Management of Agitation, Aggression, Irritability, and Hyperactivity

Correct diagnosis and management of agitation, aggression, irritability, and hyperactivity is important for rapid resolution of symptoms and to reduce associated morbidity. In the following, we describe a stepwise approach to diagnosing and managing agitation, aggression, irritability, and hyperactivity. This tailored approach emphasizes the need to identify specific causes for specific behavior in individual patients. The key issue is to first identify underlying causes in order to subsequently

Table 9.2 Summary of general approach to the diagnosis and management of agitation, aggression, irritability, and hyperactivity

Step 1. Assess for underlying physical or psychiatric causes and consider

Physical illness, e.g., infection, pain, sensory deficits

Delirium or psychosis

Review of patients’ medication

Step 2. Address underlying specific causes identified in step 1, such as acute physical illness

Step 3. Map behavior

Type, frequency, when and where of behavior

Step 4. Consider immediate pharmacological treatment of severe agitation and aggression (rarely indicated)

Severe agitation and aggression that cause extreme distress for the patient or that put the patient or others at high risk may warrant immediate initiation of pharmacological treatment

Step 5. First-line treatment: non-pharmacological

Aimed at the patient, carers, and/or environment

Careful observation; wait for possible spontaneous decrease of symptoms

Step 6. Second-line treatment: pharmacological

Consider anti-dementia medication, atypical antipsychotics, antidepressants, anticonvulsants/ mood stabilizers, and, in rare instances, benzodiazepines

When antipsychotic treatment is considered necessary, start low, go slow, monitor carefully, keep treatment period as short as possible, plan discontinuation/reconsidering the treatment, and be aware of black box warnings

Step 7. Assess treatment effect

Use appropriate scale for assessment of treatment (see Table 9.1)

Step 8. Pay attention to carers

Consider burden of symptoms on carers

Paying attention to the physical and psychological health of carers is important

Offer psychological counseling and respite care when needed

address these with non-pharmacological and/or pharmacological treatment as appropriate. The approach is a result of a synthesis of our own experience with agitation, aggression, irritability, and hyperactivity and approaches proposed by leading researchers in the field [86, 87]. The Describe, Investigate, Create, and Evaluate (DICE) approach was recently proposed following a process involving an extensive literature search and panel discussions with leading experts [86]. DICE outlines a four-step approach to diagnose and treat agitation and aggression. It incorporates a focus on identifying underlying causes and an emphasis on individualized efforts, suited to the patient. A comparable approach with regard to this clinical reasoning has been adopted in this chapter. Below in the section “Guidelines on Management of Agitation, Aggression, Irritability, and Hyperactivity,” guidelines addressing approaches similar to the present one may be found. Table 9.2 summarizes the approach proposed in this chapter for easy reference.

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