Management of Agitation in Patients

Assessment and Treatment Recommendations

The American Society of Critical Care Medicine recommends determining the underlying cause of agitation to guide treatment selection, and differentiating between agitation due to primary psychiatric disorders versus alcohol/benzodiazepine withdrawal 1, 2, 3
The Clinical and Molecular Hepatology society suggests assessing for signs of alcohol withdrawal syndrome, including tremors, tachycardia, hypertension, sweating, anxiety, and potential progression to delirium tremens 4
The Annals of Oncology guidelines recommend evaluating for perceptual disturbances or safety concerns that may require immediate pharmacological intervention 1
The American Geriatrics Society recommends using benzodiazepines at the lowest effective dose for the shortest possible duration 5

The Clinical and Molecular Hepatology society recommends benzodiazepines as the first-line treatment for alcohol withdrawal syndrome, with options including lorazepam, diazepam, and chlordiazepoxide 4, 3
The Journal of the American Geriatrics Society suggests using thiamine supplementation to prevent Wernicke encephalopathy in patients with alcohol withdrawal 4, 5

The Clinical and Molecular Hepatology society recommends inpatient treatment for severe alcohol withdrawal with complications such as delirium or seizures 4
The Annals of Oncology guidelines suggest using ziprasidone at the lowest effective dose for the shortest duration when treating agitation, due to concerns about QT interval prolongation 1
The Critical Care Medicine society recommends avoiding antipsychotics as first-line treatment for alcohol withdrawal, as it can worsen outcomes and mask important withdrawal symptoms 3

The Annals of Oncology guidelines warn against using antipsychotics as first-line treatment for alcohol withdrawal, and failing to provide thiamine supplementation to patients with alcohol use disorder 3, 4
The Journal of the American Geriatrics Society suggests avoiding the use of benzodiazepines in patients with agitation who are not experiencing withdrawal, as it may worsen delirium 1, 5
The Annals of Oncology guidelines recommend avoiding co-administration of high-dose olanzapine with benzodiazepines, due to the risk of fatalities 6, 7

The American Society of Critical Care Medicine suggests that dexmedetomidine may be useful for agitation precluding mechanical ventilation weaning in intubated patients with delirium tremens 8
The Society for Critical Care Medicine recommends that antipsychotics should not be used as first-line treatment for alcohol withdrawal delirium, as they can worsen outcomes, and instead considers dexmedetomidine as an adjunctive therapy for benzodiazepine-refractory cases 8
The American College of Clinical Pharmacology advises against the use of antipsychotics (haloperidol, risperidone) as first-line treatment for alcohol withdrawal delirium, as they can worsen outcomes, mask important withdrawal symptoms, and provide no demonstrable benefit 9