Management of Agitation in the Adult Patient

Educational Objectives

The goal of this program is to improve the management of agitation in the adult patient. After hearing and assimilating this program, the clinician will be better able to:

1. List principles for management of agitation included in Project BETA (2012).
2. Explain the Broset Violence Checklist rating scale.
3. Cite effective techniques of verbal de-escalation.
4. Optimize psychopharmacologic interventions in patients with agitation.
5. Manage agitation in patients who refuse medication.

Summary

Agitation: excessive verbal and/or motor behavior, mood lability, or aggression; it is classified by Emergency Medical Treatment and Labor Act (EMTALA) as an emergency medical condition; has a high chance of involvement of law enforcement, physical interactions, and dissatisfaction from the patient and family members

Etiology: mental illness can exacerbate agitation; other causes include involuntary detention, suppression of rights, possibility of legal repercussions, paranoia, intoxication, or withdrawal states, feeling scared or out of control, and re-experiencing past trauma

Project BETA (2012): is Best practices in Evaluation and Treatment of Agitation; develops a uniform and better understanding among different medical disciplines of managing agitation; it is also trauma informed, patient centric, and benefits the medical team by decreasing helplessness and establishing feeling of safety; a lot of data involved inpatient populations, but it is still useful in outpatient settings

Evaluation of agitation: strong interest in reducing seclusion and restraint; important to do so in a humane way that protects everyone; most physical interactions can be avoided; patients have a right to protection against agitation; should be treated like any other scared emergency patient dealing with a life-threatening event; often, they are confused and in pain; it is unethical to deny them treatment; diagnosing conditions effectively is hard with agitation; manage agitation for ethical reasons and to ensure best diagnosis is reached; University of Texas Southwestern study (2016) on violent behavior in the emergency department found programs that decreased violence and agitation were set in places in which high risk was recognized and security was improved; they shortened 1) the time to de-escalation processing and 2) the time to treat the agitation, either via medication or if necessary by restraints; the speaker’s psychiatric emergency department in Milwaukee is large and robust, serves a large community; >50% of cases are involuntary, but use of restraint is kept below the national average using best practices; always start with immediate nurse assessment for all medical, legal, or social complications and if necessary, the institution has immediate physician assistants at the door; this increases the medical decision making and leadership; different de-escalation techniques can be used, including verbal, social, interdisciplinary communication, and physical

The Broset Violence Checklist (BVC) rating scale: 6-item scale involving confusion, irritability, boisterousness, physical threats, verbal threats, or attacks on objects; confusion can lead to agitation, particularly in delirious populations; individuals are sometimes irritated at being part of the process, and caregivers should recognize it as an etiology of agitation; boisterousness is seen in individuals who exhibit grandiosity as a target symptom of mania; speaker has seen episodes of assault because individuals got too close to a grandiose person without recognizing the agitation; each of the 6 items in BVC are assigned 1 point each; score ranges from 0 to 6; for scores 1 or 2, it is suggested to treat the symptoms; medical decision making and patient factors important; also document the suggested treatment for agitation; the BVC involves a longitudinal trajectory; important for staff to know that patient has an elevated BVC; when patient transferred, this can be communicated to those receiving the patient

The Behavioral Activity Rating Scale (BARS): single-item scale ranging from 1 to 7; 7 is extremely violent and 1 is unarousable; using a standardized skill increases safety and feeling of security of staff and patients leading to better outcomes; avoid associating agitated patients with the same clinical scenario; involve physician staff and other staff members; often, the first person to meet an agitated patient is not the physician; having the entire team understand the best practices helps in improving the morale and lowers helplessness, resulting in patients’ benefit

Principles of managing agitation: 1) rule out life-threatening causes; 2) engage in verbal de-escalation; 3) consider pharmacologic options; 4) as a last resort, consider physical plant options, including seclusion and restraint; Project BETA has 6 articles on overview, medical evaluation and triage, psychiatric evaluation, verbal de-escalation, psychopharmacology, and seclusion and restraint

Delirium: when a patient is agitated, individuals tend to focus on the agitation without awareness of underlying factors (eg, drugs) and this may cause complications; patients with mental illness have a greater risk for delirium and there is greater risk it will be overlooked, and a greater risk of chronic health conditions, leading to a higher degree of morbidity and mortality; they have a shorter lifespan than their fellow-aged peers without chronic mental illness; the staff should be reminded to look for delirium to avoid stigmatizing the population experiencing mental illness

Verbal de-escalation: a common skill in daily life; practice leads to proficiency; can be taught to many stakeholders; sometimes earlier use of verbal de-escalation results in decreased need for psychopharmacologic or costly interventions later; verbal de-escalation is not easy in the emergency department or at an inpatient unit because of limited space, time, and staff; many patients have a distrust of authority figures because of their illness or actual events in their life; they may have been involved with law enforcement, making de-escalation difficult; patient issues (eg, intoxication, past trauma, traumatic brain injuries) can make receiving de-escalation difficult; for active psychiatric symptoms (eg, thought disorders, mania), a different verbal de-escalation approach is needed; agitation may be stigmatized, particularly by non-psychiatric physicians and health providers, as purposeful, but it should be managed like any other emergency medical condition

Techniques of verbal de-escalation: 1) with verbal de-escalation, always start with “I” statements (eg, “I prefer”, “I feel”, “I think”) not “you” statements (eg, “you should”); starting sentences with the word “you” often makes individuals defensive; 2) be aware of posture; approaching the patient with crossed arms, shoulders back, and a defensive or aggressive posture, typically causes them to mimic provider; 3) maintain proper space; 4) physician should be aware of their position, and how the patient views them; 5) clinicians should always introduce themselves to the patient; physician should not assume patient knows who they are; when individuals are in crisis, a clinician should be concrete and explain their role; 6) avoid large numbers of staff crowding around the patient; it puts them on guard, and makes them more defensive and less trusting; 7) have one voice speaking; especially if they have symptoms of auditory hallucinations; having >1 voice is confusing, and can lead to confusing directives, frustration, anxiety, and poor outcomes; 8) speaking slowly and with a low volume does work; acceptable to repeat statements; it shows respect for the patient; 9) show a professional code of conduct; a patient can become more agitated if the staff is also agitated

Non-psychiatric vs psychiatric training: Dr. Berlin, a past president of the American Association for Emergency Psychiatry used the phrase "Seek first to understand, then to be understood"; this is not how physicians are trained, particularly in emergency settings where they give orders, do quick assessments and take control of the scenario; waiting for patients, eg, to interact, is not inherent in emergency response; listen to the patient and then ask what they need and want; often, patients need something simpler than expected; in for majority of cases, Maslow hierarchy is applicable; ie, individuals want to feel safe, they may be hungry, tired, cold, or hot depending upon the season and locale; they may need to talk to their family members; clinician should tell patients what they can and cannot help with, and about inadvisability of certain requests; clinician’s attitude should be free from feelings of helplessness and hopelessness; verbal de-escalation together with offering oral medications has been observed to have a high degree of success

Psychopharmacologic interventions: 1) most clinicians drastically overemphasize the risks of psychiatric medication and underemphasize the risks of untreated mental illness; follow all civil rights and autonomy and involuntarily medicate only with imminent threat of danger; this involves comparison of risk to risk; 2) many physicians and other medication-providing providers do not intervene early enough; treating early makes administration of lower doses an option later; reassess and if the patient remains agitated or in pain, then give more medication; agitation is not comfortable for the patient so it must be treated early and often; 3) sometimes restraints may be necessary, but it is ethically inappropriate to place patients in restraints without any other intervention; it is traumatizing and patient struggle results increased risk for musculoskeletal injuries or even rhabdomyolysis; placing a patient in restraints should be considered merely an avenue to get them treatment

Psychopharmacology of agitation: several factors involved; consideration of routine vs emergent issues critical; consider route of administration, history of allergies or past exposures, comorbid medical issues, target symptom that is being treated, and whether it is acute or chronic; it is incorrect to assume agitation is most effectively treated with haloperidol (Haldol), lorazepam (Ativan), and diphenhydramine (Benadryl); be patient-centric and target symptom-centric; asking patients what has worked for them in the past makes them feel in control; sometimes because of the placebo effect, a response that does not seem right based on psychiatric training (eg, patient says they take gabapentin as needed); if there is no contraindication to it, order that and add something else to it after discussing with the patient

Patient refusing medication: if because of their agitation, the patient does not want any medications and does not trust the medical professional, ask different questions during interaction; suggest medication to patient that might help them; begin with open-ended and patient-centric statements; there may be a need to use a more coercive dynamic depending upon the scenario; it is important from a medicolegal perspective to prescribe a drug to prove that the patient refused it; sometimes forced choice is necessary; prescribing a medication shows the trustworthiness of clinician and their ability to take ownership of their part; often, when the medication works and the patient has their suffering eased, it results in greater bonding and positive transference than with other strategies; not all usage of psychiatric medications during agitation is for sedation; sedation is safest in arguably minority of cases, but the majority of psychopharmacologic de-escalation can actually be done with less

Project BETA recommendations: focused on first- and second-generation antipsychotics, and benzodiazepines; for delirious agitation, recommended to resolve the cause first; otherwise, it is just a superficial approach to the de-escalation process; with agitation caused by intoxication, benzodiazepines are the first-line treatment, even with newer-generation intoxicants (eg, synthetic cathinones [bath salts], synthetic cannabinoids, [eg, K2, Spice]); add second-generation antipsychotics if needed; for alcohol withdrawal benzodiazepines are much more indicated, to treat the intoxication and also to ward off any possible life-threatening issues pertaining to delirium tremens; for intoxication with alcohol, second-generation antipsychotics are very helpful

Data: most data preferences are for second-generation antipsychotics over first generation; if psychiatric illness is the primary driver of the agitation, focus on antipsychotics as the first line; if somebody is agitated because of mania or psychosis, giving them a benzodiazepine is not going to solve the agitation; it may slow it down temporarily, but does not address hallucination or mood lability; for delirium, focus on the cause and use low-dose, second-generation antipsychotics and/or haloperidol; ketamine (Ketalar) has become popular in emergency departments, but most of its excellent evidence for agitation is in cases of non-psychiatric agitation; giving ketamine in psychosis is not necessarily best; may initially cause sedation, but agitation sometimes gets worse when patient comes out of sedation; there is some positive data on ketamine use for excited delirium (controversial); it is a level C recommendation according to the American College of Emergency Physicians (ACEP); there are also concerns of needing rescue intubation

Loxapine: inhaled loxapine powder (Adasuve) has positive data on faster resolution of agitation; delivery mechanism makes it unique; it is an inhaled powder that comes through an inhalation device that the patient self-administers; has a quicker onset than oral medications that patients would be using in a voluntary sense; there are some Food and Drug Administration (FDA) warnings, particularly involving respiratory complications; currently it requires a Risk Evaluation and Mitigation Strategy (REMS) program, requiring enrollment, auditing, and oversight

Antipsychotic drugs: Project BETA favors antipsychotics in many contexts; it studied several things, mainly related to route of administration; beneficial in an emergency department setting, (psychiatric or medical), inpatient setting, or even ambulatory clinics; sublingual tabs circumvents the first pass effect; risperidone melt tabs and/or olanzapine dissolvable tablets (Zyprexa Zydis) are used more often because they have a good titration schedule, work fast, and are effective for agitation

Intramuscular (IM) medications: sometimes, the least restrictive method, typically because of issues relating to imminent threat of danger, are IM medications; most antipsychotics are in the form of an IM variable; Project BETA favors the second-generation antipsychotics; most antipsychotics are in IM forms that have been studied in agitation; (eg, haloperidol, fluphenazine, ziprasidone, aripiprazole, chlorpromazine, olanzapine); when co-administering with benzodiazepines and anticholinergics, avoid doubling the sedation; also be aware of anticholinergic burden; many antipsychotics have an anticholinergic profile; each of these have their own unique profile; important to balance the side effects and the risks and benefits for patient

Readings

Keating GM. Loxapine inhalation powder: a review of its use in the acute treatment of agitation in patients with bipolar disorder or schizophrenia. CNS Drugs. 2013;27:479-489; doi: 10.1007/s40263-013-0075-9; Marder SR. A review of agitation in mental illness: treatment guidelines and current therapies. J Clin Psychiatry. 2006;67:13-21; Mo H et al. Ketamine safety and use in the emergency department for pain and agitation/delirium: a health system experience. West J Emerg Med. 2020;21:272-281; doi: 10.5811/westjem.2019.10.43067; Nordstrom K et al. Medical evaluation and triage of the agitated patient: consensus statement of the American Association for Emergency Psychiatry project Beta medical evaluation workgroup. West J Emerg Med. 2012;13:3-10; doi: 10.5811/westjem.2011.9.6863; Richmond JS et al. Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry project beta de-escalation workgroup. West J Emerg Med. 2012;13:17-25; doi: 10.5811/westjem.2011.9.6864; Stowell KR et al. Psychiatric evaluation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry project beta psychiatric evaluation workgroup. West J Emerg Med. 2012;13:11-16; doi: 10.5811/westjem.2011.9.6868; Thomas J et al. Medical-legal issues in the agitated patient: cases and caveats. West J Emerg Med. 2013;14:559-565; doi: 10.5811/westjem.2013.4.16132; Wilson MP et al. A comparison of the safety of olanzapine and haloperidol in combination with benzodiazepines in emergency department patients with acute agitation. J Emerg Med. 2012;43:790-797; doi: 10.1016/j.jemermed.2011.01.024; Wilson MP et al. The psychopharmacology of agitation: consensus statement of the American Association for Emergency Psychiatry project BETA psychopharmacology workgroup. West J Emerg Med. 2012;13:26-34; doi: 10.5811/westjem.2011.9.686; Woods P et al. The Brøset violence checklist (BVC). Acta Psychiatr Scand Suppl. 2002;106:103-105; doi: 10.1034/j.1600-0447.106.s412.22.x.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Thrasher was recorded exclusively for Audio Digest using virtual teleconference software, in compliance with current social-distancing guidelines during the COVID-19 pandemic. Audio Digest thanks Dr. Thrasher for his cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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Lecture ID:

PS501601

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.