Updates in the Assessment and Management of Agitation
Abstract
Assessment
Risk Factors and Acute Presentations
Screening and Rating Scales for Agitation
Scale and setting | Type of screening | Comments |
---|---|---|
Psychiatric emergency service and emergency department (ED) | Quick screening | High-acuity setting |
Agitated Behavior Scale (15, 16) | 14 items rated on a 4-point scale of present to absent | Clinician rated, developed for traumatic brain injury, can be used in the ED |
Behavioural Activity Rating Scale (4, 11) | Single descriptor, seven levels (agitated to sedated) | Observational, easy to use in nonpsychiatric settings or ED |
Sedation Assessment Tool (17) | 7-point scale of agitation to sedation in two descriptors (speech and responsiveness) | Quick, adaptation of altered mental status score, can be used in the ED |
Inpatient setting | Longitudinal screening | Inpatient and long-term care |
Aggressive Behavior Scale (15) | Four-item summary scale | Scored over 7 days, best for inpatient and long-term care |
Cohen-Mansfield Agitation Inventory (9) | 29 behaviors rated on a 7-point severity scale | Labor intensive, scored over 2 weeks, caregiver rated |
Richmond Agitation Sedation Scale (4, 18) | 10-point scale (agitation to sedation) in two descriptors | Quick delirium screen for critical care setting, repeat over time |
Etiologies Influencing Agitation
Physical illness and delirium.
Type | Examples |
---|---|
Neurological | Traumatic brain injury, intracranial hemorrhage, seizure, cardiovascular accident, transient ischemic attack, encephalopathies (such as hepatic or renal), autoimmune encephalitis |
Infectious | Encephalitis, meningitis, sepsis, urinary tract infection or urosepsis (elderly), pneumonia |
Gastrointestinal or metabolic | Electrolyte disturbances, hypoglycemia, diabetic ketoacidosis, ileus, inflammatory bowel disease, chronic malnutrition, gastrointestinal obstruction |
Respiratory | Hypoxia, pulmonary embolism, respiratory failure |
Cardiac | Arrhythmia, myocardial infarction, heart failure |
Toxicology | Environmental toxins, medication reactions, neuroleptic malignant syndrome, serotonin syndrome |
Endocrine | Thyroid (thyrotoxicosis, myxedema) |
Hematologic or oncologic | Anemia, oncologic process |
Constitutional | Poor sleep, pain, hypothermia, or hyperthermia |
Substance use and withdrawal.
Psychiatric and developmental conditions.
Management
Nonpharmacological Interventions
Skill | Comments |
---|---|
Respect personal space | Maintain at least two arms’ lengths (6 feet) and allow space for both you and patient to exit |
One person | Designate one person to engage the patient; introduce yourself and your role |
One message | Be concise, speak clearly and simply, repeat instructions multiple times |
Name feelings | Listen closely to try to identify and validate the patient’s emotional experience; share how the patient’s behavior is affecting you; reflect what you are hearing to clarify emotions and meaning behind statements shared |
Appeal to the patient’s wants or needs | Listen for anything you may be able to offer the patient, such as a psychotherapeutic intervention or a comfort item; focus on what you can do for the patient |
Set limits and reinforce appropriate behavior | Respectfully communicate your expectations and the consequences of unacceptable behaviors; focus on shared values, such as safety, respect, and improvement in the patient’s quality of life or functioning |
Offer choices | Ask the patient to consider what has worked in the past; offer choices between medications or route of administration |
Pharmacological Management
Suspected etiology | Medication and dose | Comments |
---|---|---|
Primary psychiatric or undifferentiated with prominent psychosis | Olanzapine, 5 mg–10 mg (PO, ODT or IM); risperidone, 2 mg (PO, ODT or liquid); ziprasidone, 10 mg–20 mg (IM); haloperidol, 2 mg–10 mg (PO or IM); droperidol, 5 mg–10 mg (IM) | Add lorazepam 1 mg–2 mg if haloperidol or monotherapy ineffective; risk of respiratory depression for IM olanzapine and IM lorazepam within 1 hour |
Intoxication with central nervous system depressant (including alcohol) | Haloperidol, 2 mg–10 mg (PO or IM); olanzapine, 5 mg (PO); risperidone, 2 mg (PO, ODT or liquid) | Avoid benzodiazepines if possible; FGAs still heavily favored, but SGAs likely safe if given PO; IM risks respiratory depression |
Stimulant intoxication, alcohol or benzodiazepine withdrawal OR undifferentiated without psychosis | Lorazepam, 1 mg–2 mg (PO or IM); diazepam, 5 mg–10 mg (PO); midazolam, 5 mg–10 mg (IM) | Add SGA if prominent psychotic symptoms |
Delirium | Risperidone, 1 mg–2 mg (PO, ODT); olanzapine, 5 mg–10 mg (PO, ODT or IM); haloperidol, <5 mg (PO or IM); ziprasidone, 10 mg–20 mg (IM) | Avoid benzodiazepines; high risk of EPS with haloperidol doses >3 mg; consider QTc monitoring |
Antipsychotics.
Benzodiazepines.
Other medications or formulations.
Restraint and Seclusion
Evaluation and Management of Agitation in Youths
Evaluation
Screening tool | Description | Comments |
---|---|---|
Abbreviated Brief Rating of Aggression by Children and Adolescents (55) | 14-item instrument | Used to predict potential for agitation and aggression on an inpatient unit |
Dynamic Appraisal of Situational Aggression (inpatient) (56, 57) | Seven items rated present or absent | Assesses likelihood of aggression in the next 24 hours |
Modified Overt Aggression Scale (58, 59) | Four-part behavioral rating scale; four types of agitation or aggression rated over past week | Inpatient or residential setting |
Nonpharmacological Interventions
Pharmacological Management
Medication | Dose | Peak effect (minutes) | Maximum daily dose (mg by weight or age) | Other considerations |
---|---|---|---|---|
Clonidine | PO, 0.05 mg–0.1 mg | 30–60 | <40 kg, 0.2 mg; >40 kg, 0.3 mg– 0.4 mg | Monitor for hypotension and bradycardia |
Diphenhydramine | PO or IM, 12.5 mg– 50 mg or 1 mg per kg body weight | 120 | Age <12, 50 mg– 100 mg; age >12, 100 mg–200 mg | Avoid in delirium and in youths at risk of paradoxical reaction (e.g., autism); can use to mitigate EPS risk from antipsychotics |
Lorazepam | PO, IM, or IV, 0.5 mg– 2 mg or 0.05 mg– 0.1 mg per kg body weight | PO, 60–120; IM or IV, 10 | Age <12, 4 mg; age >12, 6 mg– 8 mg | Avoid in delirium and in youths at risk of paradoxical reaction (e.g., autism); can use to mitigate EPS risk from antipsychotics |
Chlorpromazine | PO or IM, 12.5 mg– 60 mg or 0.55 mg per kg body weight | PO, 30; IM, 15 | Age <5, 40 mg; age >5, 75 mg | Monitor for hypotension; IM dose half of PO dose |
Haloperidol | PO or IM, 0.5 mg– 5 mg or 0.55 mg per kg body weight | PO, 30; IM, 15 | <40 kg, 6 mg; >40 kg, 15 mg | Monitor for hypotension; monitor EKG, particularly with IM or IV use; IM dose half of PO dose; EPS risk lower with IV use |
Olanzapine | PO or IM, 2.5 mg– 10 mg | PO, 240–480; IM, 15–45 | Age > 12, 20 mg | ODT formulation available; do not give IM within 1 hour of IM or IV benzodiazepines |
Risperidone | PO, 0.25 mg–1 mg or 0.005 mg–0.01 mg per kg body weight | 30–60 | Age <12, 1 mg–2 mg; age >12, 2 mg–4 mg | ODT formulation available; watch for EPS |
Quetiapine | PO, 25 mg–50 mg or 1 mg–1.5 mg per kg body weight | 30 | Age >12, 600 mg– 800 mg | Monitor for sedation and hypotension |
Etiology | Evaluation considerations | Pharmacological management |
---|---|---|
Delirium | Regular medical evaluation; environmental modification | Avoid benzodiazepines and anticholinergics; PO, clonidine, quetiapine, risperidone, and olanzapine; IM or IV, olanzapine and haloperidol |
Substance intoxication or withdrawal | History, physical examination, urine toxicology to guide understanding of potential substances implicated | Alcohol or benzodiazepine withdrawal, lorazepam with or without haloperidol; alcohol or benzodiazepine intoxication, haloperidol or chlorpromazine; opiate withdrawal, clonidine, opiate replacement, or supportive treatment; stimulant or phencyclidine intoxication, lorazepam with or without haloperidol |
Developmental delay or autism | Behavioral intervention; assess for sources of pain or discomfort; support communication; address sensory factors | Benzodiazepines, antihistamines may cause paradoxical response; PO, alpha-2 agonist or antipsychotic; IM, olanzapine or chlorpromazine |
Primary psychiatric diagnosis | Clarify diagnostic formulation | Catatonia, lorazepam; anxiety or trauma, lorazepam or clonidine; ADHD, alpha-2 agonist, antihistamine, or antipsychotic; oppositional defiant or conduct disorder, antipsychotic or lorazepam; mania or psychosis, antipsychotic with lorazepam or diphenhydramine if concern for EPS |
Unknown or mixed etiology | Reinforce environmental and behavioral strategies while searching for etiologic factors | Mild or moderate, diphenhydramine, lorazepam, or olanzapine; moderate or severe, chlorpromazine, haloperidol, olanzapine, or lorazepam |
Future Directions
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