Agitation

Agitation – Treatment Options

Introduction
Agitation is a state of excessive psychomotor and emotional activity, often associated with restlessness, irritability, anxiety, or aggression. It can arise from multiple causes, including psychiatric conditions (schizophrenia, bipolar mania, anxiety disorders), neurologic disorders (dementia, delirium, traumatic brain injury), substance intoxication or withdrawal, and acute medical conditions (hypoxia, hypoglycemia, infections, electrolyte imbalances). The main goals of treatment are to ensure safety, identify and correct underlying causes, and manage acute symptoms.

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1. Non-Pharmacological Interventions

• Verbal de-escalation: Calm, non-threatening communication to reduce anxiety and aggression.

• Environmental modification: Reduce noise and stimulation, provide a safe and supportive setting.

• Reassurance and orientation: Especially helpful in delirium and dementia.

• Physical restraint: Used only as a last resort and for the shortest possible duration when the patient poses immediate danger.

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2. Pharmacological Management
(Choice depends on etiology and clinical urgency)

• Benzodiazepines

  • Lorazepam (1–2 mg IM/IV/oral, repeat if needed): Widely used for rapid calming.

  • Particularly effective in alcohol withdrawal, stimulant intoxication, and anxiety-related agitation.

  • Caution: may worsen delirium in elderly or cause respiratory depression.

• Antipsychotics

  • Typical antipsychotic:

    • Haloperidol (2–5 mg IM/IV/oral): Commonly used 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 avoid co-administration with benzodiazepines.

• Mood stabilizers

  • Valproate, lithium, carbamazepine – used in longer-term management for bipolar or recurrent agitation.

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3. Emergency Management (Severe or Dangerous Agitation)

• Rapid tranquilization is indicated when agitation poses immediate risk:

  • Combination of haloperidol + lorazepam is frequently used.

  • Continuous monitoring of airway, breathing, circulation, and vital signs is essential.

• Hospitalization and close observation may be required in severe psychiatric or medical cases.

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4. Addressing Underlying Causes

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

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

• Psychiatric: Initiate or optimize treatment for schizophrenia, bipolar disorder, anxiety, or depression.

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5. Long-Term Management

• Behavioral interventions and psychotherapy for recurrent or chronic agitation.

• Caregiver training in dementia and developmental disorders to manage early signs.

• Regular psychiatric or neurologic follow-up to adjust medications and prevent relapse.