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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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