4 AGITATIONS

CASE PRESENTATION
You receive a call late Saturday night from a local residential home
concerning a confused resident who is shouting and screaming
uncontrollably. The patient is described as a pleasant 84-year-old female
who is mildly forgetful but fully independent. She became confused earlier
today. Her daughter had visited her this afternoon and noted to the staff
that her mother seemed more confused than usual. The patient was
drowsy earlier in the evening and slept for a few hours. Upon waking she
refused to stay in bed. She is presently walking up and down the corridor,
shouting, You better get a doctor before its too late because Im going to
have a baby. She is pulling off her clothes and will not let the nurses put
her back to bed. There have been no previous episodes of disturbed
behavior.
The patient is on no medications. A neurological consultation, performed
six months ago, included CT scan, EEG, and blood work. Early mild senile
dementia of the Alzheimer type (AD) was diagnosed.
Her vital signs this morning were: temperature, 37.4 oC; BP, 120/70; heart
rate, 72, regular. The nurse has been unable to determine vital signs this
evening due to the agitated state of the patient. Over the telephone you
hear the patient shouting in the background, Ma, ma, maI want my
mother, and yelling at the nursing staff. The nurse requests you to
prescribe a sedative since this patients behavior is disturbing other
residents.

D.W. Molloy
Consider the following statements (true or false)
1. The most likely cause of this patients agitation is dementia, that is,
senile dementia of the Alzheimers type.
2. The underlying cause of agitation is usually identified in the majority
of elderly demented patients who present with an acute onset.
3. History and physical examination is unlikely to reveal any treatable
cause for this womans agitation.
4. This woman should be put in bed with restraints and bedsides to
prevent her from falling and hurting herself.
5. The most appropriate treatment would be to give haloperidol 0.251.0 mg IM, or thioridazine 12.5-50 mg IM Q4H, with review in the
morning.
1. FALSE
Agitation may be defined as observed inappropriate verbal or motor
activity which cannot be explained by need or external need alone [1].
Agitated behavior is usually repetitive and frequently consists of repeated
questions, complaints, words, or movements (Table 4-1). Agitation may be
a manifestation of delirium. Delirium, a transient disorder of cognition and
attention, accompanied by disturbances of the sleep-awake cycle and
psychomotor behavior [2.3] is estimated to occur in 30% to 50% of
patients over the age of 70 at some point during hospital admission [4.5].
Up to 10% of hospitalized elderly medical and surgical patients are
delirious at any given time [2.6]. Features that make a diagnosis of
delirium more likely are listed in Table 4-2.
Content of the complaint should never be ignored. The complaint
can frequently provide an important clue to the underlying cause of
agitation. In this case, the patient expressed that she is going to have a
baby. This may represent a attempt to explain or verbalize abdominal

discomfort that may be a result of obstruction, urinary retention, fecal

impaction, perforation, or biliary or urinary colic. Some patients with
dyspnea and confusion complain that they are being smothered. The
pacing of this patient also suggests that she is experiencing physical
discomfort.
Table 4-1 Verbal and Physical Characteristics of Agitated Behavior
Repetition

Abuse

Behavior

Verbal

Calling out
Questions
Complaints
Single Words
Phrases

Cursing
Threats
Screams

Strange noise
Grunts
Coughs

Physical

Walking
Pacing
Wandering
Dressing
Undressing
Pounding
Rattling the bed

Biting
Fighting
Striking out
Throwing object

Bizarre movements
Twitches

Table 4-2 Clinical Features of Delirium

Features in the presentation of an illness that make delirium more likely:
Rapid onset of symptoms and/or signs
Symptoms and signs that fluctuate
Reduced awareness of environment
Memory loss and disorientation
Presence of organic factor(s) that may be related from history
physical exam, or investigations
Two or more of the following
perceptual disturbance (delusions, ballucinations)
change in psychomotor activity
change in sleep-wake cycle
incoherent speech
Adapted from Diagnostic and Statistical Manual of Mental Disorders. 3rd ed.,
Washington, DC; American Psychiatric Association, 1980.

This woman suffers from mild forgetfulness from senile dementia of

the Alzheimers type. Acute deterioration in her condition cannot be
explained by AD alone. Alzheimers disease usually causes a gradual,
relentless deterioration in cognitive function over years. An acute insult to
her nervous system in the most likely cause of her confusion and agitation,
for example, hypoxia, infection, dehydration, stroke, myocardial infarction,
metabolic abnormality, or drug-induced delirium (Table 4-3).
2. TRUE
Agitation is not a diagnosis but a symptom of an underlying abnormality. If
the underlying cause of agitation is identified quickly and treated, the
agitation may reserved.
In this case the vital signs taken earlier this morning are not helpful,
since the onset of confusion and agitation occurred hours later. Normal
vital signs in an elderly patient do not rule out an underlying infection.
Some elderly patients with pneumonia or septicemia dont even have an
elevated white cell count.
The elderly may have various causes for acute confusion that must
be considered and investigated (see Table 4-3). Incorrect diagnoses and
management of diseases manifesting agitation may prove fatal or cause
irreversible damage.

48 Common Sense Geriatrics

Table 4-3 Causes of Delirium in the Elderly
1. Drugs
Any drug can cause delirium in the
elderly but especially drugs with
anticholinergic properties.
Digitalis, sedatives, levodopa,
steroids, antihypertensives,
anticonvulsants, cimetidine, drug
whithdrawal
2. Cardiovascular system (CVS)
Myocardial infarction, congestive
heart failure
Arrythmias
3. Metabolic
Dehydration
Electrolyte abnormality
Hypothyroidism/
Hyperthyroidism
Diabetes mellitus
Renal/liver abnormalities
Nutritional deficiencies
4. Respiratory
Pneumonia
Acute exacerbation of chronic
Obstructive pulmonary disease

5. Central nervous system (CNS)

Subdural hematoma, stroke, transient
ischemic attacks (TIA), epilepsy,
neoplasm, infection
6. Mechanical
Fecal impaction
Urinary retention
7. Environmental
Any change in environment
8. Infection
Urinary tract
Biliary tract
9. Hematologic
Anemia, especially following an
acute/subacute bleed B12 deficienty
Myeloma
10. Other
Giant cell arteritis
Concussion without subdural
Alcohol withdrawal or
Intoxication
Over-the-counter medications
Paint
Fracture

3. FALSE
Taking the History
It is important to determine if the patient has had her temperature taken
regularly in the past few days in order to determine a baseline. If the
patient normally has temperature of 35.5 36.0 oC and it is 37.5oC today,
this represents a significant increase in body temperature.
Note if any new medications have been started recently, or if there
have been changes in the doses of maintenance medications.
Medications, which frequently cause delirium in the elderly, must be
carefully prescribed and monitored. Drug-induced delirium and confusion
may be completely reversed by altering or discontinuing medications.
Ask about changes in the frequency or urination and defecation.
Urinary retention or fecal impaction may cause confusion and agitation in

the elderly. Is her urine cloudy or foul smelling? Has she had new
episodes of incontinence? Has she fallen recently? Is the patient in bed
and refusing to get out? It is easy to overlook a fractured hip, and the
possibility of subdural hematoma must always be considered. Consider a
fracture, no matter how trivial a history of falls or injury.
Ask if she has been drinking more than usual or if she is gaining
weight. Are her ankles more swollen than usual? It is very important to
ascertain if she has had similar episodes of confusion and agitation in the
past, and if so, how they were investigated, diagnosed, and/or treated.
Clinical Examination
A general examination should be performed on all agitated or confused
patients. Take your time talking to the patient to develop confidence and
trust before you begin your exam. Establish physical contact at the start
by stroking her hair, holding her hand, or adjusting her clothing. Explain
that you are the doctor and that you have come to help. Be patient and go
slowly and gently. Agitated patients forget who you are and may think you
mean them harm. It may help to wear a white coat in order to alleviate her
anxiety.
General inspection may reveal anemia, cyanosis, pigmentation,
bruising from falls, edema, tachypnea, neglect, or weakness on one side
from a recent stroke, dehydration, or evidence of hypothyroidism. Try to
get vital signs if possible. Examine the cardiovascular system for heat rate,
rhythm, elevated jugulovenous pulse (JVP), or evidence of failure. Percuss
the chest carefully since the patient may not cooperate and breathe when
you want. Dullness in a base is easier to find than decreased breath
sounds in an uncooperative patient. Dullness in both bases with an
elevated JVP is very suggestive of cardiac failure.
In this case the patient believes she is going to have a baby. This is
very significant and should prompt you to examine her abdomen carefully.
An agitated patient will not localize pain in the abdomen but may display

rigidity and guarding over the affected viscus. Listen for bowel sounds. It
they are increased, get a straight abdominal film to help in the diagnosis of
obstruction. If they are absent, get a straight film and surgeon. Always do
a rectal exam.
Rectal examination may reveal fecal impaction, evidence of rectal
bleeding, or prostatic hypertrophy in males. Fecal impaction may cause
confusion and agitation in the elderly. Urinary retention is also commonly
overlooked as a cause of confusion with agitation in elderly patients. Men
with prostatic hypertrophy are particularly at risk. If you have any doubts,
especially in obese patients, catheterize them to check the residual
volume. Catheters should be removed immediately and not left in situ,
since agitated patients do not tolerate catheters, and it can even make
them worse.
In-and-out catheterization serves two purposes:
1. To rule out urinary retention, and
2. To get a catheter specimen of urine for routine microscopy and
culture.
On examination of the nervous system, look closely for localizing or
lateralizing signs. Check for neck stiffness, tone, and reflexes and do the
plantar responses. If you can, observe the fundi for papilledema; however,
funduscopic examination is usually impossible in agitated patients.
Investigations
If after your examination you still cannot diagnose the cause of the
agitated patients confusion, some simple tests may help. Hemoglobin and
complete blood count will detect anemia or leucocytosis if they are
present. Blood sugar, electrolytes, urea, and creatinine will detect acute
renal failure, hyponatremia, acidosis, or glucose abnormalities. It there is
some concern that the patient has intra-abdominal pathology, order liver
enzymes and a serum amylase. Be sure to check thyroid function since

hypothyroidism or thyrotoxicosis are easily overlooked in the elderly due to

atypical presentations.
An ECG is mandatory. Myocardial infarction can be silent and may
present with confusion in the elderly. Do a chest x-ray to rule out
pneumonia or cardiac failure, and do a flat plate, erect abdomen, and/or
ultrasound if you suspect intra-abdominal pathology.
Check the patient for recent fracture. Consider an x-ray of lumbo
sacral spines and/or hip as patients with vertebral fractures may complain
of plain in the abdomen or lower limbs, which can be misleading.
All patients who present with acute delirium should have blood
cultures done since sepsis in the elderly may not cause fever or
leucocytosis. Dehydration commonly cause confusion, so if you are in
doubt, give intravenous fluids. This may be easier said than done in
combative patients. In all cases, staff should be encouraged to ensure
adequate fluid intake by mouth, and, where feasible, urinary output should
be measured.
4. FALSE
Restraints are absolutely contraindicated in this patient at this time. It
would be completely inappropriate to confine her to bed with bedsides. If
restrained she may struggle to escape and choke herself. If she escapes
from the restraints she may climb out over the bedsides and fall from a
greater height, suffering even greater trauma than if she just fell from the
bed.
If a patient becomes extremely agitated in bed and attempts to
climb out over the sides, remove the bed and place the patient on a
mattress on the floor. Bedsides often make agitation worse, because
patients may feel imprisoned, which increases their paranoia, frustration,
and confusion.
In this case, you might wish to call the patients daughter and ask
her to come in and sit with her mother. Family members can supply

support, reassurance, and comfort to distressed elderly patients in these

situations. A familiar voice and face may work wonders in calming the
patient.
Restraints frequently make confusion, paranoia, and agitation
worse. Patients can get tangled in them, choke themselves, or cut off the
circulation to their limbs. Restraints have a limited place in the
management of agitated patients. If one feels it is necessary to give
intravenous fluid, nasogastric suction, or catheterization in a thrashing,
agitated patient, then chemical or physical restraints are often necessary
to facilitate treatment or monitoring. However, use of restraints in a patient
such as this is inappropriate, cynical, and cruel without having first seen
her or examined her for a reversible cause of her agitation. Putting her in
restraints may allow the underlying process to go unchecked and could
even prove fatal.

5. FALSE
This woman was seen by her family doctor, who referred her promptly to
the Emergency Room. She had acute cholecystitis and dehydration. She
was treated with intravenous fluids and rehydrated, and appropriate
antibiotics were started. She was given boxing gloves, that is, her hands
were taped in a clenched position grasping a roll of bandage. She was put
on a mattress on the floor of a well-lit, quiet, private room and had an aide
sit with her for 24 hours until her delirium/agitation resolved. She was
given haloperidol 0.5 mg IM Q4H PRN and settled on this therapy.
There is a limited place for physical and chemical restraints in the
treatment of agitation [7.8.9]. They may be used after careful assessment
of the patient and/or initiation of treatment. It is inappropriate to use
chemical restraints without first seeing the patient.