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: