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  1. When is agitation due to delirium versus dementia?

  2. What are the most common causes of agitation in hospitalized older patients?

  3. What are the best non-pharmacologic techniques to manage agitation in older patients?

  4. Which medications are best for treating agitation in older patients?

  5. What are the potential complications of agitation?

  6. 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 aggression often involving resistance to care. Psychomotor agitation includes restless motor activity such as pacing, rocking, or other purposeless movement, as well as sleep disturbances, repetitive vocalizations, and restlessness. 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 52% 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 distress for patients, but agitation and aggression were most distressing for hospital staff.

In addition to psychological distress, agitation in hospitalized patients is associated with increased 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.

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

Delirium

Delirium is present in 14–24% of patients admitted to the hospital, and arises in 6–56% of patients during hospitalization. The prevalence of delirium increases with age. Among older adults, it can be the sole presenting symptom for medical illness such as infection or cardiac ischemia. The diagnosis of delirium is made from bedside observation, and although the diagnostic criteria are still evolving, most agree that it consists of an acute change in cognition that results in ...

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