The agitated older adult in the emergency department: a narrative review of common causes and management strategies

Abstract

Agitation and aggression are common in older emergency department (ED) patients, can impede the expedient diagnosis of potentially life‐threatening conditions, and can adversely impact ED functioning and efficiency. Agitation and aggression in older adults may be due to multiple causes, but chief among them are primary psychiatric disorders, substance use, hyperactive delirium, and symptoms of dementia. Understanding the etiology of agitation in an older adult is critical to proper management. Effective non‐pharmacologic modalities are available for the management of mild to moderate agitation and aggression in patients with dementia. Pharmacologic management is indicated for agitation related to a psychiatric condition, severe agitation where a patient is at risk to harm self or others, and to facilitate time‐sensitive diagnostic imaging, procedures, and treatment. Emergency physicians have several pharmacologic agents at their disposal, including opioid and non‐opioid analgesics, antipsychotics, benzodiazepines, ketamine, and combination agents. Emergency physicians should be familiar with geriatric‐specific dosing, contraindications, and common adverse effects of these agents. This review article discusses the common causes and non‐pharmacologic and pharmacologic management of agitation in older adults, with a specific focus on dementia, delirium, and pain.

COVID‐19 hospital and emergency department visitor policies in the United States: Impact on persons with cognitive or physical impairment or receiving end‐of‐life care

“… 32 , 33 In the case of persons living with advanced dementia, caregivers serve the invaluable role of interpreting the non‐verbal clues of these persons, who otherwise may communicate pain, fear, overstimulation, or an unmet need only through agitation. 34 The roles of caregivers of older adults may practically parallel those of parents of young children, and the fact that parents were most likely to be granted an explicit exemption from visitor policies in our study demonstrates that hospitals recognize the benefit of such critical roles in the care of the patient. Caregiver presence would arguably have been more crucial during the pandemic, as persons with cognitive or physical impairment experienced further functional declines, 3 , 9 , 35 where the widespread use of face masks potentially exacerbated disorientation in those with advanced dementia, 36 , 37 and where constraints in hospital resources or competing demands often limited the hospital staff's ability to attend to patients with special needs or disabilities.…”

Efficacy of Doll thErapy compared with standard treatment in the control of behavioral and psychologic Symptoms and CaRegIver Burden in dEmentia: DESCRIBE a randomized, controlled study

“…Pharmacologic treatments used to control A/A are often burdened by severe collateral effects that may prolong hospital stay and increase the risk of in-hospital mortality [56] , whereas nonpharmacologic approaches have less collateral effects [20,21] .…”

Visitor policies and health equity in emergency care of older adults

“…This is not only because of variability in pre‐existing working relationships with colleagues, but also because of what felt like constant policy changes over the early months of the pandemic that have left us uncertain about advocacy. When at the bedside, caregivers play an important role in orienting older adults and can help prevent and manage agitation and delirium 10,11 . Inadvertently excluding non‐English speaking caregivers from the ED could potentially lead to disparities in adverse outcomes associated with ED delirium such as increased length of stay, falls, and mortality 10 .…”