Agitation Management

Agitation Management – Jonathan Constant, Jonathan Smith

Background

  • Agitation in the hospital result from discomfort, illness, medication effects or frustrations the pt is unable to meaningfully communicate
  • Anticipate issues, monitor (COWS, CIWA) and pre-emptively treat withdrawal 

 

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
    • Epilepsy, Delirium, Dementia
    • Frontal lobe syndromes (TBI, CVA, neoplasm, neurodegenerative process)
    • Behavior/Developmental: Intermittent explosive, XYY genotype, Intellectual Disability

 

Evaluation

  • Examine (when calm) for source of pain, signs of infection, obstructions, 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, BMP, hepatic function, UA
  • CT head + EEG if focal neurologic deficits or acute change in clinical status
  • If suspicion: Blood cultures, RPR,  B12, folate, CK ( ↑ w/ restraints & aggression)

 

Management

  • Environment
    • Periodic room searches; search personal belongings
    • Virtual or 1:1 sitter placement, VUPD presence if warranted
    • Delirium precautions
    • 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
    • Be wary of transference, countertransference and situational tension
  • Know when to disengage/leave room
  • Restraints
    • Should be used only when necessary to protect patient or others from harm
    • Should not be used to coerce patient to accept or remain in treatment
  • 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

Acute Agitation

  • Antipsychotics
    • Widely effective for acute agitation, especially in delirium and psychotic disorders
    • Choice of agent depends on patient characteristics (movement disorders, QTc)
    • Moderate agitation options:
      • Olanzapine 2.5 - 5mg po q6h prn typical starting dose (ODT available
      • Quetiapine 12.5 - 25mg q6h po prn for patients at higher risk of 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 QTcF greater than 500 msec (QTcB overestimates at HR >60)
  • Benzodiazepines
    • May have fewer adverse effects compared to antipsychotics (dystonia, akathisia, EPS)
    • Can use alone or in addition to antipsychotic agent
    • Can worsen delirium, disinhibit patients with neurocognitive-related agitation
    • Preferred for agitation related to intoxication/withdrawal of sedatives
      • Lorazepam preferentially used due to PO, IV and IM availabilit
      • Lorazepam 2mg PO/IM/IV q6h prn typical starting dose (1mg if older/frail)
        • Can increase frequency if warranted though monitor respiratory suppression when combined with other respiratory suppressing agents
  • 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
    • 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/Buspar
    • Some studies supporting use, though weeks to benefit
    • Useful if co-occurring depression/anxiety disorders

 

Agitation/Aggression due to personality disorder/secondary gain:

  • Behavioral plan development (see Borderline Personality Disorder chapter)
  • Environmental safety precautions and medication management as outlined above
  • If continued disruptions, may require multidisciplinary team meeting with treating team(s) +/- ethics, psychiatry, palliative care to determine appropriateness of administrative discharge vs. enforced treatment

​​​​​​​