Droperidol for Agitation in Older Adults in the Emergency Department

Droperidol is safe and effective for the treatment of severely agitated patients in the ED [1-3]. But what about its use for agitation in elderly patients specifically?

Droperidol Efficacy

Two Australian studies evaluated droperidol in more than 200 older adults (≥ 65 years old) in the prehospital and ED settings [4,5]. Both studies found droperidol to be effective in elderly patients with acute behavioral disturbances. The median time to sedation was ~20-30 minutes with doses ranging from 2.5-10 mg (Table 1).

Characteristic	Page, et al (n=162)	Calver, et al (n=47)
Median Age	78 years	81 years
Initial Droperidol IM Dose	5 mg	10 mg (n=30) 5 mg (n=15) 2.5 mg (n=2)
Median Time to Sedation	19 mins	10 mg: 30 mins 5 mg: 21 mins 2.5 mg: NA
Patients Sedated with ≤ 10 mg Droperidol	144 (89%)	34 (72%)

Table 1: Efficacy of droperidol in older adults

Droperidol Safety

Additionally, each study broke down each time a patient experienced an adverse event (Table 2). Overall, these adverse events were uncommon (4.5%), mild in nature, and resolved spontaneously or with minor interventions. No patients developed Torsades de Pointes.

Study	Age/Sex	Droperidol Dose	Adverse Events	Management	Time Post-Droperidol
Page, et al (n=162)	76 yo Male	5 mg	SBP <90 (88/54)	Spontaneous Resolution	–
	87 yo Female	10 mg	SBP <90 (80/46)	Spontaneous Resolution	–
	79 yo Female	5 mg	SBP <90 (83/48) O2 sat <90% (80%)	Supplemental Oxygen 500 mL IV Fluid	–
	82 yo Male	5 mg	RR <12 (RR 10)	Spontaneous Resolution	–
	86 yo Male	5 mg	O2 sat <90% (88%)	Supplemental Oxygen	–
Calver, et al (n=49)	75 yo Male	10 mg	SBP <90	–	30 mins
	68 yo Female	10 mg	SBP <90	–	5 mins
	73 yo Male	10 mg	Airway Obstruction	–	100 mins
	87 yo Female	2.5 mg	Oversedation	–	480 mins

Table 2: Safety of droperidol in older adults

Bottom Line

Taking the above points into account, droperidol appears to be both effective and safe in agitated adults ≥ 65 years of age for the treatment of agitation. The study authors recommend starting with 5 mg and repeating, if necessary, rather than initially using a dose of 10 mg.

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References

Perkins, J., Ho, J. D., Vilke, G. M., & DeMers, G. (2015). American academy of emergency medicine position statement: Safety of droperidol use in the emergency department. The Journal of Emergency Medicine, 49(1), 91–97. doi: 10.1016/j.jemermed.2014.12.024. PMID: 25837231.
PharmERToxGuy. Onset of IM Medications for Severe Agitation. Posted Dec 12, 2019.
PharmERToxGuy. QTc Prolongation and Torsades de Pointes with Droperidol in the Emergency Department. Posted Aug 30, 2020.
Calver, L., & Isbister, G. K. (2013). Parenteral sedation of elderly patients with acute behavioral disturbance in the ED. The American Journal of Emergency Medicine, 31(6), 970–973. doi: 10.1016/j.ajem.2013.03.026. PMID: 23685060.
Page, C. B., Parker, L. E., Rashford, S. J., Kulawickrama, S., Isoardi, K. Z., & Isbister, G. K. (2020). Prospective study of the safety and effectiveness of droperidol in elderly patients for pre-hospital acute behavioural disturbance. Emergency Medicine Australasia: EMA, 32(5), 731–736. doi: 10.1111/1742-6723.13496. PMID: 32216048.

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Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP

Leadership Team, ALiEM
Creator and Lead Editor, Capsules and EM Pharm Pearls Series
Attending Pharmacist, EM and Toxicology, MGH
Associate Professor of EM, Division of Medical Toxicology, Harvard Medical School