AGITATION

Brought to you by : SYNERGY

Narasumber : dr. Irmia Kusumadewi, SpKJ(K)

DIAGNOSIS: AGITATION

Violent Patients
Patients may be violent for many reasons
Interview with a violent patient must attempt to
ascertain the underlying cause of the violent behavior,
because cause determines intervention.
The differential diagnosis of violent behavior includes
psychoactive substance-induced organic mental
disorder, antisocial personality disorder, catatonic
schizophrenia, medical infections, cerebral neoplasms,
decompensating obsessive-compulsive personality
disorder, dissociative disorders, impulse control
disorders, sexual disorders, alcohol idiosyncratic
intoxication, delusional disorder, paranoid personality
disorder, schizophrenia, temporal lobe epilepsy,
bipolar
disorder,
and
uncontrollable
violence
secondary to interpersonal stress.

 The psychiatric interview must include

questions that attempt to sort out the
differential for violent behavior and
questions directed toward the prediction
of violence.
The best predictors of violent behavior are
(1) excessive alcohol intake; (2) a history
of violent acts, with arrests or criminal
activity; and (3) a history of childhood
abuse.

Table 34.2-4 Assessing and Predicting Violent Behavior

1.Signs of impending violence
1. Very recent acts of violence, including property violence
2. Verbal or physical threats (menacing)
3. Carrying weapons or other objects that may be used as
weapons (e.g., forks, ashtrays)
4. Progressive psychomotor agitation
5. Alcohol or drug intoxication
6. Paranoid features in a psychotic patient
7. Command violent auditory hallucinationssome but not all
patients are at high risk
8. Organic mental disorders, global or with frontal lobe findings;
less commonly with temporal lobe findings (controversial)
9. Patients with catatonic excitement
10.Certain patients with mania
11.Certain patients with agitated depression
12.Personality disorder patients prone to rage, violence, or
impulse dyscontrol

 Assess the risk of violence

Consider violent ideation, wish, intention, plan,
availability of means, implementation of plan, wish
for help.
Consider demographics : sex (male), age (15-24),
socioeconomic status (low), social supports (few).
Consider past history: violence, nonviolent
antisocial acts, impulse dyscontrol (e.g., gambling,
substance abuse, suicide or self-injury, psychosis).
Consider overt stressors (e.g., marital conflict, real
or symbolic loss)

Assessment

Prevalence
92% of patients w/dementia disruptive
agitation
>40% of pediatric pts agitation/aggression as
chief complaint

Instruments
PANSS PANSS EC: 5 item, score range 0-35
assesses the severity of aggression and efficacy
of treatment
OAS (Overt Aggression Scale) : objective tool for
tracking behavior in hospital settings identifies

Assessment

Instruments
BARS (Behavioral Activity Rating Scale) : assesses
behavioral activity in patients with psychosis,
ranging from a state of sedation through normal
activity to a state of agitation
7 categories : single item questions ranging
from difficult or unable to rouse to violent and
requiring restraint
Assesses the efficacy of agents that treat
agitation and have a calming effect in
psychotic patients

Assessment

Assessment

Provide Security
Training: applying restraints, careful monitoring of patients prone
to agitation/aggression, helping workers remain awake & calm
Key rule: make sure that pts, workers are always provided
security well observed

Evaluation & Prediction of Agitation/Aggression Risk

Observe for subtle clues e.g. I feel like hurting someone today
Observe psychomotor agitation, threatening speech, rapid
pacing, ready to pounce stance, increased or selective attention,
suspiciousness, paranoid thoughts, emotional lability
Proactive aggression : predatory, planned, manipulative
Reactive aggression : impulsive, unplanned

Assessment

Assessment

Instrument

PANSS
Aggression Risk Profile
Agitation-Calmness Evaluation
Buss-Perry Agrression Scale

Assessment

Assessment

Assessment

Agitation

Initial presentation
Natural progression of underlying condition
Reaction to ED experience

Definition : a state of behavioral dyscontrol that will likely

result in harm to the patient or health care workers without
prevention
Stages

Verbal children will use general threats/abusive language

Motor remain in near constant motion such as pacing
Property damage destructive, breaks nearby objects
Attack attempt to harm self or others

Assessment

Diagnosis
Medical : head injuries,
intracranial infections,
metabolic abnormalities,
ingestions
Psychiatric : MDD, bipolar
only diagnosed after other
causes of agitation have been
excluded.
Vulnerable populations: pts
w/intellectual disabilities,
ADHD, autism spectrum
disorders

Intoxication/ingestion :
intentional/accidental
alcohol, anticholinergics,
hallucinogen, cannabis.

Assessment

AGITATION MANAGEMENT
STRATEGIES

INTERVENTIONS
Non-Pharmacologic Management and
Restraint Reduction Strategies
Pharmacologic Management

Non-Pharmacologic Management
and Restraint Reduction Strategies
Due to increased regulations related to
restraint use (Joint Commission,2012)
various strategies to manage agitation
and reduce restraint use
Restraints can be associated with:
Injury
Patient rights
Patient dignity
Fatal medical complication such as deep vein
thrombosis (De Hert, et al, 2010)

Key Strategies to Improve Patient

Violence
Communication skills
Therapeutic communication with the patient
Be concise when addressing an agitated patient
Repetition is essential whenever setting limits,
offering choices or proposing alternatives (Fishkind,
2008)

Avoid asking why questions ( why did you throw

that glass? )
Speak with I statements rather than You
statements (I would be happy to assist you in
eating your lunch, as long as you do not throw the
food at me instead of: You must not throw food)

Four-step Approach in Treating

Aggressive Patients
1.
2.
3.
4.

Environmental Regulation
Calming
Isolation and Restraint
Pharmacological Approach

Rabia Bilici, et al, 2012

1. Environmental Regulation
Ensure the safety of other patients and
workers
Comfort the patient
Remove patients relatives
Reduce waiting period
Remove external stimulations around the
patient
Provide a quite room
Lay the patient on bed
Provide a glass of water or juice
Rabia Bilici, et al, 2012

1. Environmental Regulation
Never stay alone in an unsafe area
Remove all potentially objects from
the room
Keep safety distance with the
agitated patient
Warning: direct gaze, placing hands
behind may be perceived as threat
Monitor any changes in mood,
speech and psychomotor activity
of
Rabia Bilici, et al, 2012
the patient

2. Calming
First method verbal calming
Address the patient in a calm, controlled,
non-provocative manner with a reassuring
voice
Sample of phrases that can be used:
I understand that you feel not well and
experienced difficult times
You are suffering and you seem to be confused
You are here to receive help and we are trying to
help you and solve your problem
Please let us help and dont be afraid
Rabia Bilici, et al, 2012

3. Isolation and Restraint

Is the last choice
Do not use for punishment or
comfort for workers
Always shield the rights, dignity and
confidentiality of the patient
Should be applied by adequate and
trained personnells
Rabia Bilici, et al, 2012

Pharmacotherapy for
Agitation

Principle
Highest priority: reduce the incidence
of patient and staff injuries and
reduce patients psychological
discomfort
Calm the patient without sedation
May initially serve as primary or
adjunct to verbal intervention
Give option of route of administration

Frequently Used Substance

Benzodiazepines
Second-generation Antipsychotics
Haloperidol
Combine SGA + BZD
Combine Haloperidol + BZD

Algorithm
First Line for Agitation
Orally disintegrating or liquid Risperidone
(Risperdal, 2 mg) combined with oral
Lorazepam (Ativan, 2 mg) or orally
disintegrating Olanzapine (Zyprexa, 5-10 mg)
When oral is not appropriate:
Lorazepam IM (2 mg) is recommended for
delirium, substance withdrawal, and unknown
causes or condition not associated with
psychosis

Algorithm
Severe agitation secondary to
psychosis
Ziprasidone IM (20 mg)
supplemented with Lorazepam IM (2
mg); or Haloperidol IM (5 mg) and
Lorazepam IM (2 mg) or Olanzapine
IM (5-10 mg)

Frequency
Medication may be given every hour,
up to three or four doses every 24
hour

Side Effects
With antipsychotics, the most
common are dystonic reactions or
akathisia
With Benzodiazepines, the most
common are sedation and ataxia

Drugs For Sedation

Fulde G, Preisz P. 2011. Managing Aggressive and Violent

Patients. Australian Prescriber 34(4): 115-8

Drugs For Sedation

Benzodiazepines
Essentially safe drugs; toxicity is related to
very high doses or in patients with
hypovolaemia or other significant
physiological compromise
Diazepam: quickly absorbed, long half-life
(upto 36 hrs, may accumulate in repetition)
Lorazepam: shorter half-life (12-16 hrs)
Midazolam: rapid onset, short elimination halflife (2-4 hrs), steeper dose-response curve
Fulde G, Preisz P. 2011. Managing Aggressive and Violent
Patients. Australian Prescriber 34(4): 115-8

Drugs For Sedation

Antipsychotics
Olanzapine: Rapid onset, half life of
30 hrs; dose of 5-10 mg should be
effective; next dose after 2 hrs
Haloperidol: Rapid onset, lasting 2-4
hrs; over-sedation or hypotension,
extrapyramidal adverse effects

Fulde G, Preisz P. 2011. Managing Aggressive and Violent

Patients. Australian Prescriber 34(4): 115-8

Intramuscular Medications Used to

Manage Acute Agitation in Adults
The following table is taken from:

Bostwick JR, Hallman IS. 2013.

Agitation Management Strategies:
Overview of Non-pharmacological
and Pharmacological Interventions.
Medsurg Nursing. 22(5): 303-18

Thank
You