Agitation and Aggression

 

Agitation and Aggression 

Perhaps the most problematic behaviour in the management of patients with a mental illness and /or mental health issues is the potential for agitation and aggression and in some cases the enactment of these behaviours. Underlying mental illness and personality traits often make it difficult to deal with episodes of aggression. Currently, instances of aggression rely heavily on medical staff to prescribe appropriate medication to primarily manage the patient esculating anxiety and arousal and secondly, to sedate patients in the event that their behaviour esculates to physical violence. This can be problematic both for the patient and the health professional. Sullivan (1998) has suggested that mental health nurses confront potentially hostile and aggressive patients on a regular basis however, recent developments on this topic suggests that the issue of workplace aggression and violence are now part of the broader discussion (Beech and Bowyer, 2004).

Aetiology of Dementia

 

Aggression can be verbal and/ or physical and is most likely in the acute phase of psychosis especially if the patient is experiencing auditory hallucinations or paranoid delusions. Anger may also be a response to environmental factors but combined with personality traits and the emotional stresses associated with hospitalisation, the expression of these feelings may be exaggerated or distorted (Orygen Research Centre, 2004; Hill, 2000; McGeorge and Landow, 2000).

 

A contributing factor to aggression is often agitation which is a degree of psychological and motor hyperactivity. It is symptomatic of the patient’s underlying psychological and/or physical disturbance and is often seen in acutely psychotic and dementing patients. It is a major contributing factor to aggression. Most patients will become anxious and upset when faced with threats to their health status and it is prudent to manage this anxiety in a timely and expedient mannner to prevent escalations. Unfortunately, the staffs who are likely to spend the most time are usually the most junior who (i) lack the experience in identifying potential agitation and (ii) are unfamiliar with the appropriate pharmacological intervention required. Senior medical staffs are often not available due to the demands on their time and expertise. This often means that there is a time delay before appropriate management is instigated and thus in many instances the patient’s behaviour has escalated.

 

People may express uncontrolled agitation or aggression due to an uncontrolled primary psychiatric condition such as mania, bipolar disorder, or psychosis or an untreated medical condition affecting the brain as an infection, tumour, or metabolic disease. In addition, agitation and aggression can occur because of medication toxicity caused by an excessive amount or variety of medicines ingested and may occur with alcohol or drug intoxication and withdrawal.

Assessment

 

Get what history is available from relatives, bystanders or staff if in a clinical setting (particularly history of substance ingestion, current previous medications, current physical illnesses).

Conduct whatever physical examination is possible. This may only be observation from a distance. Observe for impaired breathing, skin discoloration, and other signs of physical illness.

 Treatment of Sleep Disturbance

 

Counselling Interventions for Agitation and Aggression

 

Alert and elicit the help of other healthcare staff or authorities (appoint another present on the scene to assist with the communication if necessary).

Take distance and help others remain a safe distance from the agitated person.

Safety – if possible, try to remove from the environment items that are potentially hazardous to safety (i.e. glass or other sharp dangerous objects).

Remain calm and confident. Listen, pay attention, do not argue.

If possible (without subjecting yourself to harm) try to talk down or deescalate the individual by using a soft speech tone, expressing support and reassurance, and minimizing physical gestures.

 

 Medication Therapy for Agitation and Aggression

 

The objectives of management ought to be;

 

• To reduce the patient’s level of agitation and the distress experienced by the patient.

•  To reduce the potential for harm to the patient or others.

•  To reduce the potential for damage to property.

• To enable appropriate medical / mental health treatment to be administered. Benzodiazepines[1] may be used (e.g. lorazepam 0.5-2mg every 4 hours until symptoms subside) but the patient should be monitored for disinhibition or uninhibited behaviour that has been associated with these drugs. If agitation is severe and persistent, a low dose high-potency antipsychotic (e.g. haloperidol 0.5-5mg po or IM every 4 hours until symptoms subside) may be used. Drug therapy, if used, should target control of specific symptoms. Rapid calming or tranquilizing of a patient is usually achieved with a benzodiazepine or an antipsychotic (typically a conventional antipsychotic, but a 2nd-generation drug may also be used) administered IM or IV (see Table 15.1.2.1: Approach to the Patient With Mental Complaints: Drug Therapy for Agitated Psychiatric Patients). Benzodiazepines act more quickly (within a few minutes) but may cause confusion and often have erratic IM absorption. Sometimes a combination of both drugs is most effective.

Precautions

 

·       Resuscitation and experienced staff need to be available at all times to ensure first-line management in the event of respiratory depression.

·       The patient’s respiratory function needs to be monitored when benzodiazepines are administered.

·       Considerations of the patient’s usual medications are likely to contribute to the patient’s mental state.

Ongoing Management

 

1.     Once patient’s arousal has subsided provide the patient with the opportunity to discuss / de-brief about incident and attempt to discover the reason for patient’s arousal. This may include utilising skills such as listening skills and negotiation techniques.

2.     Ensure that a pre-emptive management plan is in place for subsequent episodes of violence.

3.     Provide opportunity for staff to ventilate / de-brief post incident.

4.     If the management of the underlying cause of the aggression is beyond the scope of practice of the health worker refer to an appropriate mental health practitioner.