Treatment Goals
The first goal is to ensure safety of the patient and those around him. Secondly, symptoms need to be reduced to such a degree that safety is no longer a problem and further medical and psychiatric assessments can be completed in order to identify potential causes. Subsequent interventions aim to prevent further aggression and to regain the patient’s capacity for cooperation with treatment as soon as possible. Once the cause has been identified, appropriate treatment with accompanying goals specific to the underlying condition are implemented. Many pharmacologic interventions for acute agitation and aggression involve some post-dose sedation, which is not necessarily the primary goal. An optimal response would be a reduction in agitation or aggression but the patient remains alert, oriented, and able to participate with further assessment and treatment.
Treatment Strategies
Nonpharmacologic vs. Pharmacologic: The initial treatment choice is between using a medication or nondrug measures such as verbal interaction, seclusion, or restraint. The likely cause of the aggressive or agitated episode along with the likely need for long-term medications to manage an underlying disease state directs the initial treatment. Psychotic patients are usually given antipsychotics for a duration dependent upon the cause, whereas nonpsychotic patients are often initially treated with nonpharmacologic measures or, if medication is indicated, benzodiazepines. Combination therapy of any of the drug and nondrug measures is appropriate when patients are difficult to control. An important strategy to prevent further episodes is to ensure that medications used to treat underlying conditions are optimized. Depending on the cause, the choice of medication may be based on a drug’s ability to treat the agitation as well as its ability to potentially treat the underlying illness.
Nonpharmacologic Strategies: One of the most important nondrug approaches is verbal redirection. Verbal redirection not only can calm a patient who is already aggressive, but also prevent escalation from verbal agitation to full-blown violence. Placing a patient in a calm environment (such as a quiet room without a radio or television playing) and interacting with them in a non-authoritarian, caring manner is often effective. This may mean speaking in a calm voice without giving authoritative commands or "staring down" the patient. Seclusion and restraint are more restrictive nondrug measures. The American Psychiatric Association has guidelines for the appropriate use of restraint and seclusion in order to minimize risks to both patients and staff. Indications are to prevent harm to others or to the patient, to prevent serious disruption in the treatment environment, for behavioral treatment or if the patient requests it. Seclusion alone is used to place a patient in a less stimulating environment.Restraint requires medical monitoring to ensure that the patient does not suffer any medical consequences such as choking, dehydration, hyperthermia, or fractures.
Related posts:
- Acute Agitation and Aggression in Psychiatric Illnesses. Part 8. Treatment Atypical Antipsychotics: Atypical antipsychotics have become a standard of care in schizophrenia and they are increasingly being used as mood stabilizers. Additionally, new dosage forms are making them more useful in acute agitation. The IM formulation of olanzapine is pending approval by the FDA...