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What best describes the situation?
Protest (this is less than agitation) Agitation Restlessness Delirium Aggression Violence What will happen if the situation is not addressed properly? Harms can increase if situation is not addressed properly. A correct determination of the situation is essential. A wrong conclusion can lead to wrong treatment and further harms. What is agitation? Agitation can be defined as excessive verbal and/or 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 key to safety is to intervene early in order to prevent progression of agitation to aggression and violence. What are common causes of agitation? Agitation due to provocation. Agitation due to severe stress. Agitation due to deprivation of rights under the color of law. Agitation due to harms. Agitation due to intentional enforced harms. Common causes of Protest Protest (this is less than agitation) Provocation Severe Stress Intentional enforced harms What are various causes of agitation? There are more than 35 causes of agitation. What is the cause of agitation in this situation? How many individuals are involved in this situation? What causes agitation or makes it worse? Your health care provider will take a medical history and do a physical examination. To help better understand your agitation, your health care provider may ask the following questions: Obtain the History Has the patient’s environment changed? Is the patient psychotic? Are you more talkative than usual or do you feel pressure to keep talking? Do you find yourself doing purposeless activities (e.g., pacing, hand wringing)? Are you extremely restless? Are you trembling or twitching? Time pattern Was the agitation a short episode? Does the agitation last? How long does it last -- for how many day(s)? Factors that make it worse Does the agitation seem to be triggered by reminders of a traumatic event? Did you notice anything else that may have triggered the agitation? Do you take any medications, especially steroids or thyroid medicine? How much alcohol do you drink? How much caffeine do you drink? Do you use any drugs, such as cocaine, opiates, or amphetamines? Other What other symptoms do you have? Is there confusion, memory loss, hyperactivity, or hostility (these symptoms can play an important role in diagnosis). Determine the Context of the Disturbed Behavior Is this a sudden change in behavior or mental status? Is this an acute exacerbation of a chronic problem? What is the patient’s baseline level of cognition & behavior? Are there patterns of or triggers for the problematic behaviors? Restlessness What is restlessness? Restlessness differs from agitation. This behavior often comes after a patient has gone through the agitation stage. This is also considered part of the recovery process. Someone who is restless will have trouble sitting still, will not be able to focus or concentrate, and may be impulsive. The patient may appear nervous and anxious. He may pace or fidget all the time. What causes restlessness or makes it worse? Restlessness most often is increased or due to too much stimulation to the brain (like agitation.) But this may also occur if a patient is very confused and not getting enough stimulation. What can family members do to help? •Talk to the patient in a calm, quiet voice. •It is not helpful to yell or argue with the patient. Someone with a brain injury is not able to reason. •If your loved one becomes aggressive (yelling, striking out) call for help. Ensure your safety first. •Remove all things that may distract or stimulate the patient. For instance, keep the TV off. •Limit guests and keep visits short. It is vital for the patient to rest. •Provide frequent prompts about where your loved one is and their injuries. But be sure not to quiz the patient about what she remembers. •Tell the hospital staff what helps the patient relax. Delirium What is Delirium? Delirium is an under-recognized, but surprisingly common problem, particularly among older adults who are hospitalized. People who are delirious have trouble thinking clearly, focusing their thoughts and paying attention. Delirium is different than the long-term confusion seen with dementia or Alzheimer’s disease. Delirium can come on within hours, and may come and go throughout the day. What Causes Delirium? It can be caused by a number of things – medications, infection, and simply being in an unfamiliar environment like the hospital. Patients at particular risk for delirium are those who have: Memory or thinking problems Severe illness Dehydration Problems seeing or hearing How Is Delirium Treated? Depending on the cause of the delirium, treatment may include medication as well as regular contact from our staff and HELP volunteers. Family members also play an important role in helping a patient with delirium. (See the next page for examples of what you can do to help your loved one). How is delirium diagnosed? There are several sub-types of delirium which can be diagnosed in patients who are critically unwell. Hypoactive delirium is the most frequent subtype of delirium in palliative care settings and is associated with lethargy, stupor and varying functioning levels of consciousness. Can delirium be reversible? Delirium may be reversible if there is an underlying metabolic, pharmacologic or psychosocial disorder which can be treated, and this is also true with over 50% of delirium episodes reversible in the palliative setting. In some patients delirium can be persistent and associated with longer term cognitive problems much of the evidence about prognosis and treatment of delirium comes from the aged care and critical care literature. Acute Management of Agitation An essential step in the management of agitation is the determination of its underlying cause. One approach to evaluating agitation is to carefully characterize the quality of the agitation, the time of day and setting in which it occurs, whether it occurs in a cyclical or a noncyclical pattern, and any possible environmental stimuli. Treatment of acute agitation in psychotic disorders Several psychotic disorders, including schizophrenia, may be associated with symptoms of acute agitation and aggression. Who should be placed in restraints? What chemical restraints are available? What is the legality of restraints? Pharmacologic Management   Most common injection forms of psychotropic drugs
 Midazolam: Midazolam is the benzodiazepine that has the fastest onset of action and the shortest duration of effect. Who takes the decision? Any physician is able to take this decision; it need not be a specialist in either emergency medicine or psychiatry. |
There are several kinds of abuse and each kind can take many different forms.
Physical |
Emotional |
Verbal |
Sexual |
Deprivation of rights under color of law. |
Social |
Hitting Slapping Shoving Hair Pulling |
Put Downs Guilt Trips Humiliation Intimidation Mind Games |
Name Calling Threats Yelling |
Unwanted Touch of any kind
Sexual Force of any kind
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What are your basic needs for survival?
Discrimination on the basis of race, color, gender, disability, religion, familial status and origin. |
Spreading rumors Controlling contact with friends
Isolation from friends or family |
Posttraumatic Stress Disorder.
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Is there a difference between acute stress reaction and acute stress disorder? No. Acute stress reaction or reactions and acute stress disorder mean the same. Is there a difference between acute stress disorder and posttraumatic stress disorder? Yes, there is. What is the difference between acute stress disorder and posttraumatic stress disorder? ASD refers to symptoms manifested during the period from two days to four weeks post trauma, whereas PTSD can only be diagnosed from four weeks onward. Here are further guidelines. |