Agitated State

Agitated State – Treatment Options

Introduction
Agitation is a state of heightened arousal characterized by restlessness, irritability, excessive motor activity, and sometimes aggression. It may occur in psychiatric disorders (e.g., schizophrenia, bipolar mania, delirium), neurological conditions (e.g., dementia, traumatic brain injury), substance intoxication or withdrawal, and medical emergencies (e.g., hypoglycemia, hypoxia, electrolyte imbalance). Management aims to ensure safety, identify and treat underlying causes, and provide symptomatic relief.

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1. Immediate Non-Pharmacological Measures

• Safety first: Remove dangerous objects, ensure adequate staff support in clinical settings.

• De-escalation techniques: Calm verbal reassurance, clear communication, non-threatening body language.

• Environmental control: Reduce noise, provide adequate lighting, and ensure personal space.

• Reorientation: Especially important in delirium and dementia (clocks, familiar staff, gentle reminders).

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2. Pharmacological Management
(Choice depends on underlying condition, severity, and patient profile)

• Benzodiazepines

  • Lorazepam (1–2 mg IM/IV/oral, repeat as needed) is widely used.

  • Effective in agitation due to alcohol withdrawal, stimulant intoxication, or acute anxiety.

  • Caution in elderly and those with respiratory depression.

• Antipsychotics

  • Haloperidol (2–5 mg IM/IV/oral) – effective for psychosis- or delirium-related agitation.

  • Atypical antipsychotics (olanzapine, risperidone, quetiapine, ziprasidone) – preferred for fewer extrapyramidal side effects.

  • Olanzapine (IM 10 mg) useful in acute agitation but should not be combined with benzodiazepines due to respiratory risk.

• Mood stabilizers (valproate, lithium, carbamazepine)

  • For long-term management of agitation in bipolar disorder or recurrent mood-related episodes.

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3. Treat Underlying Causes

• Medical triggers: Correct hypoglycemia, hypoxia, infections, electrolyte imbalance, or pain.

• Substance-related: Manage withdrawal syndromes (alcohol, benzodiazepines, opioids) or intoxication appropriately.

• Psychiatric illness: Initiate/adjust long-term therapies for schizophrenia, bipolar disorder, or depression.

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4. Emergency and Severe Agitation

• Rapid tranquilization may be required when de-escalation fails and patient poses immediate risk:

  • Haloperidol + lorazepam combination is common (synergistic effect, reduces required dose).

  • Continuous monitoring of vital signs and airway is mandatory.

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5. Long-Term and Supportive Management

• Behavioral therapy and anger management for recurrent agitation.

• Family and caregiver education on early signs of escalation and safe handling.

• Regular follow-up for psychiatric or neurologic disorders with medication adjustments as needed.