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INTRODUCTION

Key Clinical Questions

  • image When is agitation due to delirium versus dementia?

  • image What are the most common causes of agitation in hospitalized older patients?

  • image What are the best nonpharmacologic techniques to manage agitation in older patients?

  • image Which medications are best for treating agitation in older patients?

  • image What are the potential complications of agitation?

  • image How can agitation due to delirium or dementia be prevented?

It is horrible to see an agitated patient in the hospital, even worse to try to care for one, and probably worst of all to be an agitated patient. There is often significant internal and external pressure on hospital staff to “control the patient,” and this can lead to thoughtless action. But the best (and often the only) way to address the agitation is to think carefully about the problem before acting. This chapter will attempt to present a thoughtful approach to agitation in hospitalized older adults.

Agitation in an older patient can take multiple forms: aggression, psychomotor agitation, and psychosis. Aggression refers to verbal or physical hostility, often involving resistance to care. Psychomotor agitation includes restless motor activity such as pacing, rocking, or other purposeless movement, as well as sleep disturbances, and repetitive vocalizations. Psychosis includes delusions, hallucinations, and misidentifications. Patients can experience any combination of these symptoms.

EPIDEMIOLOGY OF AGITATION IN OLDER HOSPITALIZED PATIENTS

Agitation is a common symptom in older hospitalized adults. It may be present on admission, or develop during the hospital stay. Reports of the incidence of agitation in this population vary widely, but may be as high as 50% or more in older ICU patients. The risk of behavioral disturbance is highest for patients who have cognitive impairment on hospital admission.

IMPACT OF AGITATION IN HOSPITALIZED PATIENTS

Agitation causes significant distress for patients, caregivers, and hospital staff. Hallucinations and delusions have been associated with the highest levels of anguish for patients, but agitation and aggression were most disturbing for hospital staff.

In addition to psychological distress, agitation in hospitalized patients is associated with higher risks of death and institutionalization, longer length of hospital stay, and increased health care costs. It increases the risk of injury to patients and staff, as well as the risk of complications such as falls, restraint-related injuries, and unintended removal of indwelling catheters and tubes.

If delirium is the cause of a patient’s agitation, outcomes are particularly poor. Delirium increases mortality rates for ICU patients two- to four-fold, and 1.5-fold for general medicine patients. Multiple studies have also shown a risk of prolonged or permanent cognitive impairment after an episode of delirium, raising significant concerns about the possibility that delirium may actually lead to dementia in some cases.

DIFFERENTIAL DIAGNOSIS

Agitation can have multiple causes in an older hospitalized patient. The most common causes are delirium, dementia, ...

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