Agitation is a state of severe restlessness and inner tension that can affect anyone, often signaling an underlying issue when it occurs frequently or intensely. Understanding its causes, recognizing its signs, and knowing when to seek help can make a significant difference in managing this challenging condition.

What Is Agitation?

Agitation is a feeling of severe restlessness, irritability, or inner tension that can make a person feel extremely unsettled. It goes beyond the occasional frustration or stress that everyone experiences from time to time. When someone is agitated, they may feel like they cannot calm their mind or sit still, and this feeling often shows up through various physical behaviors and emotional responses.^[1]

The experience of agitation can range from mild to severe, and it can develop quickly or gradually over time. Some episodes last only a few minutes, while others may continue for extended periods. While brief, mild episodes of agitation are a normal part of being human and can happen when we face stressful or frustrating situations, frequent or severe agitation often indicates that something more serious is going on.^[1]

Agitation often involves behaviors that seem purposeless or repetitive. A person might pace back and forth, fidget constantly, or perform the same movements over and over without a clear goal in mind. These behaviors are typically involuntary, meaning the person cannot easily control them even when they want to stop.^[2]

Recognizing the Signs and Symptoms

Agitation can show itself in many different ways, and not everyone will experience all the same signs. Some people may be aware they are feeling agitated, while others might not recognize what is happening to them. The physical and behavioral signs of agitation can be quite noticeable to family members and caregivers.^[1]

Early signs of agitation often include physical behaviors like clenching fists or wringing hands repeatedly. A person might pick or pull at their hair, skin, or clothing without realizing they are doing it. Shuffling feet, constant pacing, or an overwhelming urge to move around with no clear purpose are also common indicators. The person may appear unable to stay in one place or sit down for any length of time.^[3]

Emotional and behavioral signs are equally important to recognize. Agitated individuals may become excessively cranky or irritable, even over small things. They might display hostile attitudes, become uncooperative with others, or have sudden outbursts of emotion. Some people experience difficulty focusing or concentrating on tasks, while others may talk excessively or struggle to control their impulses.^[1]

As agitation worsens, the signs can become more intense and concerning. Increased restlessness may progress to disruptive or even violent behavior. Some individuals express their agitation through aggression, which can be verbal or physical and may be directed at objects, other people, or even themselves. In more severe cases, agitation can involve moaning or crying out, making facial grimaces or clenching teeth, or attempting to remove clothing or medical equipment.^[6]

In people with serious illnesses or those nearing the end of life, agitation can take on a specific form called terminal agitation or terminal restlessness. This occurs in the final days or weeks of life and may include symptoms like constant movement in bed, trying to get out of bed repeatedly, confusion, disorientation, or inability to communicate clearly. During these times, the person may not sleep much and can appear unable to calm down despite efforts to comfort them.^[15]

Epidemiology and Patterns

Agitation appears across different populations and settings, though determining exact numbers can be challenging because the condition varies so much depending on age, underlying causes, and circumstances. The patterns of agitation differ significantly based on where and in whom it occurs.^[4]

In long-term care facilities, where researchers can track behavior patterns day to day, agitation is particularly common among people with dementia (a condition that affects memory and thinking abilities). About 33 percent of dementia patients living at home and approximately 80 percent of those in care facilities show signs of agitated or aggressive behavior. This makes agitation one of the most frequent and challenging symptoms for caregivers of people with dementia to manage.^[4]

Age plays a role in how often agitation occurs and how it presents. Younger adults, particularly those between 16 and 19 years old, tend to show more aggression compared to slightly older adults aged 20 to 26. However, in older populations, especially those over 65, agitation often appears as a symptom of infections like urinary tract infections, or conditions like delirium, which is a state of sudden confusion and disorientation.^[4][1]

Among people with intellectual disabilities, about 10 to 20 percent may display challenging behaviors that include agitation, along with self-harm and aggression. People with mental health disorders also experience higher rates of agitation compared to the general population. For instance, individuals with conditions like schizophrenia or bipolar disorder may experience agitation as part of their illness, particularly during acute episodes.^[4]

In emergency departments and psychiatric hospitals, agitation is a common presenting problem. Studies show that aggression was the main reason for approximately 26 percent of psychiatric emergency department visits. In psychiatric inpatient wards, patients with conditions like schizophrenia, bipolar disorder, and other psychotic disorders account for the majority of aggressive incidents. More than 90 percent of patients admitted to psychiatric hospitals who experienced agitation had moderate to severe levels of aggressive behavior during their episodes.^[10]

Causes of Agitation

Agitation can develop from a wide range of medical conditions, situations, and personal circumstances. Understanding what triggers agitation is important because treatment depends heavily on identifying and addressing the underlying cause. The root causes can be physical, psychological, or a combination of both.^[1]

Researchers believe that agitation involves an imbalance of certain neurotransmitters, which are chemical messengers in the brain. These include dopamine, serotonin, and others that help regulate mood, behavior, and how we respond to our environment. When these chemicals become unbalanced, it can trigger feelings of inner tension and restlessness that manifest as agitation.^[1]

Many chronic, long-term conditions can lead to agitation. Dementia and Alzheimer’s disease are particularly common causes, as changes in the brain make it difficult to process new information and create neurotransmitter imbalances. Mental health conditions also frequently involve agitation as a symptom. These include anxiety disorders, depression, bipolar disorder, schizophrenia, and autism spectrum disorder. In these cases, agitation may come and go or worsen during particular phases of the illness.^[1][3]

Sudden, acute medical problems can trigger agitation as well. Infections, especially in people over 65 years old, commonly cause agitation. Urinary tract infections are a frequent culprit in older adults. Other acute causes include physical trauma, particularly head injuries, and serious systemic conditions like sepsis, which is a life-threatening response to infection throughout the body. An overactive thyroid gland, called hyperthyroidism, can also make people feel agitated. Additionally, imbalances in electrolytes, which are minerals in the blood that help regulate important body functions, can lead to agitation.^[1]

Certain medical states create specific types of agitation. Delirium, a sudden state of confusion and disorientation, frequently includes agitation as a main feature. The period after a seizure ends, called the postictal state, often involves agitation and confusion as the brain recovers. Exposure to toxins or poisoning can also cause agitation through their effects on the nervous system.^[1]

Substances and medications play a significant role in causing agitation. Using drugs or alcohol can lead to agitation while under their influence. Equally problematic is withdrawal from substances like alcohol, nicotine, marijuana, hallucinogens, or opioids, which can trigger severe agitation as the body adjusts to their absence. Some medications prescribed for other conditions may have agitation as a side effect.^[1][3]

Environmental and situational factors should not be overlooked as causes of agitation. Being in unfamiliar surroundings, such as when admitted to a hospital, can trigger or worsen agitation. Changes to familiar routines or environments can be particularly distressing for people with dementia or cognitive impairment. Intense stress or trauma can trigger agitation episodes. Even basic unmet needs, like pain, poor positioning, discomfort, constipation, or lack of sleep, can manifest as agitation, especially in people who have difficulty communicating their needs.^[1][6]

Risk Factors

Certain groups of people and specific circumstances increase the likelihood that someone will experience agitation. Understanding these risk factors helps identify who might need closer monitoring or preventive care.^[4]

Having a mental health condition significantly increases the risk of experiencing agitation. People with schizophrenia, bipolar disorder, anxiety disorders, or depression are more prone to agitated states, particularly during acute phases of their illness. Studies have shown that while mental disorders increase the risk of violent or aggressive behavior, they are not the sole cause, and many other factors contribute. However, the combination of a mental disorder with substance use, such as alcohol, dramatically increases the risk of agitation and aggressive behavior.^[4]

Age creates different risk profiles. Older adults, especially those over 65, face higher risks of agitation due to increased likelihood of having dementia, experiencing infections, or developing delirium. Younger adults between 16 and 19 tend to show more aggressive forms of agitation compared to older young adults. People with intellectual disabilities face elevated risks throughout their lives, with about 10 to 20 percent experiencing challenging behaviors including agitation.^[4]

Cognitive impairment and dementia represent major risk factors. As mentioned in the epidemiology section, the majority of people with dementia in care facilities experience agitation. The progressive changes in the brain that occur with dementia make it increasingly difficult to process information, communicate needs, and regulate emotions, all of which contribute to agitation risk.^[1]

Substance use and withdrawal pose significant risks. Anyone who regularly uses alcohol or drugs faces increased chances of agitation, both during intoxication and during withdrawal periods when they stop using. The type of substance matters, as withdrawal from alcohol, opioids, or benzodiazepines can be particularly associated with severe agitation.^[1]

People with certain medical conditions carry higher agitation risk. Those with thyroid problems, particularly overactive thyroid, may experience agitation as part of their symptoms. Anyone hospitalized for serious illness faces increased risk due to the stress of illness, unfamiliar environment, medications, and potential for developing complications like infections or delirium.^[1]

Situational factors can elevate risk as well. Being in an overstimulating environment with too much noise, too many people, or excessive activity can trigger agitation, especially in people with cognitive impairment or mental health conditions. Conversely, isolation and loneliness can also increase agitation risk. Life changes, losses, and major stressors all contribute to heightened vulnerability to agitation.^[6]

Prevention Strategies

While not all agitation can be prevented, especially when it stems from progressive medical conditions, many strategies can help reduce its frequency and severity. Prevention approaches focus on addressing potential triggers before they escalate into full agitation.^[13]

For people with dementia or cognitive impairment, environmental modifications can make a significant difference. Keeping routines simple and consistent helps reduce confusion and stress. Providing a calm, quiet environment with minimal stimulation can prevent overstimulation that triggers agitation. This means limiting the number of people present, reducing background noise from televisions or radios, adjusting lighting to avoid being too bright, and maintaining comfortable room temperatures.^[6][13]

Addressing basic physical needs is crucial in preventing agitation. Ensuring that a person is comfortable, not in pain, properly positioned, and not experiencing constipation or urinary retention can stop agitation before it starts. Regular monitoring for signs of discomfort or unmet needs allows caregivers to intervene early. For people who have difficulty communicating, establishing a routine for checking these basic needs becomes especially important.^[6][14]

Managing stress and providing emotional support helps prevent agitation in many situations. Encouraging people to talk about their feelings and concerns, providing reassurance, and maintaining meaningful social connections can reduce the anxiety and inner tension that lead to agitation. For those experiencing grief or facing difficult life circumstances, having trusted people to talk with and appropriate mental health support can be protective.^[14]

Proper medication management plays a role in prevention. Working with healthcare providers to ensure medications are appropriate, reviewing potential side effects that might include agitation, and monitoring for interactions between multiple medications can prevent medication-related agitation. For people withdrawing from substances, having medical supervision and support can reduce the severity of withdrawal-related agitation.^[1]

For people with mental health conditions, following treatment plans consistently helps prevent agitation episodes. This includes taking prescribed medications as directed, attending therapy appointments, and using coping strategies learned in treatment. Early intervention when symptoms begin to worsen can prevent full-blown agitation episodes.^[3]

Avoiding known triggers, when possible, helps with prevention. If certain situations, times of day, or activities tend to trigger agitation in a particular person, planning around these patterns can be beneficial. For example, many people with dementia experience worsening agitation in the late afternoon or evening, a phenomenon called sundowning. Knowing this pattern allows caregivers to plan quiet, calm activities for these times and avoid scheduling stressful events or procedures during high-risk periods.^[13]

How Agitation Affects the Body and Mind

Understanding the changes that occur in the body and brain during agitation helps explain why people experience the symptoms they do. Agitation involves complex interactions between different body systems, particularly the nervous system and brain chemistry.^[1]

At a biochemical level, agitation appears to involve disruptions in neurotransmitter systems. These chemical messengers, including dopamine and serotonin, normally help regulate mood, behavior, motor activity, and our responses to stimuli. When their levels or functioning become imbalanced, the brain’s ability to maintain calm and appropriate responses to situations becomes impaired. This imbalance creates the inner tension and restlessness that characterize agitation.^[1]

In conditions like dementia and Alzheimer’s disease, physical changes to brain structure combine with neurotransmitter imbalances to produce agitation. The progressive damage to brain cells makes it increasingly difficult for the person to process new information, understand their environment, or communicate effectively. These cognitive difficulties create frustration and confusion, which manifest as agitation. The person may not understand where they are, why they are there, or what is expected of them, leading to distress and agitated behaviors.^[1]

When agitation occurs due to medical conditions affecting other organ systems, the pathway to brain dysfunction varies. For example, when the kidneys or liver begin to fail, waste products build up in the bloodstream. These toxins circulate to the brain and interfere with normal brain cell function, causing confusion and agitation. Similarly, when infections spread throughout the body in sepsis, inflammatory chemicals affect brain function and can trigger severe agitation and delirium.^[15]

Reduced oxygen delivery to the brain, which can happen when the heart or lungs are not working properly, directly affects brain cell function. Without adequate oxygen, brain cells cannot perform their normal activities, leading to confusion, disorientation, and agitated behavior. This explains why people with severe heart or lung disease, or those experiencing significant blood loss, may become agitated.^[15]

The body’s stress response system also plays a role in agitation. When a person experiences severe stress or trauma, the body releases stress hormones like cortisol and adrenaline. These hormones prepare the body for action by increasing heart rate, blood pressure, and alertness. In excessive amounts or when released chronically, these hormones can contribute to feelings of inner tension and restlessness, perpetuating the agitated state.^[3]

In the brain regions responsible for impulse control and emotional regulation, disruptions can lead to the behavioral symptoms of agitation. The frontal lobes of the brain normally help us control our impulses, plan appropriate responses, and regulate our emotions. When these areas are affected by disease, injury, or chemical imbalances, a person may lose the ability to control agitated behaviors even when they recognize they should stop. This explains why agitation often involves impulsive actions and difficulty calming down even when the person wants to.^[2]

The physical manifestations of agitation—the pacing, fidgeting, and restless movements—occur because the disrupted brain signals create an overwhelming urge to move. The motor control systems receive abnormal signals that drive repetitive, purposeless movement. The person may feel they must move to relieve their inner tension, even though the movement does not actually provide relief. This creates a cycle where agitation drives movement, but the movement fails to calm the person down, potentially leading to exhaustion.^[2]

In people nearing the end of life with terminal agitation, multiple body systems are shutting down simultaneously. The combination of organ failure, medication effects, metabolic disturbances, and reduced oxygen delivery to the brain creates a complex picture where normal brain function becomes increasingly difficult to maintain. The body’s attempts to cope with these profound changes often manifest as the restlessness and agitation seen in the final days of life.^[15]