Updates in the Assessment and Management of Agitation

Common risk factors for agitation (6, 9, 11, 12) and signs and symptoms of acute clinical presentations (9, 13, 14) are described in Box 1.

Current consensus does not value one screening tool over another (11). The choice of rating scale should be determined by best clinical fit for area, patient mix, time constraints, ease of use, and workflow. Commonly used screening tools (4, 9, 11, 15–18) are listed in Table 1. The AAEP’s Project BETA noted that the Behavioural Activity Rating Scale is easy to use even by individuals with limited or no training in its use (11). The utility of screening tools is often demonstrated in research, but use of such tools has limitations in busy high-acuity settings, such as the ED (19). These tools provide a snapshot of a patient’s current state, which may evolve over time, thus requiring frequent reassessment (9).

The determination of etiology or etiologies contributing to the presentation of agitation will best inform targeted agitation management strategies. It is critical for the astute clinician not simply to view agitation in a singular lens and utilize rote management strategies based on provider comfort; rather, one should customize management to the unique patient’s needs based on a thoughtful biopsychosocial assessment of factors precipitating and perpetuating the presentation of agitation. Because of limitations on time, information, and patient engagement, expeditious assessment and identification of an underlying medical problem are necessary (9, 19).

At the initial presentation and triage, basic vital signs and pertinent lab tests should be obtained. Direct observation of the patient’s presentation and brief assessment of mental status often are the highest yield (4). Lab testing should be targeted, focusing on suspected etiology and common antagonizing factors, rather than universal screening labs (11). Point-of-care glucose and oxygen saturation should be conducted, as well as a urine drug screen on notably impaired or agitated patients, particularly when intoxication is suspected but not confirmed by history (4, 9, 11). Patients with suspected delirium should receive a focused examination with vital signs to localize potential sources of systemic illness to then guide diagnostic assessment, which may include a comprehensive metabolic panel, complete blood count, urinalysis, urine drug screen, and often head imaging. Additional collateral information to aid in assessment should be gathered quickly and efficiently. This can include verbal reports from law enforcement, emergency medical services, family, partners, referral sources, outpatient providers, and current care team members. Agitation is a medical emergency, and information needs to be gathered regardless of confidentiality concerns and patient consent (19). Medical records should be reviewed, even if only a cursory review can be conducted, to determine psychiatric and medical history, establish a baseline, and assess for recent substance use and intoxication (4, 9, 19).

Disagreement with staff, pain and discomfort, and perceived failure to address needs are common precipitants of agitation (27). Environmental factors can also play a role in agitation. Crowding, bright lights, increased wait times, and noise pollution provoke agitation (20). The physical space should feel safe for the patient and staff. When possible, moving the patient to a low-stimulation environment can aid in de-escalation (14, 28).

Verbal de-escalation remains the first-line treatment. Staff should be trained in de-escalation techniques and be aware of their own countertransference to avoid provoking the patient further. Ideally, four to six team members should be present to engage the patient, both to discourage violent behavior and to have enough staff present if de-escalation attempts fail and restraint is necessary (14). This should be balanced with an awareness of how increased staff presence may escalate a patient’s agitation, particularly for individuals with significant trauma histories, autism, or developmental delay.

Communication skills for verbal de-escalation, on the basis of expert consensus, are described in Table 3 (14, 28, 29). Patients should be engaged with an open posture, with hands visible and relaxed. Eye contact should be casual and nonthreatening (14). Validation, reassurance, appropriate and skillful use of humor, and reframing may help to defuse a tense situation. If verbal de-escalation is successful, continual reassessment is recommended to monitor for signs of re-emerging agitation (28). After an episode of agitation, especially episodes involving involuntary medication or restraint, debrief with the patient and staff to reflect on understanding the factors influencing agitation and response to treatment (14).

Sometimes verbal de-escalation is sufficient to calm the patient, especially when the source issue is addressed (hunger, overstimulation, pain). When the source still exists, coupling de-escalation with medication is key. Whenever it is safe to do so, offer oral medication first and involve the patient in shared decision making regarding choice of medication. Patients often have a preference or seek to avoid medications, on the basis of previous experience, and their perspective can be invaluable to selecting an appropriate regimen and avoiding more coercive measures.

Oral and intramuscular (IM) medications have similar efficacy, with IM formulations having quicker onset of action (8, 30). Table 4 describes medications used in the treatment of agitation (8, 9, 28, 30–34). When selecting a medication, consider the patient’s physical health status (including nutrition and renal and hepatic function), preferences, known comorbid conditions, and any past reactions to medications. In terms of the medication itself, be mindful of the route of delivery, onset and duration of action, and anticipated side effects. Patient- and medication-related factors should then be paired with a working conceptualization of the etiologies potentially affecting the patient’s presentation.

Restraint or seclusion is considered a last resort when less restrictive options are ineffective to ensure safety. If a patient can maintain safety in a locked room and one is available, seclusion is favored over physical restraint (43). Because patients are restrained or secluded involuntarily, state and organizational guidelines for involuntary treatment must be followed. The Joint Commission (44) advises that restraint or seclusion episodes must be:

Use of restraints is associated with significant morbidity and mortality. Death has occurred due to strangulation from improper placement or due to other complications, such as rhabdomyolysis, thrombosis, positional asphyxia, or blunt force trauma (45). Restraint episodes are distressing and dehumanizing and can result in long-lasting trauma and distrust of the health care system (45–47). Incidence of posttraumatic stress disorder following restraint and seclusion ranges from 25% to 47% (47). Restraint episodes put staff at risk of physical and psychological harm (43) and are subject to bias. Recent studies found that Black, male, and homeless patients are more likely to be restrained (48, 49). Jin and colleagues (50) have proposed recommendations to mitigate bias in caring for agitated patients. At institutional and systems levels, they propose increasing support for focused research, improving staffing and overcrowding in EDs, and improving bias and restraint education. On an individual level, they recommend the following five questions to assess whether bias is affecting one’s care of an agitated patient:

Determining the etiology of agitation is of paramount importance. Evaluation of agitation in at-risk youths begins with heightened awareness of early signs of its preceding presentation, its evolution, and the associated risk factors. Evaluation should incorporate understanding of development, family-related factors, and systems of care that may affect the care experience of youths (54). Specific screening tools utilized among youths (55–59) are identified in Table 5.

Observation of the interactions between the caregiver and the child provide information about potential causes of agitation. It is important to keenly monitor how the caregiver responds to the child’s distress, how the child displays and communicates that distress, the sense of secure attachment between the child and the caregiver, and the reinforcing or mitigating factors affecting the delicate interplay between the child and caregiver (7). Gathering history involves interviewing the child and the child’s caregivers, initially together and then separately (60). The age and developmental status of the child drives the decision of the sequencing of the interviews and may inform whether the child is able to separate meaningfully from the caregiver (61). When selecting whom to interview first alone, consider interviewing adolescent patients alone to honor their autonomy and highlight the value of their report, which can aid in rapport building (62). Further collateral may need to be gleaned from specific sources unique to youths.

The interviewer should be mindful to obtain thoughtful birth, developmental, social, family, and early childhood histories. Interviewing the child requires a strong understanding of the child’s development, cognitive status, and evolving language use and levels of insight. Key clinical pearls for interviewing youths (54) are described below:

Management of agitation in youths involves even greater focus on prevention, early nonpharmacological intervention, and environmental modification, which may mitigate the use of psychopharmacology (7). The use of standardized protocols and developmentally appropriate, trauma-informed, and family-centered care practices aid in de-escalation. Involvement of support staff trained in de-escalation, distraction, and comfort measures, such as Child Life, should also be considered (7, 54, 63).

As noted previously, a thoughtful environment is a powerful way to promote a therapeutic atmosphere. Access to certain sensory stimulation that is soothing, such as a weighted blanket, may be highly effective in promoting calm or de-escalating an irritable child (63). Recognizable objects from home, as well as the availability of support family, can be very comforting to the child exhibiting agitation. Use of a token economy, such a sticker chart, can also be a helpful tool in reinforcing positive behaviors (64). It is important to address developmental needs that can exacerbate risk of aggression due to added frustration, barriers to communication, or reduction of the child’s sense of control in a situation. These factors include communication challenges and sensory limitations, as well as delays in meeting activities of daily living (63).

Principles of pharmacological management of agitation in youths are similar to those described previously for adults, with a few key considerations specific to youths. A more extensive review of consensus guidance on the pharmacological management of agitation in youths is provided in the Pediatric BETA Guidelines by Gerson et al. in 2019 (7). Key recommendations from that study are summarized in Table 6 and Table 7. Special consideration is given to management of youths with autism and intellectual disability. Of note, Table 6 and Table 7 highlight the use of alpha-2 agonists and antihistamines. Although clonidine (an alpha-2 agonist) and diphenhydramine (an antihistamine) are highlighted here, guanfacine and hydroxyzine may also be utilized with good effect and may be considered if there is lack of response or oversedation with the use of clonidine or diphenhydramine (65–69).

Pharmacological management begins with a careful review of current and past prescribed home medications, including over-the-counter, alternative, and dietary products, given the higher propensity of medication sensitivities or side effects in some youths (70, 71). In particular, antihistamines and benzodiazepines can cause excitation or paradoxical worsening of agitation, and whether this occurs should be asked routinely in patients, particularly younger children, youths with developmental delay, and youths with autism (7, 54). Furthermore, current medication use should include review for drug-drug interactions that may result in avoidable toxicities in youths (72). Often a half or extra dose of an effective, previously prescribed, psychotropic medication is the best approach (7, 73, 74). Lower doses and slower titration may be required to reach therapeutic effect while limiting side effects, when the acuity of presentation does not warrant more rapid titration (75, 76). In general, preteen patients less than 40 kg in weight will require weight-based dosing, and adolescents, often greater than 40 kg in weight, will receive doses similar or slightly reduced, compared with adult doses (77). Given the greater variability in response, tolerability and efficacy should be routinely assessed, and dosing should be adjusted accordingly. Generic agents are safe and effective, yet the pharmacokinetic bioequivalence of generic compounds ranges from 80% to 125%, compared with brand-name drugs (78). Thus, switching between brand and generic medication can change the efficacy or produce side effects, particularly in medically ill youths, younger youths, or youths with developmental disorders who may be more sensitive to these changes (79).