Agitation

What is Agitation?

Agitation is a state of severe restlessness or frustration, often encountered in mental health hospitals, emergency rooms and care homes for seniors. Different methods are used to manage this behavior depending on the specific environment and individual involved. The US agency responsible for drug regulation and research, known as the Food and Drug Administration, describes agitation as either extreme restlessness coupled with emotional distress or excessive physical activity triggered by inner tension.

There can be several triggers for aggressive behavior and to some extent, it can be a natural reaction. In the past, agitated individuals were typically subdued using physical restraints, isolation, or high doses of antipsychotic drugs. Over time, less harsh techniques have been introduced and have proven to be more effective while still providing necessary therapeutic support. Approaches that don’t involve coercion are usually the best way to diffuse tense situations.

However, there are instances where agitation becomes so extreme that medication is needed, whether the patient agrees to it or not, to ensure everyone’s safety. Recent guidelines from mental health experts regarding these circumstances are somewhat unclear and can be complicated by subjective observations. Aggressive behavior can take the form of verbal or physical actions towards objects and other individuals. In some instances, individuals may even harm themselves. Attempts or threats of suicide are also classified as aggressive behavior. This explanation will help you understand various causes of behavioral disturbances, ways to identify them, and different management approaches in specific settings.

What Causes Agitation?

Aggressive behavior or disturbances can be caused by a mix of triggers and personal traits. This agitation, which can appear as excessive physical activity or inner unease, can be a normal reaction to certain situations, but it can also hint at an underlying health issue.

Common causes of this agitation include being in a new environment, going through drug intoxication or withdrawal, having alcohol in your system, or dealing with general medical conditions. Some of these medical conditions can be getting hurt (especially a head injury), widespread infection, sepsis, dementia, delirium, exposure to toxins, imbalances in body salts and hormones, and a state following a seizure.

Mental health conditions like anxiety, depression, bipolar disorder, autism spectrum disorder, and substance use can also cause agitation.

Risk Factors and Frequency for Agitation

Determining the reasons and patterns of aggressive behavior can be tricky because it varies based on age, reason for the aggression, different influencing factors, the person’s surroundings, and how severe the behavior is. The best place to study this behavior is often in long-term care facilities because healthcare professionals can track a patient’s behavior from day to day. This setting also minimizes other variables that could impact the study.

• About 33% of dementia patients living at home and 80% in care facilities exhibit agitated or aggressive behavior.
• Young adults (ages 16 to 19) tend to show more aggression than slightly older adults (20 to 26).
• With intellectual disabilities, about 10% to 20% of people may display challenging behaviors, including self-harm and aggression.
• People with mental disorders are more likely to act violently compared to the general population.
• Although it used to be believed that mental disorders automatically led to aggressive behavior, current studies show that while there’s a higher risk, mental disorders aren’t the only cause of aggression.
• A study in Sweden found that 1 in 20 people with a mental disorder have committed violent crimes, including assault. Comparable results have been reported in studies conducted around the world.
• People with schizophrenia who also reported drinking alcohol were roughly 25 times more likely to commit a violent crime than those without mental health issues, according to a Finnish study.

Aggression is an issue seen across the world, and it affects people of all cultures and backgrounds.

Signs and Symptoms of Agitation

Interacting with an agitated individual can be challenging. Getting a detailed history at this stage can be counterproductive, as it might cause retaliation, especially in people with a psychotic condition. It’s important for a doctor or mental health professional to communicate clearly and calmly, letting the person know they are understood and cared for. The goal is to gradually build trust, which might open a way for discussing basic historical information.

When trying to understand the reason behind the agitation, the professional should avoid leading questions or assumptions which might trigger sudden outbursts. If a medical condition has caused confusion or delirium, the professional might focus on questions related to the person’s orientation.

A mental status exam can provide valuable insights. For example, if post-seizure confusion is causing the agitation, asking about a seizure history can be helpful. If the agitation stems from psychosis, understanding the person’s delusions or hallucinations can clarify things.

Once the individual is calmer and better oriented, a brief physical examination can be carried out. However, it’s crucial to approach with care and ask for their consent first too. It’s also important to ensure that the patient is truly calm and not passively aggressive. This precaution is critical as agitated individuals might use different items like stethoscopes, pens, or badges as weapons. So, making sure the person is non-aggressive is paramount before initiating a physical exam.

Testing for Agitation

When faced with an upset patient, it’s important to prioritize safety first. You should be aware of any items around you that could potentially be used as a weapon – like chairs or food trays. Pay attention to the exits in the room, and be mentally prepared for any sudden physical reactions. Having other staff members close by is also a good idea, as tension can rise fast, especially if the upset person is physically strong. Also, when talking to the patient, try to maintain a safe space of one to two arm’s lengths.

Remember, bodily actions and non-verbal signals can convey a lot, so avoid any movements or expressions that may appear confrontational. Show the patient that you’re open to hearing what they have to say, and not just there to give them medication.

Assessing the situation quickly is critical when dealing with an upset patient. Try to control any outbursts as much as possible – excessive shouting can stress out other patients, potentially leading to physical altercations. After this, you’ll need to determine if calming down the patient using words will suffice, or if further action, such as medication, isolation, or using restraints, are necessary.

Treatment Options for Agitation

When dealing with agitated patients, it’s crucial for healthcare providers to understand the nature of the agitation to provide the best care possible. These include common behaviors that can cause self-harm and how to manage each of them. Proper training helps healthcare teams address hostile behavior while using minimal interventions. This implies learning tactics such as Pro-Act (Professional Assault Crisis Training), which is done around the world to create a more safe environment for both staff and patients.

Training also reduces unnecessary usage of sedatives or coercive treatments, which can harm the bond between a doctor and patient. This can also result in a safer, less threatening environment for healthcare providers.

For managing agitated patients, the ideal approach is noncoercive de-escalation. This is a skill that can be honed with practice and use in real-life situations. If a patient already trusts a particular health worker, they should lead the initial engagement. The aim is to make patients feel heard and understood. Open conversations are encouraged, and if necessary, the patient can be asked if they might be open to taking medication.

Some other strategies to calm the patient down can be offering them a quiet room or giving them options to take medication or physical restraints. However, if all the above fails, including verbal de-escalation and medications, a patient may have to be physically restrained, this should be a last resort due to the past cases where such force has resulted in fatalities.

When it comes to using medication, the goal is to use it to calm the patient to a point where they can have a conversation rather than to make them overly sedated. In cases where a patient is extremely agitated to the point of self-harm, sedation might be necessary. The choice of medicine varies depending on the patient’s agitation level and response to previous medications.

Antipsychotics are commonly used as first-line treatment for severe agitation. If a patient is agitated due to alcohol withdrawal, benzodiazepines are chosen over antipsychotics. However, the consensus can vary among different healthcare settings. In some cases, antipsychotics like haloperidol can be combined with sedatives like lorazepam. It’s essential to consider side effects when choosing a particular drug. Intravenous medications should only be used as a last resort.

It’s crucial for various facilities to have an agreed-upon strategy in dealing with acute agitation based on its cause. If a patient is agitated due to delirium or dementia, the preferred treatment is haloperidol, given twice daily. Patients whose primary agitation is due to alcohol withdrawal should be given benzodiazepines. In patients with autism spectrum disorder, medications like risperidone or aripiprazole can help in controlling challenging behaviors. Treatment strategies should always be flexible towards the preferences and needs of the patient.

Overall, managing agitated patients requires a calm, patient approach and a solid understanding of each patient’s unique situation and needs. Developing critical thinking, de-escalation tactics, and understanding when medication or restraint is necessary are integral parts of the training for handling these situations.

What else can Agitation be?

Agitation, a state of discomfort or restlessness, can be caused by various conditions including:

• Head Injury: This often causes headaches, unconsciousness, changes in mental state, and excessive sleepiness.
• Delirium: Commonly caused by infections or imbalances in body fluids and minerals, it results in confusion and sudden agitation. Characteristics include fluctuating awareness levels, disoriented speech, and temporary hallucinations, usually of sounds.
• Dementia: Gradual or sudden memory loss and cognitive decline can lead to confusion and agitation. Some diseases can confuse these symptoms and cause delirium. Regular mental health checkups are useful for tracking this condition.
• Psychosis: This can occur due to mental or postnatal disorders, certain medications, illegal drugs, sleep deprivation, or medical conditions. It’s perceived as a symptom of personality disorders, schizophrenic disorders, severe depression, or bipolar disorder. Symptoms include delusions, hallucinations, disorganized speech, apathy, dull emotional response, isolation, and lack of attention.
• Drug Intoxication or Withdrawal: This causes short-lived, severe agitation, which usually responds well to treatment. However, certain drugs like PCP can lead to a manic state that is hard to control. A urine drug screening and blood alcohol level are useful for identifying synthetic or designer drug use.

These challenges underscore the importance of careful and comprehensive evaluations for agitated patients to ensure the correct diagnosis and treatment plan.

What to expect with Agitation

The outcome for someone dealing with agitation can be influenced by what’s causing it. Things like reducing stress, improving sleep quality, and making sure needs are met can help with recovery. Using tactics to prevent agitation can also be beneficial for recovery. If agitation is being caused by a psychiatric or medical condition, medication can often help. The prognosis in the long term can vary, all depending on the root cause of the agitation.

Possible Complications When Diagnosed with Agitation

Agitation in patients can raise the risk of harm to both the patients themselves and the medical staff caring for them. This can lead to other issues such as:

• Falls
• Removal of indwelling catheters and tubes
• Injuries related to the use of restraints

Preventing Agitation

Teaching patients and making sure they follow these instructions provides the greatest chance for prevention.