Problem SolvERs is the inaugural column by ACEP Now Associate Editor Dr. Catherine Marco, answering clinical questions while working at the patient’s bedside. 

A 91-year-old man is brought to the emergency department (ED) by emergency medical services (EMS), from the nursing home where he resides. According to EMS, the nursing home staff called 9-1-1 because of altered mental status and agitation. On physical examination, the patient is agitated, yelling nonsensical words, and trying to hit anyone who comes near him. The hospital staff are unable to get vital signs or start an IV.  

Question: What is the best management of agitation in the elderly?

Answer: Clinical questions arise regularly in the ED. Time allows for a brief search for information, but perhaps not a comprehensive review of the literature. How should such on-shift clinical questions be researched?

There are numerous options for answers to clinical questions. Clinical textbooks, such as Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, or Rosen’s Emergency Medicine, are valuable resources for studying and answering clinical questions. Search engines may provide more current information. Google hosts more than 3.5 billion searches per day and has a 92 percent share of the global search engine market. Online review sources such as UpToDate are also rapidly accessible. Review of the literature is important, but can be difficult to accomplish in real time in the clinical environment. PubMed, a free search engine maintained by the United States National Library of Medicine at the National Institutes of Health, accesses the MEDLINE database of references and abstracts on life sciences and biomedical topics. 

For this clinical question, let’s go to PubMed. Multiple searches may be necessary to locate the relevant medical literature. Search terms “agitation” and “elderly” yield 7,257 results, far too many for an emergency physician to peruse while their patient is too agitated to get vital signs. Narrowing the search terms to “agitation,” “elderly,” and “emergency” in the last five years narrowed the search to 356 articles. Scanning through these results, it is easily recognized that many of these articles refer to music therapy and other nonpharmacologic modalities. An additional search term, to now include “agitation”, “elderly”, “emergency” and “pharmacologic” is now narrowed to 50 articles.

Articles of interest to the emergency physician include:

An article published by Gottlieb et al. in Journal of Emergency Medicine states:¹

“All patients should receive a point-of-care glucose test, with additional testing depending upon the specific patient presentation. Initial management should involve verbal de-escalation techniques, followed by pharmacologic interventions, with physical restraints reserved as a last resort. Pharmacologic options include first-generation antipsychotics (FGAs), second-generation antipsychotics (SGAs), benzodiazepines, and ketamine. Finally, the management of pediatric, pregnant, and elderly patients warrants special consideration…When medications are required, a lower dose should be used, with some experts recommending using no more than half the normal starting dose. Additionally, due to the potential for decreased breakdown and excretion of medications, titration should be slower than in younger patients. Benzodiazepines should be avoided, as their use in the elderly is associated with worse outcomes (e.g., central nervous system depression, respiratory depression, falls) even after a single dose. Although the literature is limited, either FGAs or SGAs are reasonable first-line pharmacologic agents. However, one should be cognizant of the increased potential for QTc prolongation, as many elderly patients are on concomitant medications that may interact with or prolong the QTc interval.” 

Another article by Mouaffak et al., published in Expert Opinions in Pharmacotherapy, states: 

“Titration with a lower starting dose is recommended in elderly patients, due to possible decreases in pharmacokinetic clearance, and due to the risk of concomitant diseases and drug interactions. Exposure to some Aps (antipsychotic agents) has been associated with QTc prolongation and arrhythmias, and a small but significant increase in the risk of stroke and mortality with Aps has been seen, particularly in older people with dementia-related psychosis.”² 

These statements confirm recommendations from the first article.

A third article by Aftab et al., in Psychiatry Clinics in North America focuses on the agitated elderly patient.³  Key points from this article include:

• As a result of multiple physiological and pharmacokinetic changes, the elderly are more vulnerable to the side effects of medications and require lower doses of medications and slower rates of titration.
• The geriatric population is a high-risk group for suicide, with more serious intent, fewer warning signs and more lethality. Suicide risk assessment should be part of a standard emergency psychiatric assessment.
  • Prompt diagnosis and treatment of delirium in emergency settings is essential given the association with worse outcomes such as prolonged hospital stay, risk of cognitive decline, and increased mortality.
  • Behavioral interventions for agitation in dementia are the first-line measure before pharmacologic interventions. Pharmacologic options with demonstrable efficacy are mostly limited to antipsychotics, the use of which is problematic, as all antipsychotics increase the risk of mortality in dementia.

As a result of this brief literature search, it is evident that the recent literature supports the use of pharmacologic agents for the treatment of agitated elderly patients. Appropriate agents may include risperidone, olanzapine and aripiprazole. Low doses should be initiated.  Benzodiazepines should be avoided.  Suicidal risk should be assessed. Etiologies of altered mental status should be investigated, including trauma, pain, infection, or medication effect. 

Dr. Marco is professor of emergency medicine at Wright State University in Ohio and associate editor of ACEP Now.

References

1. Gottlieb M, Long B, Koyfman A. Approach to the Agitated Emergency Department Patient. J Emerg Med. 2018 Apr;54(4):447-457. doi: 10.1016/j.jemermed.2017.12.049. Epub 2018 Feb 1. PMID: 29395692.
2. Mouaffak F, Ferreri F, Bourgin-Duchesnay J, Baloche E, Blin O, Vandel P, Garay RP, Vidailhet P, Corruble E, Llorca PM. Dosing antipsychotics in special populations of patients with schizophrenia: severe psychotic agitation, first psychotic episode and elderly patients. Expert Opin Pharmacother. 2021 Dec;22(18):2507-2519. doi: 10.1080/14656566.2021.1958781. Epub 2021 Aug 17. PMID: 34338130.
3. Aftab A, Shah AA. Behavioral Emergencies: Special Considerations in the Geriatric Psychiatric Patient. Psychiatr Clin North Am. 2017 Sep;40(3):449-462. doi: 10.1016/j.psc.2017.05.010. PMID: 28800801.