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Best practices for managing agitation in elderly hospitalized patients

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I do solo overnight EM coverage in a critical access hospital.  We have 16 in-patient beds and I am responsible for calls from the floor from 22:00-07:00.

One of my most frequent calls are for agitated elderly patients whom the nurses can't re-direct.  Often they are pulling at lines and tubes, trying to get out of bed, and not infrequently verbally and sometimes physically aggressive.  Usually, these patients are there for some disease process: UTI, COPD exacerbation, CP rule-out, that keeps them from returning to their nursing home.  By the way, those ECF's are of "varying" quality.  In most cases, these patients are still receiving their routine medications, including sleep aids, psyche meds, etc.

My go to pharmacology tends to be:

- any of their routine meds that have been missed.  The downside to this is that these are oral meds which means a slow onset.  Not helpful in an acute situation.

- Ativan: 0.5-1.0 mg IV or IM

- Haldol: 5 mg IM

I tend not to use Benadryl - by the time I'm involved I don't think that will be strong enough.  I also tend not to use Geodon: between the time needed to reconstitute and the slow onset it doesn't seem to be a great option - though I routinely use in the ED for severe agitation.  I've not tried ketamine because I'm worried about emergence reactions in patients who are already disoriented by being in a totally different environment.

Do folks have any other suggestions, either for initial approach or if the ativan and haldol don't work?  Thanks!

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So I always avoid benzos in the elderly, often times it will just exacerbate whatever delirium they are experiencing in a similar fashion to benadryl. I personally love Seroquel if they're able to take PO, haldol if they're not. 

As long as you're comfortable with an infusion (or your staff is) dexmedetomidine is my go to.

Always joke that Precedex is the ketamine of the upstairs.

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