Agitation Management

Ben Johnson

Background

Agitation in the hospital results from discomfort, illness, medication effects or frustrations the patient is unable to meaningfully communicate.
Aggression is a specific form of agitation in which the person is threatening or attempting to harm another person or physical objects.
Agitation is a broader term which may also include irritability, anxiety, pacing, yelling, sexually inappropriate behavior, pulling at restraints or medical devices, among others.

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:
- Personality disorder: antisocial, borderline, paranoid, narcissistic, attempts to manipulate staff or situation
- Delirium
- Dementia
- Psychoses: mania, depression, schizophrenia, delusional disorder
- Substance use disorder: both intoxication and withdrawal states from alcohol, PCP, stimulants, cocaine, synthetics
- Frontal lobe syndromes (TBI, CVA, neoplasm, neurodegenerative process)
- Behavior/Developmental: Intermittent explosive disorder, intellectual disability including autism spectrum disorder

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
Recent medication changes including recently started medications and home medications that have been held or recently discontinued
UDS + review of CSMD for evaluation of intoxication/withdrawal
- Keep in mind limitations of sensitivity and specificity of immunoassay trained against specific epitopes
  - Opiate antibodies commonly have codeine and morphine as their target analytes and will not detect fentanyl and many other synthetic or semisynthetic opioids that are structurally distinct from morphine
  - Benzodiazepines antibodies commonly have oxazepam (diazepam and chlordiazepoxide metabolite) as a target analyte with poor cross sensitivity to lorazepam and clonazepam
  - Amphetamines broadly includes commonly prescribed stimulants used to treat ADHD as well as methamphetamine
CBC, CMP, UA
CT head + EEG if focal neurologic deficits
- For evaluation of AMS, typically order only non-contrasted CTH, may follow up with contrasted MRI

Management

Environment
- Periodic room searches; search or remove personal belongings, VUPD presence if warranted
- Virtual or 1:1 sitter placement; unit can obtain CSO sitter for high risk patients
- Delirium precautions (see delirium section)
- Disposable trays and utensils (minimize potential weapons in the room)
Medication reconciliation
- Reduce or eliminate total anticholinergic load and other deliriogenic medications (see delirium)
De-escalation: Always first line and best if attempted early when patient is anxious or irritable, although impractical if patient is unable to communicate effectively, is explosive or already engaging in violent/potentially harmful behavior
- Nonverbal:
  - Keep yourself between the patient and the door to allow exit if needed
  - Maintain safe distance, avoid sudden movements, don't touch the patient
  - Maintain neutral posture, sincere eye contact
- Verbal:
  - Speak in calm, clear tone, avoid confrontation, and offer to solve problem if possible
  - Do not insist on having the last word and try to not take provocations personally
  - See MI section on “OARS” for strategies
  - Redirection: Acknowledge patient's frustrations (“OARS” as above); shift focus on how to solve the problem
  - Aligning goals: Emphasize common ground and big picture; make small concessions; what can you and the patient agree on?
- Restraints
  - Should be used only when necessary to protect patient or others from harm
    - Mechanically restrained patients cannot be left unmonitored and must have a virtual or in person sitter ordered
  - 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 (non-violent)– most commonly used
    - Hard restraints (violent)– reserved for severe behavioral health (only 2 sets in house)
    - Mittens
    - Posey Vest – prevents exiting bed, allows limbs to be free, can be attached to bedside recliners
    - Posey Bed – wandering patient (TBI, severe dementia)
  - VUMC Orders: “restraint” → order set
    - Non-violent non-self-destructive (order lasts up to 48 hrs.) Most patient’s needing restraint: non-psychiatric, delirium, dementia, intubation
    - 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. Not all forms of agitation can be treated pharmacologically, but all forms of aggression toward staff need to be addressed immediately.

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
- Use QTcF and not QTcB
  - Estimated QTc on standard EKGs is commonly QTcB (QT/RR1/2) and is artificially increased in the setting of tachycardia and overestimates the number of patients with a potentially dangerous QTc prolongation
    - Bradycardia is a significant risk factor for TdP
    - Tachycardia is somewhat protective from TdP
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
- Haloperidol 0.5 - 1mg IV/IM q6h prn for older/frail individuals
- Haloperidol 2-3mg IV/IM q6h prn for other patients
- Titrate up to 5-10 mg and can increase frequency as warranted
- When using IV haloperidol obtain daily EKG, Mg and K levels should be kept above 2 and 4, respectively
- Stop IV haloperidol if QTcF > 500 msec

Benzodiazepines

Lacks EPS that can occur with antipsychotics but can worsen delirium & disinhibit patients with neurocognitive-related agitation
First choice for agitation without clear etiology or in patients with severe aggression
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 ICU admission and sedation:
- Dexmedetomidine (preferred), propofol or midazolam

Maintenance medications

Antipsychotics
- Reserve scheduled antipsychotics for aggression that poses 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 in TBI or dementia
- Most commonly used: Valproate
  - Levetiracetam could worsen aggression/agitation
Beta Blockers and Alpha Agonists
- Noradrenergic over-activity implicated in aggression expression (think adrenaline spike + confusion)
- Commonly Used: propranolol, clonidine, guanfacine
Serotonergic agents: SSRI/SNRI/buspirone
- Useful if co-occurring depression/anxiety disorders
- Peak onset of action takes weeks