What is the evaluation and management approach for psychomotor agitation?

Evaluation and Management of Psychomotor Agitation

The evaluation of psychomotor agitation requires immediate concurrent assessment and management, prioritizing identification of life-threatening medical causes through focused history, physical examination with vital signs, point-of-care glucose testing, and targeted laboratory workup, while simultaneously employing verbal de-escalation as first-line management before considering pharmacological interventions. 1

Initial Assessment: Rule Out Medical Causes First

Medical causes must be systematically excluded before attributing agitation to psychiatric illness, as undiagnosed medical conditions can be life-threatening if missed. 2, 1

Critical History Elements

• Medication review focusing on anticholinergic agents, sympathomimetics, or drug interactions that can precipitate or worsen agitation 1
• Substance use screening to identify intoxication or withdrawal states that mimic psychiatric symptoms 2, 1
• Pain assessment, as undiagnosed pain is a disproportionate contributor to agitation, particularly in patients with communication difficulties 1, 3

Physical Examination Priorities

• Vital signs monitoring is mandatory, as abnormal vital signs suggest medical illness requiring immediate attention 1
• Cognitive function assessment to distinguish delirium from primary psychiatric disorders 2
• Focused neurological examination to identify focal deficits suggesting structural brain pathology 4

Essential Laboratory Workup

• Point-of-care glucose testing for all patients immediately 4
• Comprehensive metabolic panel including glucose and electrolytes to identify metabolic derangements 1
• Urinalysis to rule out urinary tract infection, especially in elderly patients 1, 3
• Toxicology screen if substance use is suspected based on clinical presentation 1

Common Medical Causes to Exclude

The differential diagnosis includes metabolic, neurologic, infectious, toxicologic, and psychiatric etiologies 4:

• Hypoxia, hypoglycemia, and electrolyte disturbances 3
• Infections, particularly urinary tract infections and pneumonia in elderly patients 3
• Urinary retention and constipation, especially in patients unable to communicate discomfort 3
• Anticholinergic toxicity, where antipsychotics can worsen agitation and should be avoided 1
• Delirium masquerading as psychiatric illness 2

Management Algorithm: Stepwise Approach

Step 1: Verbal De-Escalation (Always First-Line)

Non-pharmacological interventions must be attempted before pharmacological management unless there is imminent risk of harm. 1, 5

• Use calm tones, simple one-step commands, and gentle touch for reassurance 3
• Provide adequate lighting, reduce noise, and ensure effective communication 3
• Allow adequate time for the patient to process information before expecting a response 3

Step 2: Pharmacological Intervention (When De-escalation Fails)

Pharmacological interventions should only be used when the patient is severely agitated, threatening substantial harm to self or others, and behavioral interventions have failed. 1, 3

For Undifferentiated Acute Agitation in Adults:

• First-line options: Haloperidol 5 mg IM or lorazepam 2-4 mg IM 5
• Combination therapy of parenteral benzodiazepine (lorazepam) and haloperidol may produce more rapid sedation than monotherapy 5
• For cooperative patients: Oral lorazepam plus oral risperidone is preferred over haloperidol 5

For Elderly Patients with Dementia:

• Low-dose haloperidol (0.5-1 mg orally or subcutaneously) is first-line for severe agitation after behavioral interventions have failed 3
• Risperidone 0.5-2 mg/day orally is an alternative, but avoid doses above 2 mg/day due to extrapyramidal symptoms 3
• Avoid benzodiazepines as first-line for agitated delirium except in alcohol or benzodiazepine withdrawal, as they can increase delirium incidence and cause paradoxical agitation in 10% of elderly patients 3

For Chronic Agitation in Dementia:

• SSRIs are preferred: Citalopram 10 mg/day (maximum 40 mg/day) or sertraline 25-50 mg/day (maximum 200 mg/day) 3
• Assess response within 4 weeks; if no clinically significant response, taper and withdraw 3

Step 3: Physical Restraints (Last Resort Only)

Physical restraints should be minimized and used only as a last resort, for the shortest duration, and under strict medical supervision. 5, 6

Critical Pitfalls to Avoid

• Never rely solely on blood alcohol level; assess cognitive function individually if substance use is involved 1, 5
• Do not use antipsychotics in anticholinergic toxicity, as they can worsen agitation 1
• Avoid continuing antipsychotics indefinitely in elderly patients; review need at every visit and taper if no longer indicated 3
• Do not prescribe antidepressants without screening for bipolar disorder, as this can precipitate mania 1
• Never assume psychiatric cause without medical workup, as reversible medical causes must be identified first 1

Special Population Considerations

Elderly Patients Over 75 Years:

• Respond less well to antipsychotics, particularly olanzapine 3
• All antipsychotics increase mortality risk in elderly patients with dementia; discuss this risk with patients or surrogates before initiating treatment 3
• Start with lowest effective dose and evaluate response daily with in-person examination 3

Pediatric Patients:

• Require thorough diagnostic evaluation before initiating medication therapy 7
• Consider increased potential for weight gain and dyslipidemia with atypical antipsychotics 7

Ongoing Monitoring

• Daily reassessment of the need for continued antipsychotic treatment with in-person examination 3
• Discontinue treatment as soon as possible once agitation resolves 3
• Monitor for adverse effects including QT prolongation, dysrhythmias, hypotension, falls, and metabolic changes 3