Table 4.

Summary of low-, intermediate-, and high-risk interventions, as well as risks or contraindications of certain medications, and interventions to avoid.

Intervention Risk Category	Intervention Details
Low-risk interventions or activities:  for all patients	Treat underlying conditions and symptoms, restart home medications if possible. Follow prevention steps. Transfer to hospital-style bed or chair/recliner instead of gurney, which limits mobility/independence and may increase falls risk. Verbal de-escalation if actively agitated.
Medium-risk interventions: for moderate agitation or patient at risk of harming self or staff	Step 1: PO medications.  If the patient is prescribed an antipsychotic at home, administer this. Other options include the following: Risperidone ≤1 mg. Caution in frail or volume-depleted patients; may cause orthostatic hypotension. Olanzapine 2.5–5 mg. Contraindications/risks: Caution in intoxicated or volume-depleted patients; may cause orthostatic hypotension or sedation.  Quetiapine 25–50 mg at night. May cause orthostatic hypotension and somnolence.  Haloperidol 1–2 mg PO. May have more extrapyramidal adverse effects than the atypical antipsychotics.
	Step 2: IM or IV medications if patients are not cooperative with PO medications or are at risk of harming themselves or staff:  Ziprasidone10–20 mg IM. Caution in uncontrolled heart failure or cardiac disease, intoxicated patients, or volume-depleted/orthostatic patients.  Olanzapine 2.5–5 mg IM. Caution in intoxicated or volume-depleted patients; may cause orthostatic hypotension or sedation.  Haloperidol 0.5–1 mg IM. Higher risk for extrapyramidal adverse effects than the atypical antipsychotics. Higher risk with IV, so IM is preferred. Can redose if needed, but avoid doses of 5–10 mg haloperidol because it may cause prolonged effects/sedation, EPS, or other adverse effects. Use caution or avoid IV haloperidol because of adverse effects.
High-risk interventions	Benzodiazepines should be avoided if possible because they may cause prolonged sedation, paradoxic agitation, or worsening of delirium. If they are used, low doses such as 0.5 mg lorazepam should be given rather than the more common 2 mg used in younger patients. However, if a patient is receiving benzodiazepines long term, his or her home medication should be continued to prevent precipitating withdrawal.  Physical restraints should be avoided if at all possible because patients can become injured, and their use precludes mobility.
Interventions to avoid	Diphenhydramine is appropriate for treatment of acute allergic reactions or anaphylaxis, but should not be used for agitation because of its sedative and anticholinergic properties.

PO, Oral; IM, intramuscular; IV, intravenous.