Contributor: Aaron Lessen, MD

Educational Pearls:

What are the common causes of agitation in the elderly?

Baseline dementia causing a behavioral disturbance
Delirium precipitated by an acute medical problem such as a UTI, pneumonia, overdose/side effect of home medications, urinary retention, constipation, pain, hypoxia, electrolyte abnormality, etc.
Exacerbation of a primary psychotic condition such as schizophrenia or bipolar disorder.

What environmental changes can help reduce agitation?

What are the best options if medications are required?

If the patient is unsafe or non-pharmacologic measures fail, consider a second-generation ("atypical") antipsychotic using the lowest effective dose:
- Olanzapine
- Risperidone
- Quetiapine
One special consideration is Dementia with Lewy Bodies, which can be very sensitive to antipsychotics.
- In this case, Quetiapine is the preferred agent.

Avoid when possible:

Diphenhydramine and other anticholinergics, which can worsen delirium (including urinary retention and sedation)
Benzodiazepines, which may worsen confusion, falls, and respiratory depression
Haloperidol, which has a higher risk of extrapyramidal symptoms and QT prolongation than many atypicals

References

Badwal K, Kiliaki SA, Dugani SB, Pagali SR. Psychosis Management in Lewy Body Dementia: A Comprehensive Clinical Approach. J Geriatr Psychiatry Neurol. 2022 May;35(3):255-261. doi: 10.1177/0891988720988916. Epub 2021 Jan 19. PMID: 33461372.
Kurlan R, Cummings J, Raman R, Thal L; Alzheimer's Disease Cooperative Study Group. Quetiapine for agitation or psychosis in patients with dementia and parkinsonism. Neurology. 2007 Apr 24;68(17):1356-63. doi: 10.1212/01.wnl.0000260060.60870.89. PMID: 17452579.
Shenvi C, Kennedy M, Austin CA, Wilson MP, Gerardi M, Schneider S. Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool. Ann Emerg Med. 2020 Feb;75(2):136-145. doi: 10.1016/j.annemergmed.2019.07.023. Epub 2019 Sep 26. PMID: 31563402; PMCID: PMC7945005.

Summarized and edited by Jeffrey Olson, MS4

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