Agitation Management

Background 

• Agitation in the hospital can result from many different reasons and may include irritability, anxiety, pacing, yelling, sexually inappropriate behavior, pulling at restraints or medical devices, among others.
• Aggression is a specific form of agitation in which the person is threatening or attempting to harm another person or physical objects.

Presentation 

• Impulsive aggression: spontaneous, explosive, reactive/reflexive, not pre-meditated.
• Instrumental aggression: pre-meditated, controlled, purposeful behaviors.

Differential diagnosis for aggression

• Personality disorder: antisocial, borderline, paranoid, narcissistic.
• Secondary gain
• Delirium
• Dementia/cognitive deficits
• Psychosis
• Mania
• 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.
• Pain.

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 include 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 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, 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 and documented within an hour of initiation of restraint.
    • Found in Epic under, “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).V
    • 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 for 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