Evaluation of Anti-Agitation Medication Prescribing Patterns by Age in the Emergency Department
Background: Acute agitation frequently occurs in the emergency department. Appropriate management is critical for the safety of all parties involved. Benzodiazepines and antipsychotics are commonly used for agitation, but safety concerns exist with these medications in older adults, even with acute use. The purpose of this study was to compare prescribing practices of anti-agitation medications between adults aged 18 to 64 years and those aged ≥ 65 years.
Methods: This study was a retrospective chart review of patients who presented to the Veteran Affairs Southern Nevada Healthcare System emergency department and received haloperidol, droperidol, lorazepam, olanzapine, or ziprasidone from August 1, 2019, to July 31, 2022. Veterans were excluded if they had alcohol intoxication, alcohol withdrawal, benzodiazepine withdrawal, or medication administration unrelated to agitation. Safety outcomes included oxygen saturation < 95%, supplemental oxygen use, intubation, QTc prolongation, and new hypotension within 1 hour of medication administration.
Results: For the 232 patients who met inclusion criteria, baseline characteristics differed significantly. When comparing patients aged 18 to 64 years and those aged ≥ 65 years, the younger cohort had higher rates of substance use disorder diagnosis (55.3% vs 27.5%, P < .001), positive urine drug screen (69.7% vs 22.5%, P < .001), and 72-hour legal hold (59.9% vs 32.5%, P < .001), and lower rates of cognitive impairment or dementia (0.7% vs 48.8%, P < .001), and altered mental status-related diagnosis (2.0% vs 18.8%, P < .001). Anti-agitation medication selection significantly differed based on age (P = .02). Other than lorazepam (P = .007), no significant differences were noted in the dose ordered. No significant differences were observed for safety outcomes or additional anti-agitation doses.
Conclusions: Anti-agitation prescribing practices may differ between adults aged 18 to 64 years and those aged ≥ 65 years. The findings of this study also suggest that the most common agitation etiologies may differ based on patient age. Additional higher-quality studies are needed to further explore acute agitation in older adults.
Limitations
As a retrospective chart review, this study is unable to prove any differences in prescribing patterns for anti-agitation medications based on age. As a single-center study, the prescribing patterns and baseline characteristics are unique to the facility and not generalizable to all patients with acute agitation in the ED. Future, higher-quality studies with adequate power in diverse patient populations are needed to further elucidate differences in acute agitation etiology and anti-agitation medications based on patient age.
The anti-agitation medication used may have been skewed for patients with multiple and/or previous ED encounters. If information was available on previous causes of agitation and/or previous efficacy of regimens, this may have influenced selection. Additionally, clinical pharmacy specialists began providing daytime coverage in the ED in April 2022. As a part of their role, these pharmacists provide recommendations for medication selection in the management of acute agitation and can order anti-agitation medications. While no pharmacist prescriptions were identified in the study, their recommendations may have influenced medication selection toward the end of the study period.
Given the retrospective nature of the study, it is unclear whether medication selection may have been guided by the patient’s presentation or comorbidities to avoid adverse effects. This may have influenced the safety outcomes observed. Another limitation to this data is vital signs documentation. Vital signs were rarely documented in the ED within 1 hour of medication administration, meaning the vital signs captured may not be related to the agitation medication. Among the patients with documented vital signs, 20 patients were documented within 10 minutes, likely prior to when the medication had taken full effect. This time variability further limits the ability to link safety outcomes to medications and demonstrates a need for additional research. Very few patients had electrocardiogram data after medication administration. If patients did have an electrocardiogram measured in the ED, this more commonly occurred prior to any medication administration, which may have also guided clinicians in initial medication selection.
This study may have also overlooked risperidone use. Though risperidone is on the VASNHS formulary, it was not expected to be commonly used in the ED setting due to it only being available by mouth. However, oral medication use was higher than expected, and there were instances where clinicians initially ordered 1 of the included anti-agitation medications but patients ultimately received risperidone. Based on these findings, the current study may have overlooked this as an anti-agitation medication regimen. In addition, by excluding alcohol intoxication, alcohol withdrawal, and BZD withdrawal, this study did not fully capture the agitated population in our ED.
Conclusions
Anti-agitation medication prescribing patterns may differ between adults aged 18 to 64 years and those aged ≥ 65 years. The findings of this study also suggest that the most common agitation etiologies may differ based on patient age. Future studies should further explore anti-agitation medication use and agitation etiologies among older adults to guide medication prescribing.
Acknowledgments
We acknowledge Ted Turner, PharmD, BCPP, and Phong Ly, PharmD, BCPS, for their support and assistance on this project.
