Agitation and aggression

BAP/NAPICU: Clinical management of acute disturbance

1-2mg (500mcg-1mg >65 or frail).

25-50mg (12.5-25mg >65 or frail).

2-5mg (500mcg-1mg for >65 or frail).

Prescribing Notes:

Rapid tranquilisation is an urgent situation and intramuscular medication is necessary when the oral route is not possible or appropriate.
A benzodiazepine is always recommended as first line treatment.

History Notes

27/10/2022

East Region Formulary content agreed.

Midazolam used when lorazepam is not available.

By intramuscular injection dose as appropriate to patient.

By intramuscular injection 5mg repeated after one hour if necessary; maximum dose 10mg daily.

If no response to first line treatment, treatment is repeated after 1 hour.

If no response to second line treatment, administer after 2 hours.

By intramuscular injection, 5mg repeated after 2 hours if necessary; max. daily parenteral dose 10mg.

By intramuscular injection. To be given as per protocol. Maximum 50mg IM daily.

Patient should be fully assessed by prescribing doctor before each administration to ensure clinical suitability. Following administration, the patient must be observed for adverse effects on vital parameters and extrapyramidal side effects.

By deep intramuscular injection. 50-150mg repeated if necessary after 2 or 3 days. Duration of treatment should not be more than two weeks. Maximum accumulated dosage should not exceed 400mg and number of injections should not exceed four.

Prescribing Notes:

Rapid tranquilisation is an urgent situation and intramuscular medication is necessary when the oral route is not possible or appropriate.
A benzodiazepine is always recommended as first line treatment.
Olanzapine 10mg IM is an alternative in patients who have known acute dystonic sensitivity to haloperidol. Refer to SPC for guidance on administration and contra-indications.
Zuclopenthixol acetate is a therapeutic option for the ongoing management; after an acutely psychotic patient has required repeated injections of benzodiazepines or short-acting antipsychotic medications. Zuclopenthixol acetate should only be given after calming has been achieved, in those situations when it is likely to reduce the need for repeated intramuscular injections.

History Notes

09/04/2024

Addition of Clopixol accuphase, ERWG March 24.

27/10/2022

East Region Formulary content agreed.

For all formulations shown in this pathway – intravenous administration only to be used in locations where access to intensive monitoring and anaesthetic support are available.

As per local guidance.

Prescribing Notes:

Rapid tranquilisation is an urgent situation and intramuscular medication is necessary when the oral route is not possible or appropriate.
A benzodiazepine is always recommended as first line treatment.

History Notes

27/10/2022

East Region Formulary content agreed.

Non-pharmacological treatment is the first line option in the treatment of aggression and agitation in dementia patients.

Risperidone or haloperidol or other second generation antipsychotics.

Initially 250micrograms twice daily, then increased in steps of 250micrograms twice a day on alternate days, adjusted according to response; usual dose 500micrograms twice daily (max per dose 1mg twice daily).

Haloperidol should not be given to patients with Lewy Body Dementia or Parkinson’s Disease.

0.5-5mg daily in 1-2 divided doses, dose adjusted according to response at intervals of 1-3 days. Reassess treatment after no more than 6 weeks.
Elderly: 500micrograms daily, reassess treatment after no more than 6 weeks.

Prescribing Notes:

Antipsychotic drugs may be helpful for a minority of patients with dementia who demonstrate marked aggressions, severe agitation or distressing psychotic symptoms. Other forms of management should also be considered before prescribing antipsychotics. It is important to remember that such behaviour can be a temporary phenomenon and that the ongoing need for antipsychotics should be regularly reviewed. In the elderly, antipsychotics should be used with caution because of the side-effect profile, including extrapyramidal symptoms, sedation, anticholinergic effects, cardiovascular effects and tardive dyskinesia. In people with dementia, antipsychotic use is associated with an increased mortality rate and risk of cerebrovascular events.
Antipsychotics should be considered when behavioural disorders are accompanied by hallucinations and/or delusions. Prescribers should be alert to the possibility of a diagnosis of Lewy Body Dementia (LBD), particularly if visual hallucinations are present. Antipsychotics can lead to irreversible deterioration in patients with LBD. Quetiapine is treatment of choice in patients with LBD and Parkinson’s disease, haloperidol should not be given to these patients.
Haloperidol has a high risk of extrapyramidal side effects, especially in the elderly. The manufacturer of haloperidol recommends a baseline ECG before starting haloperidol and at regular intervals during treatment due to risk of QT prolongation /ventricular arrhythmias.
The antidepressant trazodone is useful in the management of agitation, irritability and at times aggression in older people. It is relatively safe and the dose can be titrated against the symptoms.
As symptoms often resolve spontaneously, it is worth considering postponing treatment for a few days or using “as required” medication initially.
The drug chosen should be commenced at the lowest possible dose, titrated carefully and monitored with regular reviews, with treatment aimed at short term use only.
It is important to consider physical causes of behavioural disturbance such as pain and delirium.
Depression is common in people with dementia and may present with behaviour disturbance.
Elderly patients are also particularly susceptible to postural hypotension and to hyper and hypothermia in hot or cold weather. It is recommended that:
- Antipsychotic drugs should not be used in older patients to treat mild psychotic symptoms i.e. non-distressing symptoms;
- Initial doses of antipsychotic drugs in elderly patients should be reduced (to half the adult dose or less), taking into account factors such as the patient’s weight, comorbidity, and concomitant medication. Doses used should be the lowest possible, titrated carefully and closely monitored;
- Treatment should be reviewed regularly;
- Patients/caregivers should be cautioned to immediately report signs and symptoms of potential cerebrovascular adverse events such as sudden weakness or numbness in the face, arms or legs, and speech or vision problems.
Antipsychotics should be deprescribed if there is no clinical benefit in older patients. Guidance can be found from local specialists, Polypharmacy Guidance and Deprescribing antipsychotics: a guide for clinicians.
In patients with Parkinson’s Disease dementia with psychotic features clozapine is indicated and licensed.

History Notes

27/10/2022

East Region Formulary content agreed.