Agitation
Agitation is a state of severe restlessness or inner tension that can affect anyone, from brief episodes during stressful moments to persistent symptoms that signal an underlying medical condition.
Table of contents
- What is agitation?
- Signs and symptoms
- What causes agitation?
- When to seek medical help
- How is agitation diagnosed?
- Treatment options
- Agitation in dementia and Alzheimer’s disease
What is agitation?
Agitation is a feeling of irritability, mental distress or severe restlessness. It may feel like inner tension. And it often involves involuntary (out of your control) behaviors that serve no clear purpose, like fidgeting. Agitation can range from mild to severe and can develop rapidly or slowly. It can be brief or long-lasting.[1]
Agitation can develop from a wide range of medical conditions. But brief, mild episodes of agitation are also a normal part of being human. Stressful or frustrating situations can make you feel agitated.[1] It’s pretty common to feel unsettled if you have hormone problems or a psychological condition.[3]
Researchers don’t know the exact cause of agitation. But they think it involves an imbalance of certain neurotransmitters (chemical messengers), like dopamine, serotonin and others.[1]
Signs and symptoms
Examples of behaviors and characteristics of agitation include:[1]
- Being uncooperative
- Clenching your fists or wringing your hands
- Difficulty focusing
- Excessive talking
- Fidgeting (purposeless movements)
- Hostility
- Inner restlessness
- Lack of impulse control
- Pacing
- Violent or disruptive behavior
Early signs of agitation can also include clenching your fists, outbursts, picking or pulling at your hair, skin, or clothes, shuffling your feet, an urge to move (maybe with no purpose), uneasiness, crankiness, and stubborn behavior, often toward caregivers.[3]
Not everyone experiencing agitation will have all these behaviors or characteristics. You may be able to recognize that you’re agitated, or you may not be aware of it.[1]
Sometimes, people express agitation as aggression. This can be verbal or physical and be directed at objects or other people. In some cases, agitation may lead to self-harm. An agitation crisis happens when a person is so agitated that they could be dangerous to themselves or others.[1]
Unlike aggression, agitation typically involves unintentional behaviors that come from a feeling of inner restlessness. It’s also different from akathisia, a movement disorder that’s often caused by antipsychotic medication.[3]
What causes agitation?
Agitation can develop due to many issues and situations. It can have a multifactorial etiology (set of causes) that is often difficult to identify.[2]
Agitation can develop from chronic (long-term) conditions, complications of a sudden (acute) illness, and side effects of medications. It’s also common to experience mild, brief agitation without having an underlying condition.[1]
Some of the most common medical causes include:[1]
- Delirium
- Dementia (like Alzheimer’s disease)
- Infections (like UTIs), especially in people over 65
- Electrolyte imbalances
- Hyperthyroidism
- Physical trauma, especially head trauma
- Postictal seizure state (the period that begins when a seizure ends)
- Sepsis
- Substance intoxication or withdrawal (like alcohol, nicotine, marijuana, hallucinogens, opioids and others)
- Toxin exposure (poisoning)
Agitation can be a part of certain mental health and neurodevelopmental conditions, like:[1]
- Autism spectrum disorder
- Anxiety disorders
- Bipolar disorder
- Depression
- Schizophrenia
Experiencing intense stress or trauma can trigger or escalate agitation. New environments — like being in a hospital — can also trigger agitation or make it worse.[1]
In people with brain injury, agitation can be caused by pain, unmet basic needs like positioning or personal care, environmental issues such as too much noise from TVs and radios, too many requests at one time from caregivers, room temperature being too hot, too many lights turned on, or a particular request or procedure that is disliked.[6]
When to seek medical help
If agitation is interfering with your day-to-day life, relationships or work, you should see a healthcare provider for help. If agitation escalates to aggression, suicidal behaviors or violence, you should seek immediate medical help.[1]
It’s very important to seek medical help if you or a loved one are experiencing frequent or worsening agitation. Agitation may lead to an increased risk of suicide and violence.[1]
If you feel agitated a lot and you don’t know why, talk to your doctor. They can give you tests to find out what’s causing the condition. And if you or a loved one is thinking about suicide or hurting yourself, tell someone right away. You can reach out to a friend, family member, or a health care professional. You can also go to the emergency room, or call or text the 988 Suicide & Crisis Lifeline any time, day or night.[3]
How is agitation diagnosed?
To identify the underlying cause of your agitation, your doctor will likely start by asking you questions about your medical history and lifestyle, along with other symptoms you may be experiencing.[17]
If they suspect that you have an underlying mental health condition, they may refer you to a mental health specialist for evaluation.[17]
If they think that you have an underlying physical condition, they may conduct one or more diagnostic tests. For example, they may collect a sample of your blood to check for hormonal imbalances, collect a sample of your urine or spinal fluid to check for abnormalities. In some cases, they may order a CT scan or MRI scan of your brain.[17]
A doctor can give the person with agitation a medical exam to look for any physical problems that may cause agitation, such as pain, depression, or stress, too little rest or sleep, constipation, sudden change in a well-known place, routine, or person, a feeling of loss, too much noise or confusion, or too many people in the room.[13]
Early assessment should include point-of-care glucose, oxygen saturation, and urine toxicology screen.[2]
Treatment options
Treatment strategies are guided by the specific etiology of agitation. Effective management prioritizes diagnosing and treating acute medical conditions while ensuring the safety of the patient, staff, and environment.[2]
Your healthcare team can work with you to address agitation and reduce triggers of it. This may include strategies like simplifying your routine and environment. Medication may also help.[1]
What can you do to reduce restlessness and uneasy feelings? Listen to soothing music. Allow yourself to cry. Talk with a loved one or other trusted person about your feelings. Keep the room peaceful and quiet. Turn down bright lights.[12]
Family and caregivers can help by treating the restless or agitated loved one with respect and patience, providing a calm, relaxed setting, talking in a calm voice, helping them change positions, placing pillows against the bedside rails for safety, and making sure someone is always with them.[12]
Non-medication approaches
Approaches that don’t involve coercion are usually the best way to diffuse tense situations.[4] Effective de-escalation techniques can help ensure patient and staff safety.[2]
Here are some ways you can help minimize and cope with agitation: Be patient and try not to show frustration. Speak calmly. Listen to the person’s concerns and avoid arguing. Reassure the person that they are safe, and that you are there to help. Use other communication methods besides speaking, such as gentle touching, to help them feel less threatened.[13]
Pharmacological treatment
There are instances where agitation becomes so extreme that medication is needed to ensure everyone’s safety.[4] The practice of treating agitation on an acute care basis is also referred to as rapid tranquilization.[7]
A variety of psychotropic drugs and combinations can be used. The decision is usually made based on availability and the clinician’s experience. Common medications include:[7]
- The typical antipsychotic haloperidol (alone or in combination with antihistaminergic and anticholinergic drugs such as promethazine)
- Benzodiazepines like lorazepam, diazepam and midazolam
- Atypical antipsychotics including aripiprazole, ziprasidone, and olanzapine
The combination of haloperidol and promethazine combines the sedative properties of the antihistamine with the more selective calming action of haloperidol, with a reduced risk of extrapyramidal effects compared to haloperidol alone because of the anticholinergic properties of promethazine.[7]
Loxapine (10 mg) demonstrated superior efficacy over 5 mg in reducing agitation within 120 minutes, with inhaled formulations providing rapid relief in patients with acute psychosis. Aripiprazole was effective and caused less sedation compared to Olanzapine. Ziprasidone, administered intramuscularly, offered a faster onset and was better tolerated than Haloperidol. Lorazepam proved effective with fewer side effects than antipsychotics.[9]
Among the most frequently used medications in reviewed studies were haloperidol, olanzapine, and lorazepam.[9] US Food and Drug Administration–approved treatments with alternative routes of delivery now include inhaled loxapine powder and dexmedetomidine sublingual film.[10]
Agitation in dementia and Alzheimer’s disease
Agitation is a common part of dementia and Alzheimer’s disease. Changes to your brain make it difficult to process new information. And dementia causes an imbalance of neurotransmitters, too. These can both trigger agitation.[1]
About 33% of dementia patients living at home and 80% in care facilities exhibit agitated or aggressive behavior.[4]
Causes of agitation and aggression in people with Alzheimer’s can include pain, depression, or stress, too little rest or sleep, constipation, sudden change in a well-known place, routine, or person, a feeling of loss, too much noise or confusion, being pushed by others to do something when Alzheimer’s has made the activity very hard or impossible, feeling lonely and not having enough contact with other people, certain medications or interactions between two medications.[13]
Agitation and anxiety in people with Alzheimer’s may be caused by a number of different medical conditions, medication interactions or by any circumstances that worsen the person’s ability to think. Ultimately, the person with dementia is biologically experiencing a profound loss of their ability to negotiate new information and stimulus.[14]
Your healthcare team can work with you and your loved ones to address agitation in dementia and reduce triggers of it. This may include strategies like simplifying your routine and environment. Medication may also help.[1]
