Management of Agitation

Introduction to Agitation Management

• Agitation can be managed using a combination of non-pharmacological and pharmacological interventions, with the goal of reducing symptoms and improving patient outcomes, as recommended by various medical societies, including the American College of Emergency Physicians and the European Society for Medical Oncology 1, 2

Dosing and Administration

• For severe agitation, doses of haloperidol up to 5 mg may be required, but higher doses increase the risk of adverse effects, according to the American College of Emergency Physicians 1
• The initial dose for acute agitation should be 0.5-1 mg PRN, as recommended by the National Comprehensive Cancer Network 3
• Risperidone, an atypical antipsychotic, may be used to manage agitation in geriatric patients with Alzheimer's disease, with recommended dosages of 0.25 mg/day (maximum 2 mg/day) and an effective dose of approximately 1 mg/day in elderly patients 4, 5
• The following medications may be considered for dementia-related agitation, with specific starting doses and maximum doses:

4, 6

Monitoring and Safety

• QT prolongation requires ECG monitoring in high-risk patients, according to the American College of Emergency Physicians 1
• Respiratory depression is a risk, particularly when combining haloperidol with benzodiazepines, as noted by the European Society for Medical Oncology 2
• Prolonged use of PRN haloperidol should be avoided, especially in delirium, and used for the shortest period necessary, as recommended by the European Society for Medical Oncology 2
• Combining haloperidol with benzodiazepines increases the risk of respiratory depression and oversedation, according to the European Society for Medical Oncology 2
• Potential side effects of risperidone include hyperprolactinemia, sexual dysfunction, weight gain, somnolence, and asymptomatic prolactin elevations, and elderly patients are more susceptible to extrapyramidal symptoms and should be monitored closely 5, 7, 2, 8

Non-Pharmacological Interventions

• Providing a predictable routine, explaining procedures and activities in simple language, and simplifying tasks can help manage patient care, along with using visual reminders, reducing environmental stimulation, and redirecting activities 4
• Repetition, reassurance, and redirection can help avoid problematic situations, and non-pharmacological interventions, such as structured daily routines and caregiver education, should be considered first before initiating treatment 4, 5
• Addressing reversible causes of agitation, such as pain, urinary retention, and constipation, is essential before starting treatment, according to standard medical practice 5

Diagnostic Evaluation

• The American College of Radiology recommends using CT cerebral as the initial study when intracranial pathology or focal neurological deficit is suspected, with a diagnostic yield of 9.8% in patients with altered mental status 9
• Factors associated with abnormal neuroimaging findings include low Glasgow Coma Scale, lateralizing signs, elevated systolic blood pressure, and low body temperature 9
• Complementary studies, such as chest radiography for pneumonia, ECG for myocardial ischemia, EEG for seizures, and lumbar puncture for CNS infection, should be considered based on clinical suspicion 9

Patient Safety and Follow-Up

• Implement fall prevention strategies, including home safety evaluation, assistive devices, physical therapy for balance training, ensuring adequate hydration, and recommending slow positional changes 10, 11
• Develop individualized safety plans including personal supports, technological supports, environmental modifications, and regular review and updating as required to ensure patient safety 12
• Provide education and support for family and caregivers on non-pharmacological interventions and medication management to improve patient outcomes, and have flumazenil available for severe respiratory depression [4, 13, @3@]
• Regular medical evaluation (at least every 6 months) is necessary, and close monitoring for adverse effects, such as excessive sedation, respiratory depression, falls, paradoxical reactions, and cognitive impairment, is essential when using benzodiazepines 14, 15
• Patients should be assessed for improvement in subjective and objective symptoms, and monitored for side effects of treatments, such as hypotension, bradycardia, sedation, respiratory depression, and falls 16