Assessment and Management of Agitation

Agitation is a major healthcare issue seen frequently in emergency and acute care settings and can be potentially harmful to patients, families, caregivers, and healthcare staff. Until recently, most interventions for agitation have focused on involuntary, forcibly injected medications for heavy sedation, and placement of affected individuals into physical restraints. Modern expert consensus, however, recommends a less coercive approach to quell agitation – using verbal de-escalation and other calming techniques, and voluntarily accepted medications – if this can be done safely. In this contemporary philosophy, restraints and forcible medications instead should be reserved only for those situations in which non-coercive alternatives have been exhausted. The major initial goals of agitation care should include the exclusion of severe medical etiologies for symptoms, and an empathetic, rapid stabilization of the acute crisis and distress, while longer-term interventions include creating a therapeutic alliance and effective continuing care to help prevent future episodes. This chapter details preferred methods of both the medical and psychiatric evaluations of agitation, as well as a comprehensive guide to de-escalation techniques, and describes current consensus best practice guidelines on psychopharmacologic approaches. In addition, there are sections on the pathophysiology of agitation, proper utilization (and avoidance when possible) of locked seclusion and physical restraints, agitation measurement scales, and important research findings and metrics related to the evaluation and treatment of agitated individuals.