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.