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?

• Maintain a quiet, calm, uncluttered environment
• Dim the lights
• Ensure the patient has their glasses, hearing aids, and dentures
• Avoid excessive lines such as foleys
• Minimize restraints and other forms of immobilization
• Reassure the patient frequently and have the family check in with the patient

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

1. 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.
2. 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.
3. 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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Contributor: Aaron Lessen, MD

Educational Pearls:

• Patients with pulmonary embolism (PE) are divided into three risk categories
  • Low risk (non-massive PE): patients are stable
    • Treatment: prescribe anticoagulants and discharge home
  • Intermediate risk (submassive PE): patients are stable but display evidence of clot burden such as elevated troponin, elevated BNP, and/or right heart strain
    • Treatment is controversial
  • High risk (massive PE): patients are unstable with hypotension, hypoxia, and/or respiratory distress
    • Treatment: IV thrombolysis to prevent decompensation
• A recent randomized controlled trial evaluated treatment of intermediate risk PE patients
  • Patients were randomized to receive either thrombectomy with anticoagulation or anticoagulation alone
  • The primary outcome evaluated changes in right ventricular enlargement at 48 hours
    • A controversial primary outcome because it does not speak to mortality or incidence of other necessary aggressive interventions
    • Low clinical significance
  • The study found that thrombectomy significantly reduced right ventricular enlargement faster than anticoagulation alone. However, there was no statistical difference in mortality or need for other treatments
• Treatment for intermediate risk PE patient remains controversial
• The same study will have second follow-up at 90 days to see if there are other benefits

References

1. Lookstein RA, Konstantinides SV, Weinberg I, Dohad SY, Rosol Z, Kopeć G, Moriarty JM, Parikh SA, Holden A, Channick RN, McDonald B, Nagarsheth KH, Yamada K, Rosovsky RP; STORM-PE Trial Investigators. Randomized Controlled Trial of Mechanical Thrombectomy With Anticoagulation Versus Anticoagulation Alone for Acute Intermediate-High Risk Pulmonary Embolism: Primary Outcomes From the STORM-PE Trial. Circulation. 2026 Jan 6;153(1):21-34. doi: 10.1161/CIRCULATIONAHA.125.077232. Epub 2025 Nov 3. PMID: 41183181.

Summarized by Meg Joyce, MS2 | Edited by Meg Joyce & Jorge Chalit, OMS4

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