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4 AGITATIONS

CASE PRESENTATION

You receive a call late Saturday night from a local residential home

concerning a confused resident who is shouting and screaming

uncontrollably. The patient is described as a pleasant 84-year-old female

who is mildly forgetful but fully independent. She became confused earlier

today. Her daughter had visited her this afternoon and noted to the staff that her mother seemed more confused than usual. The patient was

drowsy earlier in the evening and slept for a few hours. Upon waing she

refused to stay in bed. She is presently waling up and down the corridor!

shouting! "You better get a doctor before it#s too late because $#m going to

have a baby.% She is pulling off her clothes and will not let the nurses put

her bac to bed. There have been no previous episodes of disturbed

behavior.

The patient is on no medications. & neurological consultation! performed

si' months ago! included (T scan! ))*! and blood wor. )arly mild senile

dementia of the &l+heimer type ,& was diagnosed.

Her vital signs this morning were/ temperature! 01.4o(2 3! 567172 heart

rate! 16! regular. The nurse has been unable to determine vital signs this

evening due to the agitated state of the patient. 9ver the telephone you

hear the patient shouting in the bacground! ":a! ma! ma;$ want my

mother!% and yelling at the nursing staff. The nurse re


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.=. :olloy

(onsider the following statements ,true or false

5. The most liely cause of this patient#s agitation is dementia! that is!

senile dementia of the &l+heimer#s type.

6. The underlying cause of agitation is usually identified in the ma>ority

of elderly demented patients who present with an acute onset.

0. History and physical e'amination is unliely to reveal any treatable

cause for this woman#s agitation.

4. This woman should be put in bed with restraints and bedsides to

prevent her from falling and hurting herself.

?. The most appropriate treatment would be to give haloperidol 7.6?-

5.7 mg $:! or thiorida+ine 56.?-?7 mg $: @4H! with review in the

morning.

1. FALSE

&gitation may be defined as "observed inappropriate verbal or motor

activity which cannot be e'plained by need or e'ternal need alone% A5B.

&gitated behavior is usually repetitive and fre


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discomfort that may be a result of obstruction! urinary retention! fecal

impaction! perforation! or biliary or urinary colic. Some patients with

dyspnea and confusion complain that they are being smothered. The

pacing of this patient also suggests that she is e'periencing physical

discomfort.

Table 4-1 Verbal and Physical Characteristics of Agitated Behavior

Repetition Abuse Behavior

Ferbal (alling out@uestions(omplaintsSingle =ordshrases

(ursingThreatsScreams

Strange noise*runts(oughs

hysical =alingacing=andering

ressingUndressingoundingGattling the bed

3itingEightingStriing out

Throwing ob>ect

3i+arre movementsTwitches

Table 4-2 Clinical eatures of !eliriu"

eatures in the presentation of an illness that "a#e deliriu" "ore li#ely$

Gapid onset of symptoms andor signsSymptoms and signs that fluctuate

Geduced awareness of environment:emory loss and disorientationresence of organic factor,s that may be related from history

physical e'am! or investigationsTwo or more of the following

perceptual disturbance ,delusions! ballucinationschange in psychomotor activitychange in sleep-wae cycleincoherent speech

&dapted from !iagnostic and %tatistical &anual of &ental !isorders. 0rd ed.!=ashington! (2 &merican sychiatric &ssociation! 587.


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This woman suffers from mild forgetfulness from senile dementia of

the &l+heimer#s type. &cute deterioration in her condition cannot be

e'plained by & alone. &l+heimer#s disease usually causes a gradual!

relentless deterioration in cognitive function over years. &n acute insult to

her nervous system in the most liely cause of her confusion and agitation!

for e'ample! hypo'ia! infection! dehydration! stroe! myocardial infarction!

metabolic abnormality! or drug-induced delirium ,Table 4-0.

2. TRUE

&gitation is not a diagnosis but a symptom of an underlying abnormality. $f

the underlying cause of agitation is identified


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48 (ommon Sense *eriatrics

Table 4-' Causes of !eliriu" in the (lderly

1) !rugs &ny drug can cause delirium in theelderly but especially drugs withanticholinergic properties.igitalis! sedatives! levodopa!steroids! antihypertensives!anticonvulsants! cimetidine! drugwhithdrawal

?. Central nervous syste" *C+%,Subdural hematoma! stroe! transientischemic attacs ,T$&! epilepsy!neoplasm! infection

) &echanical Eecal impactionUrinary retention

.) (nviron"ental &ny change in environment

2) Cardiovascular syste" *CV%,

:yocardial infarction! congestiveheart failure &rrythmias

/) 0nfection

Urinary tract3iliary tract

') &etabolic ehydration)lectrolyte abnormalityHypothyroidismHyperthyroidismiabetes mellitusGenalliver abnormalitiesIutritional deficiencies

) e"atologic &nemia! especially following anacutesubacute bleed 356 deficienty:yeloma

13) ther *iant cell arteritis(oncussion without subdural &lcohol withdrawal or

4) Respiratory neumonia

&cute e'acerbation of chronic9bstructive pulmonary disease

$nto'ication9ver-the-counter medications

aintEracture

3. FALSE

Ta#ing the istory

$t is important to determine if the patient has had her temperature taen

regularly in the past few days in order to determine a baseline. $f the

patient normally has temperature of 0?.? J 0D.7 o( and it is 01.?o( today!

this represents a significant increase in body temperature.

Iote if any new medications have been started recently! or if there

have been changes in the doses of maintenance medications.

:edications! which fre


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the elderly. $s her urine cloudy or foul smellingK Has she had new

episodes of incontinenceK Has she fallen recentlyK $s the patient in bed

and refusing to get outK $t is easy to overloo a fractured hip! and the

possibility of subdural hematoma must always be considered. (onsider a

fracture! no matter how trivial a history of falls or in>ury.

&s if she has been drining more than usual or if she is gaining

weight. &re her anles more swollen than usualK $t is very important to

ascertain if she has had similar episodes of confusion and agitation in the

past! and if so! how they were investigated! diagnosed! andor treated.

Clinical (5a"ination

& general e'amination should be performed on all agitated or confused

patients. Tae your time taling to the patient to develop confidence and

trust before you begin your e'am. )stablish physical contact at the start

by stroing her hair! holding her hand! or ad>usting her clothing. )'plain

that you are the doctor and that you have come to help. 3e patient and go

slowly and gently. &gitated patients forget who you are and may thin you

mean them harm. $t may help to wear a white coat in order to alleviate her

an'iety.

*eneral inspection may reveal anemia! cyanosis! pigmentation!

bruising from falls! edema! tachypnea! neglect! or weaness on one side

from a recent stroe! dehydration! or evidence of hypothyroidism. Try to

get vital signs if possible. )'amine the cardiovascular system for heat rate!

rhythm! elevated >ugulovenous pulse ,LF! or evidence of failure. ercuss

the chest carefully since the patient may not cooperate and breathe when

you want. ullness in a base is easier to find than decreased breath

sounds in an uncooperative patient. ullness in both bases with an

elevated LF is very suggestive of cardiac failure.

$n this case the patient believes she is going to have a baby. This is

very significant and should prompt you to e'amine her abdomen carefully.

&n agitated patient will not locali+e pain in the abdomen but may display


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rigidity and guarding over the affected viscus. Misten for bowel sounds. $t

they are increased! get a straight abdominal film to help in the diagnosis of

obstruction. $f they are absent! get a straight film and surgeon. &lways do

a rectal e'am.

Gectal e'amination may reveal fecal impaction! evidence of rectal

bleeding! or prostatic hypertrophy in males. Eecal impaction may cause

confusion and agitation in the elderly. Urinary retention is also commonly

overlooed as a cause of confusion with agitation in elderly patients. :en

with prostatic hypertrophy are particularly at ris. $f you have any doubts!

especially in obese patients! catheteri+e them to chec the residual

volume. (atheters should be removed immediately and not left in situ!

since agitated patients do not tolerate catheters! and it can even mae

them worse.

$n-and-out catheteri+ation serves two purposes/

5. To rule out urinary retention! and

6. To get a catheter specimen of urine for routine microscopy and

culture.

9n e'amination of the nervous system! loo closely for locali+ing or

laterali+ing signs. (hec for nec stiffness! tone! and refle'es and do the

plantar responses. $f you can! observe the fundi for papilledema2 however!

funduscopic e'amination is usually impossible in agitated patients.

0nvestigations

$f after your e'amination you still cannot diagnose the cause of the

agitated patient#s confusion! some simple tests may help. Hemoglobin and

complete blood count will detect anemia or leucocytosis if they are

present. 3lood sugar! electrolytes! urea! and creatinine will detect acute

renal failure! hyponatremia! acidosis! or glucose abnormalities. $t there is

some concern that the patient has intra-abdominal pathology! order liver

en+ymes and a serum amylase. 3e sure to chec thyroid function since


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hypothyroidism or thyroto'icosis are easily overlooed in the elderly due to

atypical presentations.

&n )(* is mandatory. :yocardial infarction can be "silent% and may

present with confusion in the elderly. o a chest '-ray to rule out

pneumonia or cardiac failure! and do a flat plate! erect abdomen! andor

ultrasound if you suspect intra-abdominal pathology.

(hec the patient for recent fracture. (onsider an '-ray of lumbo

sacral spines andor hip as patients with vertebral fractures may complain

of plain in the abdomen or lower limbs! which can be misleading.

&ll patients who present with acute delirium should have blood

cultures done since sepsis in the elderly may not cause fever or

leucocytosis. ehydration commonly cause confusion! so if you are in

doubt! give intravenous fluids. This may be easier said than done in

combative patients. $n all cases! staff should be encouraged to ensure

adeust fell from the

bed.

$f a patient becomes e'tremely agitated in bed and attempts to

climb out over the sides! remove the bed and place the patient on a

mattress on the floor. 3edsides often mae agitation worse! because

patients may feel imprisoned! which increases their paranoia! frustration!

and confusion.

$n this case! you might wish to call the patient#s daughter and as

her to come in and sit with her mother. Eamily members can supply


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