Use of Antipsychotic and Sedative Medications in Older Patients in the Emergency Department

Maura Kennedy MD, MPH; Jennifer Koehl PharmD; Jingya Gao MS; Katherine A. Ciampa PharmD; Bryan D. Hayes PharmD; Carlos A. Camargo Jr MD, DrPH


J Am Geriatr Soc. 2022;70(3):731-742. 

In This Article

Abstract and Introduction


Background: Antipsychotics and sedatives are used to treat agitation in the emergency department (ED) but carry significant risk in older adults. Our objective was to determine factors associated with their administration to older ED patients.

Methods: This was an observational study using data from the 2014–2017 National Hospital Ambulatory Medical Care Survey. We identified ED visits for patients aged ≥65 years and determined whether an antipsychotic or sedative was administered. Visits related to substance use/withdrawal, other psychiatric complaints, and intubation were excluded. We performed multivariable logistic regression to identify risk factors for antipsychotic or sedative administration.

Results: Of the 78.7 million ED visits that met inclusion criteria, 3.5% involved at least one dose of antipsychotic or sedative medication; 13% involved an antipsychotic and 92% a sedative. Factors associated with antipsychotic administration included nursing home residence (adjusted odds ratio [aOR]: 2.67; 95% CI: 1.05–6.80), dementia (aOR: 5.62; 95% CI: 2.44–12.94), and delirium (aOR: 7.33; 95% CI: 2.21–24.32). Sedative administration was positively associated with CT or MR imaging (aOR: 1.86; 95% CI: 1.42–2.43), urbanicity of ED (aOR: 1.46; 95% CI: 1.02–2.08), and female gender (aOR: 1.47; 95% CI: 1.08–1.99) and negatively associated with older age (age: 75–84; aOR: 0.67; 95% CI: 0.49–0.91; age: 85+; aOR: 0.63; 95% CI: 0.45–0.88; reference age: 65–74 years). Antipsychotic and sedative administration were associated with prolonged ED lengths of stay and hospital admission.

Conclusion: We identified patient- and facility-level factors associated with sedative and antipsychotic administration in older ED patients. Antipsychotic and sedative administration were associated with prolonged ED lengths of stay and hospital admission.


By 2030, one in five individuals in the United States will be over the age of 65 years, and this will increase to one in four by 2060.[1] In addition, the number of individuals living with dementia in the United States is expected to double over the next 30 years.[2] Older adults visit the emergency department (ED) at higher rates than other age groups,[3] and people living with dementia have disproportionately higher ED utilization.[4] Up to 1.7 million ED visits in the United States involve agitation,[5] the symptoms of which can range from irritability to severe restlessness and physical aggression.[6] Common causes of agitation include drug intoxication or withdrawal and mental health conditions including anxiety, depression, and psychotic disorders.[6] The differential diagnosis is expanded in older adults and includes delirium and behavioral and psychiatric symptoms of dementia. Delirium, specifically, occurs in 6%–38% of older ED patients,[7] and approximately 10% of these patients have hyperactive delirium, characterized by increased psychomotor activity, heightened level of arousal, and/or agitation.[8] In addition, agitation is common in individuals with dementia,[9–11] and may be due to behavioral and psychiatric symptoms of dementia or delirium superimposed on dementia.[12]

Given the prevalence and clinical significance of delirium among older ED patients, delirium recognition and management has been identified as a key research and clinical care priority by geriatric and emergency medicine experts for decades, including the American Geriatrics Society, Society of Academic Emergency Medicine, American College of Emergency Physicians, and Emergency Nursing Association. Delirium recognition and management has been identified as a critical area for research as far back as 2004,[13,14] is considered a core geriatric education competency for emergency medicine residents,[15] is one of the key care processes in geriatric EDs,[16,17] and a quality indicator for geriatric emergency care.[18,19] More recently, pharmacologic management of delirium and geriatric agitation in the ED[20] and delirium prevention in the ED[7] have been identified as high priority research areas for geriatric emergency medicine. Despite this, the available data on treating agitation in the ED setting generally focus on agitation related to substance use and older adults are often excluded and/or underrepresented. For example, a systematic review and meta-analysis comparing sedative agents for agitated ED patients included seven studies, two of which excluded patients ≥65 years old. In each of the other five studies, the mean age was below 42 years old.[21] Antipsychotics and sedatives carry significant risk in older adults: the former may increase risk of death or cardiopulmonary arrest in hospitalized older patients,[22] and benzodiazepines, a class of sedative, are associated with geriatric falls and may precipitate or worsen delirium.[23] In one study evaluating the pharmacologic management of acute aggression in older adults in the ED and inpatient units, there was a high rate of sedative use with midazolam, lorazepam, and diazepam accounting for 53%, 11%, and 7% of the pharmacologic agents administered with variable dosing and several instances of oversedation when multiple doses were administered.[24] Given the dearth of literature on this topic, there is an urgent need for research into the use and harms of antipsychotics and sedatives for the management of geriatric agitation in the ED.

The objectives of this study of patients with geriatric-related conditions were to determine the frequency with which antipsychotic and sedative medications are administered to older patients in the ED, and to identify patient- and facility-level factors associated with their administration.