Calming the Agitated Patient: Providing Strategies to Support Clinicians

Abstract

Agitation is a symptom of many medical and psychiatric disorders that can manifest along a spectrum of severity. Agitation often delays treatment onset, potentially impacting morbidity and mortality, and may require emergency interventions. Management of acute agitation centers around three main goals: early recognition and treatment of the underlying etiology, rapid control of the behavior, and prevention of harm to the patient and personnel. Nurses should increase use of validated techniques, including frequent and sufficient reality orientation, validation therapy, and strategies that improve the individual’s quality of life.

Approximately 40% of hospitalized patients are age 65 or older (McDermott et al., 2017). As many as 70% of these hospitalized older adults are considered frail, further increasing their risks for worsening morbidity, greater dependence, and increased disability contributing to multiple early rehospitalizations, institutionalization, and excess mortality (Lekan et al., 2017). These older adults also may be at increased risk for developing agitation when hospitalized.

Agitation is defined as an emotional state of excitement or restlessness. Agitation is a symptom of many medical and psychiatric disorders that can manifest along a spectrum of severity and may require emergency interventions (Dimitriou et al., 2018). Agitation often delays treatment, which may impact morbidity and mortality (Almeida et al., 2016). Methods to assist nurses with addressing agitation and minimizing escalation and aggressive behaviors will be described.

Cognitive impairment may influence agitation. Many persons with cognitive impairment are not aware of their illness, and their frustration with limitations or constraints can result in agitation and aggressive behavior (Mulkey, 2019; Mulkey et al., 2019). Aggressive behaviors may include shouting, name-calling, cursing or making lewd comments, hitting, pushing, biting, pinching, scratching or grabbing, or demonstrating disinhibited sexual behavior (Linder et al., 2018).

Increased stress may result from changes in the physical or social environment, amount or type of stimuli, the individual’s routine, or demands exceeding the individual’s functional ability. These stresses increase the risk of agitation. For example, being removed from a familiar environment and surroundings, such as during admission to the hospital, may increase anxiety and be manifested by agitation (Pfeifer et al., 2018). Although agitation is independent of language deficits, they may influence development of agitation due to the relationship between language deficits and a person’s overall level of functioning, executive dysfunction, and behavioral symptoms (Schubert et al., 2016). Agitation may ensue when an individual cannot make personal needs known or cannot understand what is happening (Volicer & Galik, 2018). The resulting increased anxiety may lead to agitation and other challenging behaviors, such as resisting assistance or striking out at caregivers.

Volicer and Galik (2018) described the cause of agitation from another perspective. Their theory suggested agitation occurs because caregivers cannot comprehend the individual, resulting in anxiety related to the individual’s inability to make personal needs known. When anxiety decreases, challenging behaviors likely will decrease as well. Clinicians need to consider agitation as a symptom rather than a separate entity, occurring when a cognitively impaired person’s needs are not met due to caregivers’ lack of understanding.

Caregivers and family members commonly feel overwhelmed when trying to communicate effectively (Bunn & Handley, 2019). Because of the challenges with verbal expression, patients may communicate nonverbally through agitation and aggression. Communication can be difficult because of cognitive impairments and decline in verbal skills. Sending and receiving information often are impaired. While impairments may vary, they tend to center around choosing words, building complex sentences, understanding verbal information, and remembering what was said recently (Machiels et al., 2017). However, the ability to send and receive nonverbal information or to create short, uncomplicated sentences may remain, along with the ability to discuss things that happened long ago.

Management

The lack of randomized controlled trials complicates management of agitation to inform clinical practice, leading to few evidence-based treatment options for this syndrome (Hui et al., 2018). Management of acute agitation centers around three main goals. Early recognition and treatment of the underlying etiology and rapid control of the behavior are needed. It also is critically important to prevent harm to the patient and personnel (Linder et al., 2018).

Early Recognition and Treatment of Underlying Etiology

Agitation can become a significant barrier to treatment and increase patients’ risk of harming themselves and others (Schumacher et al., 2016). Agitation often masks diagnostics, delays treatment initiation, increases morbidity and mortality, and increases care costs (Almeida et al., 2016; Bunn & Handley, 2019; Freeman et al., 2019). Injuries and sudden deaths have been reported during attempts to restrain agitated patients for medical stabilization (Miner et al., 2018).

Regardless of the clinical setting, interventions need to target the behavior’s cause (Moheb et al., 2017). Having management strategies and individualized approaches to ensure everyone’s safety and well-being requires understanding the individual’s impairments and careful planning. Effective management requires close collaboration among providers, staff, and family to develop and implement an effective individualized care plan. Family members should be informed and clinicians should be alert for increased risk of agitation and aggression, not just inhibition and apathy. Staff concerns should be addressed and education supported.

Anticipation and basic prevention strategies may help decrease anxiety and agitation, reducing the patient’s need to exhibit challenging behaviors. Hospital admission, strange environments and people, and the resulting change in routine are known stressors, especially for persons with cognitive impairment. Obtaining information from caregivers regarding typical home routines, known precipitating and modifiable causes of agitation, preferred names, and strategies to reduce agitation at home will help clinicians develop an appropriate plan (Aubanel et al., 2020; Hoover & Whitehair, 2020; Mulkey et al., 2019).

Individuals with cognitive impairment and those unable to self-report are affected disproportionately by pain and undiagnosed illnesses compared to persons without cognitive impairment who can self-report (Aubanel et al., 2020; Hoover & Whitehair, 2020; Mulkey, 2019). Goebel and coauthors (2019) recommended holistic assessment methods when evaluating pain in persons with cognitive impairment. While observation tools have inherent limitations, Goebel and colleagues suggested the PAIN in Adults with Delirium (PAINAD) and Critical Care Pain Observation Tool (CPOT) as validated tools with high validity and reliability in these populations.

Promoting activity and exercise may be helpful. Maintaining a slow pace also encourages the patient to go slower if needed. While diversional activities (e.g., single-use disposable items such as purses, coloring books, activity aprons, books, playing cards) can be helpful in reducing agitation, Waszynski and associates (2018) found simulating presence of family through video is another potentially effective method. Similarly, Munro and coauthors (2017) used family recorded reorientation messages played automatically every hour. Using family recorded messages was associated with increased family engagement and involvement, patient comfort, and the number of delirium-free days. Although limited evidence is available, knowing and having the type of music the patient prefers also may be helpful when attempting to address over- and under-stimulation (Garcia Guerra et al., 2019). Music therapy is thought to be beneficial because it can influence the individual’s attention and elicit positive memories (Dimitriou et al., 2018).

Providers should not take inappropriate remarks or behaviors personally. Confrontation and correction are usually less successful than trying to prevent actions before they happen and reduce the risks involved if they occur (Machiels et al., 2017; Pfeifer et al., 2018). Using correction or punitive responses may be misinterpreted as abusive and result in increased agitation or aggression. Positive behavioral and environmental interventions are most effective. Responding with humor and distraction, or simply walking away, may be useful.

Rapid Control of Behavior

Staff should be encouraged to remain calm. Smiling is useful because individuals understand positive emotional expressions better than negative ones. Simple actions (e.g., using the patient’s preferred name during conversations) can improve the therapeutic relationship, trust, and care (Wolf et al., 2018). Staff should avoid startling, rushing, arguing, or touching the individual without permission. While distraction and redirection to another activity are useful techniques to manage challenging behaviors, they also may worsen agitation (Pfeifer et al., 2018). With some individuals (e.g., persons with certain types of dementia), redirection may not be effective. For example, individuals with frontotemporal dementia may not respond to redirection because cognitive abilities and memory often are retained (Pfeifer et al., 2018). If possible, the amount of stimulation should be reduced to prevent escalation of negative behaviors (see Table 1).

TABLE 1.

Strategies for Controlling Behavior

Stressor	Intervention
Unmet needs	Promote rest and sleep at night. Address fear, hunger, toileting needs.
Acute medical condition	Consider possibility of pain, urinary tract infection, medication interactions/side effects.
Sensory deficits	Encourage use of visual and hearing aids. Provide simple activity (e.g., folding washcloths, using busy vests/drapes with buttons and zippers).
Caregiver stress, depression, burden	Encourage rest and nighttime sleep away from hospital; care for one’s personal needs; use of stress-reduction techniques; time for self.
Education	Educate significant others, visitors, staff that behavior is not intentional but a result of cognitive impairment.
Communication	Keep it simple; do not over-explain or discuss what will happen in the future. Use calm voice. Avoid open-ended questions. Limit number or options or choices. Don’t argue or disagree; simply change the subject or focus of conversation.
Over/Under-stimulating environment	Limit number of people in the area. Reduce noise by turning off the TV, adjusting alarms. Remove unused or unneeded equipment. Bring patient in chair to nurses’ station or hallway for visibility.
Safety	Remove sharp or potentially harming objects from room. Use bed and chair exit alarms. Limit restraint use. Cover IVs and other lines. Use nightlight. Implement fall precautions.
Lack of activity	Provide appropriate available activities. Encourage ambulation if permitted. Relax rules as able unless safety is a concern.

Sources: Davison et al., 2017; Mulkey, 2019; Mulkey et al., 2019

Because of challenges with verbal expression, individuals may exhibit nonverbal behavioral communication such as agitation and aggression. While high-quality research is limited, some theory-based strategies may provide support. These include obtaining the individual’s attention before attempting to communicate, speaking clearly, using active-listening techniques, and making eye contact (Machiels et al., 2017). Symbolic communication (e.g., using metaphors, combining humorous and literal statements) may be particularly challenging for the patient to interpret.

Communication methods should be selected to avoid arguments and escalating behavior. These may include speaking in a soft, pleasant voice; respecting the individual’s personal space by providing enough room; and assigning consistent care providers. Validation of the individual’s emotions and using a calm, lower-pitched voice may de-escalate agitation. Using single phrases and a directing voice may help when escorting the person to a nearby area to engage in a positive activity. Attempts to reason or argue with the individual should be avoided (Mulkey, 2019; Mulkey et al., 2019). Because warning signs, such as a change in facial expression or body stance, may not occur before physical aggression, caregivers are left unprepared (Davison et al., 2017).

Nurses should increase the use of validated techniques, including frequent and sufficient reality orientation, validation therapy, and strategies to improve the individual’s quality of life (Davison et al., 2017). For example, restraints should be avoided as much as possible because they are associated with increased falls and dependence on caregivers (Mulkey, 2019; Mulkey et al., 2019). According to a review by Kales and coauthors (2015), more than 60 qualitative research studies have investigated the impact of environmental interventions. Results indicate environmental interventions have a role in preventing and reducing behaviors that are a symptom, such as agitation (Kales et al., 2015;). Non-pharmacologic strategies should be attempted first (e.g., environmental interventions, de-escalation strategies) (Pink et al., 2018). Techniques such as progressive muscle relaxation can decrease apathy, anxiety, irritability, and agitation, and improve volition and social relationships (Ikemata & Momose, 2017). Disruptions to sleep and the usual regimen may contribute to behavioral issues. Maintaining a routine when possible is important, as is making necessary changes gradually (Machiels et al., 2017; Pfeifer et al., 2018). Multi-model interventions may provide the best management of symptoms and behaviors. Reducing or eliminating problematic behaviors may improve the individual’s overall functional outcome, delaying the need for long-term care (Moheb et al., 2017). See Table 2 for a summary of possible reasons for agitation.

TABLE 2.

Possible Reasons for Agitation

• Overstimulation (e.g., excess noise, people; presence of unfamiliar items) or under-stimulation (e.g., lack of anything of interest to see)

• Safety problems (e.g., fall risk)

• Lack of activity and structure (e.g., limited activities to match interests, capabilities)

• Lack of established routines (e.g., frequent changes in time, location, sequence of daily activities)

Sources: Davison et al., 2017; Mulkey, 2019; Mulkey et al., 2019

Preventing Harm to the Patient and Personnel

Caregivers should intervene with confidence and respect, calling for assistance if aggression or risk to the patient or others escalates. To maintain safety, they should ensure an exit is available and give the individual space (about 5 feet). Staff should stand on the individual’s least dominant side and observe the location of the person’s arms and legs. If behavior becomes aggressive, the best action is to move away (Davison et al., 2017). Safety measures are needed to prevent injury while maintaining as much freedom as possible. Roaming should not be stopped entirely but may need to be adjusted and supervised. Providing a safe, protected area free of clutter and obstacles, and using non-skid foot-wear will help reduce injuries. Staff should report the behavior, determine the manifestations, and address the behavior quickly; delayed intervention will worsen behavior (Davison et al., 2017).

Nursing Implications

Nurses play a pivotal role in prevention and management of agitation. They must recognize early signs of agitation and implement strategies that promote rapid control of the behaviors to prevent harm. Interventions need to target the cause of the behavior. An individualized treatment plan should be developed in close collaboration with the individual and the family to be effective (Mulkey, 2019; Mulkey et al., 2019). Acquiring information at the time of admission regarding routines may assist with prevention plan development. Patients who cannot communicate should be assessed frequently for pain and anxiety using a validated screening tool. Patients should be evaluated for these risks to determine if assigning a sitter or transferring to a higher level of care is needed. Strategies include frequent reality orientation, diversional activities, family engagement, and avoidance of restraints whenever possible (Aubanel et al., 2020; Freeman et al., 2019).

Because environmental shifts contribute to agitation, avoiding transfers and securing a single room can be beneficial. Implementing interventions that allow patients to develop some control over their environment, such as offering choices if the patient can make decisions, also can help relieve agitation. Restraints typically are not recommended because they can exacerbate agitation and lead to injuries (Freeman et al., 2016).

When episodes of agitation occur, caregivers should remain calm, not take the situation personally, and call for help when needed. Using a lower voice can help deescalate the situation. The caregiver should maintain an exit route and avoid getting in the individual’s personal space. Reporting the behavior and working collaboratively to determine the manifestation will assist with preventing another episode. Managers should focus on retaining trust between care providers and the patient. Often, just general conversation can help relieve stress and anxiety (Mulkey, 2019; Mulkey et al., 2019).

Conclusion

Agitation is multifactorial and associated with adverse outcomes, including increased hospital length of stay and higher mortality rates and costs (Almeida et al., 2016). Agitation also can compromise patient safety and care. Safety issues must be addressed. This review provided insight into current management practices and the literature supporting those practices.