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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