Skip to content

Agitation Management

Jonathan Constant, Jonathan Smith

Background

  • Agitation in the hospital result from discomfort, illness, medication effects or frustrations the patient is unable to meaningfully communicate

Presentation

  • Impulsive aggression: spontaneous, explosive, reactive/reflexive, not pre-meditated

    • Delirium, psychosis, cognitive deficits, withdrawal/intoxication, pain, post-ictal

  • Instrumental aggression: pre-meditated, controlled, purposeful behaviors

    • Personality disorders, secondary gain, delusional thought

  • Differential diagnosis for aggression:

    • Psychoses: mania, depression, schizophrenia, delusional disorder

    • Personality disorder: antisocial, borderline, paranoid, narcissistic

    • Substance use disorder: alcohol, PCP, stimulants, cocaine, synthetics

    • Delirium, dementia

    • Frontal lobe syndromes (TBI, CVA, neoplasm, neurodegenerative process)

    • Behavior/Developmental: Intermittent explosive, intellectual disability

Evaluation

  • Examine (when calm) for source of pain, signs of infection, discomfort (ex: urinary retention or constipation), toxidromes

  • Neurological exam for focal deficits, ataxia, nystagmus, tremor, rigidity, aphasias

  • Review medication list and perform med reconciliation of home meds

  • UDS + review of CSMD for evaluation of intoxication/withdrawal

  • CBC, CMP, UA

  • CT head + EEG if focal neurologic deficits

Management

  • Environment

    • Periodic room searches; search personal belongings, VUPD presence if warranted

    • Virtual or 1:1 sitter placement,

    • Delirium precautions (see delirium section)

    • Disposable trays and utensils (minimize potential weapons in the room)

  • De-escalation: Always first line, although impractical if pt is unable to communicate effectively, is explosive or already engaging in violent/potentially harmful behavior

    • Nonverbal:

      • Maintain safe distance, avoid sudden movements, don't touch the pt

      • Maintain neutral posture, neutral, sincere eye contact, same height

    • Verbal:

      • Speak in calm, clear tone, avoid confrontation, and offer to solve problem if possible

      • Do not insist on having the last word

  • Tactics

    • Redirection: Acknowledge pt's frustrations; shift focus on how to solve the problem

    • Aligning goals: Emphasize common ground and big picture; make small concessions

  • Restraints

    • Should be used only when necessary to protect patient or others from harm

      • Mechanically restrained patients cannot be left unmonitored

    • De-escalate (4 point to 2 point, etc) and remove restraints as soon as possible

    • Documentation of restraint:

      • Face-to-face assessment has to be completed within an hour of violent restraint

      • “Restraint Charting” tab – typically in rarely used tab drop down

    • Mechanical Restraints:

      • Soft restraints – most commonly used

      • Hard restraints – reserved for severe behavioral health (only 2 sets in house)

      • Mittens

      • Posey Vest – prevents exiting bed, allows limbs to be free

      • Posey Bed – wandering patient (TBI, severe dementia)

    • VUMC Orders: “restraint” --> order set

      • Non-violent non-self-destructive (order lasts up to 48 hrs)

        • Most pts needing restraint: non-psychiatric, delirium, dementia, intubation

      • Restraint violent self- destructive adult

        • Order lasts up to 24hr with assessment every 4 hours

        • Mainly severe psychiatric symptoms

Pharmacological Management for Agitation

As discussed above, behavioral interventions are first line for agitation management in the hospital. Pharmacologic treatment should only be used when needed for patient and/or staff safety when non-pharmacologic interventions are unsuccessful or impractical

Acute Agitation

  • Antipsychotics

    • Widely effective for acute agitation, especially in delirium and psychotic disorders

    • Monitor EKG if repeated dosing or if used with other QT prolonging agents

    • Moderate agitation options:

      • Olanzapine 2.5 - 5mg po q6h prn. Orally disintegrating tab (ODT) available

      • Quetiapine 12.5 - 25mg q6h po prn for patients at higher risk of extrapyramidal symptoms (EPS)

    • Severe agitation

      • Haldol 0.5 - 1mg IV/IM q6h prn for older/frail individuals

      • Haldol 2-3mg IV/IM q6h prn for other patients

      • Titrate up to 5 mg and can increase frequency as warranted

      • When using IV Haldol obtain daily EKG, Mg and K levels

      • Stop IV Haldol if QTc > 500 msec

  • Benzodiazepines

    • Lacks EPS that can occur with antipsychotics but can worsen delirium & disinhibit patients with neurocognitive-related agitation

    • Can use alone or in addition to antipsychotic agent

    • Preferred for agitation related to intoxication/withdrawal of sedatives

      • Lorazepam preferentially used due to PO, IV and IM availability

      • Lorazepam 2mg PO/IM/IV q6h prn typical starting dose (1mg if older/frail)

        • Can increase frequency if warranted. Monitor for respiratory suppression

  • If severe agitation not responsive to above, may require sedation with infusion:

    • Dexmedetomidine, Propofol or Midazolam

Maintenance medications:

  • Antipsychotics

    • Reserve antipsychotics for severe aggression that pose significant risk and aim to wean as soon as safely possible

    • Adverse effects: metabolic, EPS, increased mortality in dementia

    • Most commonly used: Olanzapine, Quetiapine, Risperidone

  • Antiepileptic agents

  • May be effective in reduction of impulsive aggression

  • Most commonly used: Depakote

    • Levetiracetam could worsen aggression/agitation

  • Beta Blockers and Alpha Agonists

    • Noradrenergic over-activity implicated in aggression expression

    • Commonly Used: Propranolol, Clonidine, Guanfacine

  • Serotonergic agents: SSRI/SNRI/buspirone

    • Useful if co-occurring depression/anxiety disorders

    • Peak onset of action takes weeks