TL;DR

IM

• Consider Zyprexa 2.5 mg (geriatric dose)/5/10 mg IM OR Haloperidol 5 mg IM

  • Zypexa works well for patient's with dementia related behavioral problems, if they have "allergies" to Haldol, or if there is concern for EPS

  • Consider IM Haldol/Ativan in the psychotic + agitated patients as IM Zyprexa can cause hypotension if used in conjunction with IM Ativan (see caveat regarding oral dosing below)

PO

• Oral Zyprexa (5-10 mg) has long absorption time - best used if patient needs to be calm through the night

  • Good choice if you're worried about autonomic (BP, pulse) issues

  • Can combine oral Zyprexa with Ativan (hypotension only affects IM dosing)

• Haldol OR Trilafon (perphenazine) works better if you want patient to calm down faster

  • Trilafon 4-8 mg + Ativan 1-2 mg - should not affect pulse/tachycardia

  • Haldol 2-4 mg + Ativan 1-2 mg - higher concerns for EPS, tachycardia from Haldol

• Risperidone is most efficacious agent for dementia with behavioral problems but can cause reflex tachycardia

  • Can consider starting 0.25 mg PO BID on patients going back to SNF/home (can increase to 0.25 mg TID in a few days and then to 0.5mg PO BID in another few days if necessary)

• Seroquel generally worthless (unless patient is Parkinsonian, has Lewy body dementia, or has done well on it but recently stopped medication)

• Abilify has long onset of action and does not work well in ED setting

Dr. Hinds initial email (from 5/22/20):

If you have to give IM, you only have two choices for antipsychotics on formulary: Haldol and Zyprexa. IM Ziprasidone IS the most effective agent for aggression according to my sources and data but Kaiser doesn’t have it and it doesn’t really help to back order it as when you need it, you need it stat. I like Zyprexa 2.5mg IM for geriatric (dementia behavioral problem patients). Definitely for the patients who are “allergic” to Haldol or where you’re worried about EPS, IM Zyprexa at 5 or 10mg is a good choice. The only thing you have to worry about in using IM Zyprexa is that if used in conjunction with Ativan, hypotensive episodes can occur. So somebody psychotic and agitated/aggressive, may be best to stick with Haldol 5 and Ativan 2mg IM. Somebody more on the psychotic side but not too wound up or agitated, Zyprexa 5-10mg IM may be enough.

That’s IM, if patient is willing to take PO, again Zyprexa isn’t bad BUT it’s time of absorption is hours!! I’d be inclined to use Zyprexa if I get a patient in the evening (5-9 pm) and I want to cool then down for the evening and overnight. Then I’d give all at once: Zyprexa 5-10mg po (5mg for small, 10mg for bigger people) and Ativan 1-2 mg po. By the time Ativan wears off, Zyprexa will be kicking in and the nurse will nominate you for ED doctor of the year for making their night so easy. Zyprexa is also a good choice when you’re worried about someone with autonomic (BP, P) issues as it doesn’t affect them as much as many of the atypical antipsychotics. This IS an issue when a patient is persistently tachycardic and psychotic; there’s been a number of patients that end up being refused to inpatient psych as a result. (Note that there’s no problem combining PO Zyprexa and Ativan, only combining IM Zyprexa and Ativan). The above Zyprexa + Ativan combo is a reasonable strategy overnight but if you want to cool the patient down sooner, I would given a first generation antipsychotic such as Haldol but preferably Trilafon (perphenazine) at 4-8mg. Giving something like Trilafon 4-8mg + Ativan 1-2 mg will work well and should NOT worsen pulse/tachycardia. Haldol 2-4 mg + Ativan 1-2 mg is also ok but I tend to worry a bit more about EPS and even some tachycardia with Haldol.

If you don’t want to sedate the patient and just want to sharpen him up for the upcoming PET eval, just give Haldol or Trilafon without Ativan.

I do like risperidone AND it is the most efficacious agent for dementia patients with behavioral problems BUT it can cause reflex tachycardia so it’s not something that you guys have to give much in the ED (though would certainly send the dementia patient back home or back to nursing home on it. And what kind of Rx would you give for risperidone for dementia patients? Start Risperidone 0.25mg po bid, which they can increase to 0.25mg tid in a few days and then to 0.5mg po bid in another few days if necessary.)

Unless the patient is parkinsonian or Lewy body dementia (and you’re probably calling psych in that case) or has done well on it but stopped it, I do NOT recommend Seroquel as it’s generally worthless, though good for bipolar depression. Similarly, while I like abilify, it is not going to kick in soon enough in an ED setting.