatrics Society 2
Benzodiazepines (except for alcohol/benzodiazepine withdrawal) should be avoided due to the risk of worsening delirium, as recommended by the American Geriatrics Society 2
The American Geriatrics Society recommends avoiding typical antipsychotics, such as haloperidol and fluphenazine, due to severe side effects involving cholinergic, cardiovascular, and extrapyramidal systems, plus risk of tardive dyskinesia 1
For hypoactive delirium, the American Geriatrics Society recommends that antipsychotics and benzodiazepines are not used unless the patient is agitated and threatening harm 2