Agitation; Types, Causes, Symptoms, Diagnosis, Treatment

Agitation can be defined as excessive verbal / motor behavior. It can readily escalate to aggression, which can be either verbal (vicious cursing and threats) or physical (toward objects or people). Technically, violence is defined as physical aggression against other people.  The signs are unintentional and purposeless motions; the symptoms are emotional distress and restlessness. Typical manifestations include pacing around a room, wringing the hands, uncontrolled tongue movement, pulling off clothing and putting it back on, and other similar actions. In more severe cases, the motions may become harmful to the individual, such as ripping, tearing, or chewing at the skin around one’s fingernails, lips, or other body parts to the point of bleeding.

Agitation also means

Agitation (action), putting into motion by shaking or stirring, often to achieve mixing

An emotional state of excitement or restlessness

• Psychomotor agitation, an extreme form of the above, which can be part of a mental illness or a side effect of anti-psychotic medication
• Agitation (dementia), a symptom of dementia

Political agitation or demonstration (protest), political activities in which an agitator urges people to do something

• Agitation and Propaganda against the State, a former criminal offence in communist Albania
• Anti-Soviet agitation, a former criminal offence in the Soviet Union

Causes of Agitation 

• Schizophrenia
• Bipolar disorder
• Excited delirium
• Post-traumatic stress disorder
• Panic attacks
• Anxiety disorder
• Obsessive-compulsive disorder
• Alcohol withdrawal
• Claustrophobia
• Dementia
• Parkinson’s disease
• Traumatic brain injury
• Alzheimer’s disease
• Acute intermittent porphyria
• Hereditary coproporphyria
• Variegate porphyria
• Side effects of drugs like cocaine or methylphenidate
• Side effects of antipsychotics like haloperidol

Causes of Terminal Agitation

Opioid toxicity – High or prolonged opioid administration can lead sedation, neuroexcitation and even agitated delirium.

Pain – Uncontrolled and severe pain can cause agitation; this should be ruled out early. Note that communicating pain is difficult for cognitively impaired patients.

Drug interactions – Many drugs used in palliative care, such as hypnotics, antimuscarinics and anticonvulsants, can cause agitation.

Fever or sepsis – The onset of delirium can occur with fever (which can reduce cerebral oxidative metabolism).

Hypercalcaemia – Hypercalcaemia the most common life-threatening metabolic disorder in cancer patients. It can lead to a confused and agitated state so calcium levels should be monitored.

Raised intracranial pressure – Brain tumours or cerebral metastasis can increase intracranial pressure, leading to an agitated state.

Symptoms of Agitation 

Also, a person will also have experienced at least five of the following symptoms

• Feelings of sadness, hopelessness, or irritability on a nearly daily basis.
• Lack of interest or pleasure in activities almost every day.
• Experiencing significant weight loss or appetite loss that results in weight loss.
• Difficulty sleeping or sleeping excessively.
• Experiencing psychomotor agitation, restlessness, or feelings of being “slowed down.”
• Feeling fatigued or having a lack of energy nearly every day.
• Feeling worthless or having excessive and unexplained guilt almost every day.
• Difficulty thinking clearly, concentrating, or making decisions on a daily basis.
• Experiencing thoughts of death, thinking of harming one’s self, or creating a specific plan for committing suicide.
• Angry outbursts
• Clenching fists
• Disruptive behavior
• Excessive talking
• Feeling as if a person cannot sit still or focus
• Pacing or shuffling feet
• Tension
• Wringing of the hands
• Violent outbursts

Diagnosis of Agitation 

Your doctor will ask you questions and review your medical history. They will also run some tests and perform a physical exam. Your test results will be used to rule out causes of agitation.

Agitation (states of irritability, restlessness and tensions) is an acute, severe and pathological complication of many chronic psychiatric disorders, including schizophrenia and mania. Psychomotor agitation is defined as excess motor activity coupled with a feeling of inner anxiety.

Patients describe agitation as a feeling of inner distress (they feel nervous, restless, overwhelmed, out of control, in fear, in panic). It leads to an externally recognized dysfunctional state and manifests itself in swearing, hostility, lack of impulse controls, uncooperative behavior and a greater propensity to violence

Treatment of Agitation 

In the first instance, a doctor may prescribe medications called sedatives or benzodiazepines.

Examples may include diazepam  or lorazepam . These medications work quickly to help a person feel calmer and can temporarily relieve agitation.

Additional steps include

• Antidepressants – can help if your loved one is depressed and irritable. Options include citalopram , fluoxetine , nortriptyline (, paroxetine , and sertraline . Side effects of these medicines can include drowsiness,xerostomia constipation, and anxiety.
• Anti- anxiety medications – which include alprazolam , buspirone ,lorazepam  and oxazepam , often cause drowsiness.

• Medications to relieve depression – Doctors may prescribe a variety of drugs to relieve depression, including anti-depressants. If a person does not respond to these medicines, a doctor may add another drug or prescribe a different medication type entirely. Examples can include anti-anxiety medications or mood stabilizers.
• Counseling – Seeing a psychiatrist or other mental health professional can help a person identify thoughts and feelings that can signal the start of agitation or depressive symptoms. Therapy can help a person focus on thoughts and behaviors that can help them feel better when they struggle with agitated depression.
• Stress-relieving techniques – Relieving stress and depression through physical activity, meditation, deep breathing, and journaling can all help a person cope with feelings agitated depression.
• Intramuscular – midazolam, lorazepam, or another benzodiazepine can be used to both sedate agitated patients, and control semi-involuntary muscle movements in cases of suspected akathisia.
• Droperidol, haloperidol, or other typical antipsychotics can decrease the duration of agitation caused by acute psychosis, but should be avoided if the agitation is suspected to be akathisia, which can be potentially worsened. Also using promethazine may be useful.
• Recently three atypical antipsychotics, olanzapine, aripiprazole and ziprasidone, have become available and FDA approved as an instant release intramuscular injection formulations to control acute agitation. The IM formulations of these three atypical antipsychotics to be at least as effective or even more effective than the IM administration of haloperidol alone or haloperidol with lorazepam (which is the standard treatment of agitation in most hospitals) and the atypicals have a dramatically improved tolerability due to a milder side-effect profile.
• In those with psychosis causing agitation there is a lack of support for the use of benzodiazepines alone, however they are commonly used in combination with antipsychotics since they can prevent side effects associated with dopamine antagonists.

Pharmacologic Options for Acute Agitation — Intramuscular Agents

Agent	Dose (mg)	Comments
Lorazepam	0.5 to 2.0	Will treat underlying alcohol withdrawal. Caution: respiratory depression.
Haloperidol	0.5 to 10	Caution: akathisia, acute dystonic reaction, seizure threshold decrease.
Droperidol	2.5 to 5.0	No FDA-approved psychiatric indication. Caution: prolongation of the QTc interval (removed from UK market, and new black box warning in United States)
Olanzapine*	10 (2.5 for patients with dementia)	Superiority over haloperidol (schizophrenia) and lorazepam (bipolar disorder) in clinical trials. No EPS. Caution: weight gain over time.
Ziprasidone*	10 to 20	Little or no EPS. Caution: prolongation of the QTc interval.

References

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