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The Agitated Patient


“Agitation” is a word commonly used in the colloquial setting; however, people often use it to mean different things. Per Cummings et al., “There is no consensus definition of agitation and no widespread agreement on what elements should be included in the syndrome.” Therefore it is important to ask the person(s) reporting that a patient is agitated to clarify exactly what he or she means by “agitation.” Clinically, psychiatrists often refer to agitation as a state of heightened affect, characterized by excessive motor and/or verbal activity. Motor activity may include grabbing, throwing, and pacing. Excessive verbal activity may refer to cursing, screaming, etc. A patient’s agitation can stir up anxiety in staff and in other patients. Often, a call for agitation represents a call to help manage the agitated patient, as well as a call to help the staff deal with anxiety from interacting with the patient. Staff may be uncomfortable dealing with agitated patients and may look to you for reassurance and guidance. Agitation has numerous etiologies, ranging from complicated medical problems such as organic brain syndromes, to primary psychotic disorders, to substance abuse/withdrawal, to personality disorders such as antisocial personality disorder and borderline personality disorder. Your primary goal on arriving is to assess for potential dangerous behavior and to create a safe environment for everyone. Secondarily, your goal is to evaluate the patient to diagnose and treat the underlying cause of the agitation.

Phone Call

Questions

  • 1.

    What is the nature and duration of the agitation? That is, what happened and what is the patient doing now?

    • Is the patient currently a threat to self, staff, or other patients? If yes, order stat oral (PO)/intramuscular (IM) medications, and request additional help, including hospital security.

      • If administering stat medication, attempt to ascertain allergies, current medications, and known medical issues.

    • Is the patient jeopardizing his or her medical care and/or attempting to leave the hospital against medical advice? If yes, alert hospital security to prevent elopement prior to your evaluation.

    • Has the patient displayed similar behavior in the recent past? If so, try to get details about how it was managed and think about speaking with staff familiar with the patient.

  • 2.

    What is the patient’s age, reason for hospitalization, and medical history?

    • What are the vital signs?

    • What are the allergies?

    • What is the QTc from a recent electrocardiogram (EKG)?

    • Does the patient have medical problems, specifically cardiac problems?

    • Has there been a change in the level of consciousness?

    • What medications is the patient on? Was any new medication recently started?

  • 3.

    What is the patient’s psychiatric history?

  • 4.

    Does the patient have a history of substance abuse?

Orders

  • 1.

    If there is an acute danger to the patient or staff members, you will need to notify the staff over the phone that you may need to order medication and/or physical or chemical restraints as soon as you have seen the patient and that a psychiatric code should be called to alert additional staff that help is needed.

  • 2.

    Order appropriate observation and measurement of vital signs and level of alertness.

  • 3.

    For an alert, cooperative patient, consider ordering oral medication as needed (PRN) to help with symptomatic relief until you can evaluate the patient, but do evaluate the patient as soon as possible. Order low doses so that the patient will be alert for an evaluation when you arrive at the site.

Inform RN

“Will arrive in…minutes.”

In addition, ask the registered nurse (RN) to page or call the patient’s primary medical doctor or team, if at all possible, to inform you of the patient’s medical conditions and baseline behavior.

Elevator thoughts

What causes agitation?

The timing of the onset of the agitation provides important information regarding the underlying etiology. A more acute onset may suggest a medical problem or an acute intoxicated or withdrawal state (this is possible even if a patient has been in the hospital for days). Manic symptoms usually escalate over time, and a schizophrenic decompensation usually follows a prodromal period; however, exceptions do occur. Substance withdrawal syndromes usually occur 1 to 7 days after admission and are generally accompanied by changes in vital signs.

In addition, a patient may become agitated in cases in which communication between the treating team and the patient is jeopardized. Occasionally, patients who want or expect to be discharged from the hospital may become agitated when told by their primary team that they should remain in the hospital longer for more treatment, or when they have returned from court and commitment over objection has been upheld.

An assessment of the level of consciousness may also help to elucidate the underlying cause of an agitated state. Patients who are agitated because of a primary psychiatric illness should not have fluctuations in the level of consciousness and should be fully alert. Patients who are agitated because of a primary medical illness often will have fluctuations in their level of consciousness and may not be alert.

A good history and physical examination (including a full neurologic exam) will help to elucidate the underlying cause of an agitated state. Someone with multiple medical problems or taking multiple medications is more likely to have a general medical condition causing the agitation. Likewise, someone who appears to be in physical distress usually has a medical condition causing the agitation. Be sure to assess fall risk and rule out recent head injury as a cause of symptoms. If there is any doubt that the patient has had a recent head injury or that the patient has an acute neurological problem or dementia contributing to the agitation, order a noncontrast head computed tomography (CT) scan.

Psychiatric Causes of Agitation

  • Psychotic disorders

  • Mood disorders

  • Anxiety disorders

  • Personality disorders

  • Major neurocognitive disorder

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