Today we will discuss agitation. This discussion will include an introduction, approach to assessment, tips on verbal de-escalation, and considerations for physical restraints. Next lesson we will cover pharmacological interventions.
Today's Content Level: All Levels (Beginner, Intermediate, Advanced)
•Agitation = Excessive restlessness/arousal that is associated with mental distress. It has the following core psychiatric signs: tension, irritability, hostility, uncooperativeness, and impulsivity. It is not defined by violence or aggression but has the potential to progress to uncontrolled behavior, damage property, self-inflicted injury, or violence to others. 1
•Patient violence occurs in many clinical settings and is a growing issue. Up to 50% of health care providers are victims of violence sometime during their careers 2. A survey of psychiatry residents revealed that 73% reported being threatened, and 36% had been physically assaulted in residency. Two-thirds of them had received either no or inadequate training in managing combative patients 3. Clinicians must be prepared to cope effectively with agitated patients in order to reduce the risk of serious injury to the patient, themselves, and other caretakers.
•Agitation, in addition to posing a safety risk, can adversely impact many other facets of the treatment process including direct patient care, community resources, and caregiver burden.
•Agitated patients require urgent psychiatric assessment. Increased waiting times correlate with progression to violent behavior, therefore evaluation should be expedited to prevent escalation of behaviors. 4 Your initial assessment may be brief and the comprehensive psychiatric evaluation can wait until the patient calms down.
•Agitated patients may also warrant a medical evaluation, particularly if there are findings suggesting a medical cause for the agitation. Some clues warranting a further evaluation include abnormal vital signs or physical exam findings, altered mental status, decreased attention, known neurologic disease, or a new/atypical psychiatric presentation. Keep in mind that in the emergency department, drug and alcohol intoxication or withdrawal are the most common diagnoses in combative patients. 5 Rapid work-up of serum glucose (finger-stick), pulse oximetry, and complete vital signs should always be performed.
Schizophrenia / Bipolar Mania: agitation in these conditions have been linked to frontal lobe dysfunction/inhibition which is associated with agitation and violent behaviors. Also found to have higher rates of mutation in the catechol O-methyltransferase (COMT) gene involved in dopamine metabolism and catecholamine inactivation. Also demonstrates reduced GABAergic inputs, increased dopamine, and increased norepinephrine. Paranoid delusions also a known risk.
Dementia: deficits in cognitive function and other cerebral impairments (frontal and temporal lobe pathology) predispose patients with dementia to agitation. It can be an expression of distress.
Personality disorders: primarily seen in Antisocial Personality Disorder and Borderline Personality Disorder.
General medical conditions: those affecting the central nervous system with increased risk such as delirium, neurologic conditions (ex: stroke, seizure), infections (ex: meningitis, AIDS), endocrine (ex: hyperthyroidism), and other metabolic issues (ex: hypoglycemia, hypoxia).
Intoxication/Withdrawal: agitation commonly seen in intoxication with phencyclidine (PCP), methamphetamine, cocaine, and use of anabolic steroids. Also commonly seen in withdrawal from alcohol, opioids, and sedative-hypnotics. Also consider overdose and other toxidromes depending on their list of medications and clinical history.
Other features: agitation more commonly seen in those with history of violence, younger males, homeless patients, and those that have public or no insurance.
Pediatric population: agitation in this group is associated with certain psychiatric conditions such as ADHD, autism spectrum disorder, developmental disorders, bipolar disorder, oppositional defiant disorder, conduct disorder, and PTSD.
Geriatric population: highly multifactorial in this group and can be related to primary psychiatric conditions, neurologic conditions such as dementia, and general medical conditions. General medical causes, including delirium, must be ruled out.
In a typical negative progression the agitated patient first becomes angry, then resists authority, and finally becomes confrontational. In some cases, however, violent behavior may erupt without warning particularly if causes by medical illness or dementia.
Learn to recognize signs of increasing agitation:
Loud and aggressive speech
Posturing such as clenching fists, staring, gripping bed rails, etc.
Increased motor activity such as pacing or frequently changing body position.
Acts of aggression such as hitting themselves, throwing objects, pounding walls, etc.
APPROACHING THE AGITATED PATIENT
Modify The Environment
Remove dangerous objects (weapons, heavy objects, sharps, moveable furniture, electrical cords, hot liquids). Make this a routine practice.
Location of interview should be in an open area. Attempt to give the patient some privacy but do not isolate. The patient should not sit between the clinician and the exit nor should the exit be blocked. Maintain physical distance out of range of the patients grasp during the interview. A quiet area with a window enabling direct observation is optimal.
Plan for a mechanism to notify others of danger such as a panic button, bringing someone else for the interview, or consider calling for security presence (in or out of patient eyesight depending on the situation).
Patients who are agitated but still showing signs of cooperation may be amenable to verbal de-escalation techniques.
Most patient who present with agitation deserve the chance to calm in response to appropriate verbal techniques, however patients who are actively violent/threatening/aggressive/uncooperative may require immediate physical restraints and/or sedative medications (see below) 9.
Attempt the following verbal de-escalation techniques:
Approach: use a calm/nonthreatening tone. Be honest, straightforward, and in control. Use concise and simple language. Advanced terms are hard for an agitated person to understand. Use active listening. Provide reassurance that the patient is safe from harm.
Avoid appearance of threat: avoid prolonged eye contact, posturing, and direct confrontation. Also do no move suddenly, stand too close to the patient, or approach the patient from behind.
Build trust: friendly gestures can be helpful. Examples include offering a snack or something to drink (not a hot beverage), a soft chair or blanket, pain relief, or nicotine replacement therapy.
Ask directly about agitation/violence: politely address their feelings. "You look upset. Do you feel like hurting someone?" Give supportive statements about doing a good job keeping these feelings under control.
Set clear limits: calmly inform them with statements such as "I can help you with your problem but I cannot allow you to continue threatening the staff". This is important but can go either way (some patient are aware of impulse control problem and will welcome limit setting whereas in other cases this may be viewed as confrontational).
Offer choices when possible: try to understand what the patient wants. Patients feel empowered if they have some choice in certain matters.
Offer medications: you can ask the patient if they would like medication to help them to stay calm. If you deem a medication necessary you can even give the patient options and ask them their preference (both type and route). Providing an oral medication may avoid physical restraints.
If verbal techniques are unsuccessful and threat of assault to self or others becomes a significant concern the clinician should exit the room, get help, and make plans for pharmacologic interventions and/or physical restraints.
Restraints may also be used when patients are interfering with medical treatment and they lack a capacity to refuse care.
Physical restraints = any method to physically restrict the movement of the patient and their limbs. Methods include physical holds by staff trained in these techniques and mechanical chairs/devices that typically use leather straps to restrain the limbs. Leather straps are the safest type of restraints.
Physical restraints are last resort interventions and should be accompanied by medication to prevent injury and minimize the time spent in restraints. A staff member should always be visible and reassuring the patient who is being restrained.
In necessary circumstances the appropriate use of restraints can be a humane and effective technique to help facilitate diagnosis and treatment of the patient and prevent injury to themselves and medical staff.
Restraints should never be used for convenience or punishment and should be removed as soon as possible, usually once the patient calms down and/or adequate pharmacologic interventions have been effective. After restraints have been placed, patient should be reevaluated within one hour and vital signs should be monitored frequently.
Potential adverse effects: there are certain risks associated with the use of restraints. Adverse effects can result if performed with excessive force or inappropriate technique such as asphyxiation, blunt trauma, rhabdomyolysis, thrombosis, and psychological trauma. 10
I hope this lesson was a helpful introduction/reminder on how to approach an agitated patient. Next lesson we will cover part 2 and detail the pharmacological treatments of agitation.
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