Exploring Current Emergency Medical Services Approaches to Manage Agitated Older Adult Patients: An Analysis of Statewide Protocols

BACKGROUND: Agitation in older adults presents unique challenges for emergency medical services (EMS) clinicians. To safely assess, treat, and transport these patients, EMS providers must manage this agitation, which is often caused by delirium or behavioral symptoms of dementia. Strategies routinely used in younger patients, such as physical restraints and chemical sedatives, have a much higher risk of causing harm in older adults. EMS provider practices in this area are understudied. Our objective was to examine U.S. state protocols for guidance on agitation management in older adults. METHODS: We reviewed publicly available statewide EMS protocols and the National EMS Model Guidelines to identify agitation management guidance and whether modifications for older adults were included. We assessed each protocol for the presence of 26 elements using a standardized approach. RESULTS: We analyzed 34 state protocols and the National Model Guidelines. While 33 protocols (97%) included guidance for managing agitation and 19 protocols (58%) included pediatric-specific considerations, only 11 (33%) addressed older adults. Among these, the most common modification was sedative medication dose reduction (9 protocols, 27%). No protocols included modifications to guidance/criteria for physical restraint use, prioritization/escalation between physical restraint and chemical sedation, or sedative medication selection for older adults. Guidance on medication selection varied: 29 protocols (88%) included standing orders for sedative medications, most commonly midazolam (27 protocols, 82%), ketamine (23 protocols, 70%), haloperidol (17 protocols, 52%). Only 7 protocols (21%) included specific dose adjustments for older adults, typically a 50% reduction. Benzodiazepines were most commonly recommended, while antipsychotics were less common. CONCLUSIONS: Most state EMS protocols provide guidance on management of agitated patients, including use of physical restraints and chemical sedatives, yet modifications or specific guidance for older adults are uncommon. Recognizing and addressing this gap represents an important opportunity to improve quality of prehospital care for older adults.