Agitation is a syndrome rather than a disorder for itself characterized by excessive motor activity associated with a feeling of inner tension which is expressed on a wide spectrum of behaviors. This broad definition embraces not only a simple feeling of restleness, uneasiness or impatient but also aggressive, threatening and violent behavior. In this talk, Manuel Sánchez de Carmona will focus on the escalation of agitation that may occur in patients in an acute episode and give some recommendations how to manage it and prevent escalation to violence.
The ethiology of agitation encompasses a myriad of physical and mental disease states that can include dementia, fever, substance use, bipolar disorder or schizophrenia. Often the cause is not easily found out and a complete evaluation is required to determine the most plausible origin and to make a proper diagnosis. Despite the high prevalence of agitation, optimal predictors are scarce. Heinz Grünze will advice how to early identify mild to moderate agitation so as to prevent a further progression to severe agitation and aggression.
A rapid assessment is essential in an effort to quickly provide symptom relief to the patient. This relief enhances a positive clinician-patient relationship, decreases the likelihood of restraints, seclusion and hospital admissions. A broad range of instruments have been developed to measure agitation in various clinical settings considering either the clinician criteria or the caregiver point of view. The most frequent used scale in the field of psychiatry is the Positive and Negative Syndrome Scale–Excited Component (PANSS-EC) a sub-scale of the PANSS. Gustavo Vázquez will expose in detail how to manage the different scales available to assess agitation.
Up to 62% of admissions for schizophrenia are due to agitation. Atypical antipsychotics combined or not with benzodiazepines are the treatment recommended in agitated psychotic episodes. Intramuscular olanzapine or aripiprazole are some of the approved drugs for agitated psychotic episodes. Nevertheless, novel, less coercive routes of administration are being taken into account regarding the intensity of the agitation and the cooperative state of the patient. Wolfgang Fleischhacker will address this topic in detail.
Agitation is a very frequent symptom in patients with bipolar disorders. In fact, this syndrome is really frequent in a mood episode with mixed features. Antipsychotic drugs administered with or without supplemental benzodiazepines are the current standard of care in this acute situation. However, after the stabilization of the patients, mood stabilizers should be borne in mind for the maintenance treatment so as to prevent mood relapses. Eduard Vieta will show his expertise in the treatment of bipolar disorder and give his advice on how to treat patients with agitated mania.
There are different treatment alternatives for agitation. Leslie Citrone will explain how the treatment is applied according to the severity of the episode. At a glance, verbal descalation is recommended as first option. If it is fruitless, pharmacological treatment is regarded. Medication will be prescribed considering speed of onset of action, tolerability, interactions and half-life. Moreover, according to the level of cooperation of the patient, the route of administration of the drugs will be chosen. As last option, mechanical restraint can be used in particular cases.
The treatment of agitation, especially when it is not severe, is largely non-medical. Traditional methods of treating agitated patients with routine restraints and involuntary medication, have been replaced with a much greater emphasis on a noncoercive approaches. Collaborative approach such as verbal descalation avoids symptoms escalation from mild, moderate to severe. Experienced practitioners such as Scott Zeller have found that if such interventions are undertaken with genuine commitment, successful outcomes can occur far more often than previously thought. He will share his experience in the field with particular emphasis on the BETA study approach.
Oral treatment has been widely used in agitation, in particular, in the mildest form when verbal de-escalation seems not to be enough. Oral or orally disintegrating medications can be used. On one hand, this voluntary medication may be combined with other non-pharmacological techniques engaging the patient and helping him or her in becoming an active partner in the evaluation and treatment. On the other hand, these routes can entail a notably delayed onset of action. Pierre Michel Llorca will help us to take decisions about this pharmacological route of administration.
An episode of agitation is an acute behavioural emergency that can lead to violence to others or to the patient himself if the event is not adequately managed. When this situation settles, an immediate intervention is required. The use of restraint alternatives on patients is the option, but only in this scenario, and when all other measures have been used up. Injectable drugs can be administered to non-cooperative patients and may carry a relatively rapid onset of action. Luis San will explain when to opt for injectable drugs in the management of agitation.
Historically, pharmacological treatments for agitation have been delivered using oral or intramuscular formulations. Although the types of medication available have not changed dramatically, different formulations with a faster onset have been recently developed to aid in treating this difficult condition. At the moment the available routes of administration are: sublingual, oral and intranasal formulations that avoid first-pass metabolism, and inhaled formulation that enters the alveoli and appears quickly in the arterial circulaton. Lakshmi Yatham will depict each pharmacological alternative considering the approvals of regulatory bodies suvh as FDA and EMA.
The traditional goal of ‘‘calming the patient’’ often has a dominant-submissive connotation, while the contemporary goal of ‘‘helping patients calm themselves’’ is more collaborative. In mild agitation, the act of verbally de-escalating a patient is the recommended form of treatment since the patient is enabled to rapidly develop his own internal locus of control. However, agitation sometimes tends to aggression and unfortunately this approach can not be taken requiring coercive interventions. Dieter Naber will show how to deal with an agitation episode weighing the ethical and legal issue that surround the situation.
Violent or threatening behaviour is a common reason for a visit to the emergency department, and among emergency psychiatric services. The prevalence of agitated or frankly violent patients may be as high as 10%. For both nurses and physicians, agitation is among the most fear-provoking aspects of psychiatry, with an average of 8 assaults occurring per year in a typical psychiatric emergency service. Florian Seemüller will give some guidelines about the best approach to agitation in the emergency room.
The agitated state is expressed on a spectrum of behaviors from mildly to severely agitated, with rapid fluctuations. De-escalation techniques should be considered as first option. They include promoting a non-threatening dialog, reduced stimulation, and offers supportive care as well as voluntary medications when agitation appears to be linked to a mental illness. This medication should be used to calm, not sedate, patients and when possible oral medication should be chosen rather than intramuscular, if and when the patient is cooperative. Roger McIntyre will discuss the current recommendations according to the currently available consensus guidelines.
Among psychiatric patients, agitation is a common warning signal that often precedes a relapse of the disorder and a probable future admission. Thus, it is recommended to be on the alert, notice and detect these episodes in outpatients so as to prevent admission, long stays and, consequently, the associated financial burden. De-escalation techniques play an essential role in these patients since the patient is collaborative and a noncoercive approach can be taken to treat agitation. Andrea Faggiolini will describe how to deal with this situation.