The management of agitation in patients generally follows this process: 1. attempt verbal deescalation and place the patient in a low-stimulus environment, 2. chemical restraints, and 3. physical restraints. The choice of chemical restraint is dependent on the population. Antipsychotics are the best choice in patients who are agitated, in particular, in the setting of known psychiatric conditions. Atypical antipsychotics should be the first medication tried, given their high efficacy and reduced risk of oversedation. Olanzapine is a commonly used atypical antipsychotic. Moreover, atypical antipsychotics are the drug of choice when sedating older patients, as they do not carry as high a risk of causing delirium when compared to benzodiazepines or antihistamines. Multiple doses may be tried with careful attention to the safe maximum dose of the drug and the patient’s respiratory and mental status.

Diphenhydramine (A) and other antihistamines should generally be avoided in older patients, as they may lead to delirium and further agitation. On the other hand, diphenhydramine may be given with antipsychotics in younger patients for both their sedating effect and to possibly ameliorate any dystonic reaction that might occur. Lorazepam (B) is the sedative of choice in agitated patients who have used sympathomimetics such as methamphetamine or cocaine. However, they should be avoided in older patients, as benzodiazepines may also worsen delirium. Placement of physical restraints (D) is almost never appropriate without concomitant chemical restraints, as patients may harm themselves by resisting the restraints, causing musculoskeletal injury. If attempts with verbal deescalation and chemical restraints both are unsuccessful, physical restraints may be placed.