Agitation is a common symptom in elderly confused patients with organicbrain changes. The effects of agitation are detrimental to the patient, family, and healthcare professionals. The behavioral symptom decreases the patients' well-being and interferes with medical and nursing assessment and treatment. Agitation can also escalate into aggressive, violent behavior where the patient becomes a danger to self and others. Confused elderly patients with agitation present a difficult challenge for healthcare providers.
The primary purpose of this article was to examine agitation behaviors in confused elderly patients. Caretakers are educated to manage unpredictable physiological crises, such as cardiac arrest; however, they have little experience with the management of behavioral crises, such as agitation behavior. To alleviate the agitated elder's sense of distress as well as that of the healthcare providers when dealing with the behavioral crisis of agitation, it is vital to appropriately assess and effectively intervene. Agitation poses many theoretical questions. The behavior is not well-defined and effective interventions for treating or preventing agitation have not been found.
Agitation is not a diagnosis but a broad descriptive term connoting a group of behavioral signs and symptoms. It can be described as an excessive motor activity, often nonpurposeful in nature and commonly associated with feelings of internal tension, irritability, hostility, and belligerence.1 It is assumed that agitation is a term that everyone knows, defines, and uses similarly; however, specific behaviors are never discussed.
There are many causes of agitation in the elderly, both physiological and psychological. Medical and psychiatric diagnoses associated with agitation behaviors include: drug intoxication, drug withdrawal, organic brain syndrome, and functional disorders.2 In addition, there are many other factors that contribute to the development of agitation including sensory impairment, physical discomfort, communication problems, and environmental isolation or overstimulation. Any single factor or combination of factors may cause discomfort, frustration, and misinterpretation of the environment by the elderly confused patient. A situation may escalate into a catastrophic reaction, where the individual becomes excessively agitated and violent.
DESCRIPTION OF THE SAMPLE
Medical management of elderly patients with a history of agitation often includes pharmacological agents prescribed according to the etiology of the behavior. Constant monitoring for subtle changes in the patient's behavior is necessary because each patient may react differently to the medication. Nurses have not been educated to identify behavioral signs; therefore, the patient is often misunderstood. The treatments are less effective than they might be with a comprehensive assessment of client behaviors.
Mental status examinations are used frequently by nurses; however, they test the cognitive domain, such as memory loss and disorientation.3·4 Noncognitive behavioral signs associated with agitation are not included in the mental status examination. Also, cognitive examinations are not designed to assess drug effects over time.5 There are no widely accepted behavioral instruments which assess the signs of agitation.
The physician will order PRN medications and physical restraints for a patient who is agitated. It is left up to the discretion of the nurse when to carry out these orders. The nurse may give the patient the medication when the patient seems restless or wait until he or she is violent. The definition of agitation behavior is unclear; therefore, treatments are not consistently conducted appropriately. Also, the patient may become more confused and agitated if medication and physical restraints are not used appropriately.
Nurses are the logical ones to recognize changes in the patient's behavior. They have the most contact with the confused elderly patient and play a key role in assessing the patient's physical and psychological condition. Nurses are also the first to intervene with the elderly patient expressing agitated behaviors and are responsible for the patient's physical safety.
Agitation is a descriptive term frequently used by healthcare professionals. The term, however, is used loosely and the behaviors associated with it are not clearly defined. This descriptive study was designed to examine agitation behaviors and develop a profile of behaviors that are associated with nursing interventions for agitation.
This study was conducted in a large urban hospital on a medical unit for patients 62 years old and over. The staff were RNs in a gerontological nursing department. The unit had a large percentage of patients admitted for organic brain syndrome workup. The researchers selected patients with symptoms of confusion and agitation which were confirmed by the physician in the patient's medical record. The study was approved by the Institutional Review Board and patient confidentiality was ensured by a coding system.
Data were obtained by using an assessment instrument. The first part of the tool required nurses to check off the behaviors they saw when die patient had an episode of agitated behavior in which the nurse interevened with a PRN antipsychotic drug or physically restrained the patient. The agitated behaviors were stated in a checklist format developed from documentation in the literature, from nurses' progress notes, and from the researchers' experience with agitated, confused elderly patients.
The behaviors were grouped into four categories: psychomotor behaviors (18 items), aggressive/antisocial behaviors (8 items), speech patterns (11 items), and physiological behaviors (8 items). Assessment forms were placed in the patient's chart for the nurses to complete. The nurse could fill out more than one form on the same patient; however, it had to be done at a different time in which the nurse intervened with a PRN interventions were initiated again. It was assumed in this study that agitation is an episodic behavior and may occur once or repeatedly, but not continuously.
The interventions of administering an antipsychotic drug or physically restraining the patient were chosen because they were clear-cut, documented in the agitation literature, and commonly used on the unit. Both of these interventions were determined and ordered by the physicians to be used as needed prior the patient's involvement in the study.
AGITATION EPISODES AND ACTION TAKEN
The second part of the tool required the nurse to state which of the two interventions were used, either medicating and/or restraining the patient. The duration of the behaviors prior to initiating the intervention was timed in minutes. The researchers obtained demographic data from the patients' medical records. This study took place over a ten-month period.
A total of 23 elderly, confused, and agitated patients were observed; of these, 12 were males and 11 were females. Their ages ranged from 74 to 92 years old, with an average of 81 years. Five of the subjects were widowed and 18 were married. The patients had a total of four medical diagnoses related to their confusion: nine (39%) had an organic brain syndrome of unknown etiology; six (26%) had Multì-infarct Dementia; five (22%) had Alzheimer's disease; and three (13%) had Parkinson's disease with dementia.
Ninety-three forms were filled out on the 23 patients by the nurses for 93 incidents of agitation. The number of agitation episodes per person ranged from one to 19, with an average of four. In 53 (57%) of the episodes, the nurse gave both the antipsychotic medication and physically restrained the person; 36 (39%) of the episodes were handled by giving the patient an antipsychotic medication; patients were restrained without medication in only four (4%) of the episodes. It is recognized that the nurses were initiating many other interventions during the patient's episode of agitation; however, description of the additional interventions was beyond the scope of this study.
Behaviors identified by the nurses, as observed prior to initiating an intervention, are presented in Table 3. The psychomotor behavior category received the greatest number of responses (240 instances for the 18 items). There were 49 responses on the increased general movement item; all 23 of the patients displayed this behavior during one or more of their agitation episodes. Also, there were 39 episodes of climbing out of bed for 18 (78%) of the patients. The speech pattern category had the second highest response rate, with a total of 180 responses for the 11 items. Talking loudly was the most frequent response seen, with 45 episodes consisting of 18 (78%) patients.
Aggressive/antisocial behaviors was the third highest category, with a total of 149 responses for the eight items. Refusing to cooperate with directions had 52 responses involving 19 (83%) patients which was reported as the most frequent response. The last category was physiologic behaviors consisting of only 91 responses for the eight items. The total number of behaviors seen in an episode of agitation out of a possible total of 55 ranged from one to 21, with an average number of eight behaviors per patient. The length of time agitated behaviors were observed before medicating or restraining the patient varied greatly, ranging from five minutes to three hours; however, 35 minutes was the average observation time.
All 23 patients were described as having increased, generalized movement. Most of the behaviors were observed in the psychomotor category, which had the largest number of items (18). According to this study, behaviors which are seen as agitation in confused elderly patients include increased, generalized movement, climbing out of bed, refusing to cooperate with directions, talking loudly, and calling out. All of these behaviors seem mild compared to some of the other items, such as striking out and swearing.
The nurses indicated many psychomotor behaviors as episodes of agitation. It appears, however, that the interventions were not initiated until later. This indicates to the researchers that nurses recognize psychomotor behaviors as agitation but the response time is prolonged until the behaviors continue or escalate.
Physiological symptoms did not seem to be good indicators of agitation except for the not resting or sleeping category which was observed in 15 (65%) of the patients. Perhaps it was felt that physiological symptoms were not reliable indicators because of the many other contributing factors.
PATIENT BEHAVIORS OBSERVED BY NURSES
The results indicated response time for nurses to initiate interventions was related to the type of behaviors seen in the confused elderly patient. Behaviors observed in the aggressive/antisocial category lead nurses to intervene earlier (five to 15 minutes) compared with behaviors in the psychomotor and speech pattern category (30 minutes to three hours). Disruptive behaviors affecting nursing routine or behaviors that were noxious and harmful to other patients were seen less frequently; however, these behaviors initiated a quicker response from the nurse.
It is difficult to discern which behaviors were noted first or to weigh the significance of each behavior because nurses were asked to identify behaviors in all four categories simultaneously. There were no identifiable patterns of behaviors between patients to episodes of agitation. The most consistent behavior that nurses should be aware of as an early warning sign in agitation was found to be the increase in generalized movement behavior. It is a vague cue, but observed in all the cases of agitation.
Many other interventions were used to relieve agitation which were not part of the study. Nurses were creative in their approach and developed interventions based on the individual patient and their level of functioning. Some of the interventions included: structuring the patient's activities, keeping the environment stimulating but quiet, increasing physical activities such as walking with the patient, distracting the patient with music or food, primary nursing with consistent caregivers, and validating the patients' feelings and not emphasizing reality orientation.
The significance of this study to nurses in the practice setting is that agitation has many identifiable behaviors which can be easily seen and recognized by nurses on a daily basis. This study is the first step in the development of an operational definition clinically useful for nurses. It is important to have a consensus of what agitation is in the confused elderly patient in order to better define baseline activities, note worsening conditions, and evaluate response to therapy. There is an increased vulnerability to display agitation behavior in patients with organic changes in the brain.
The extent to which agitation behavior is universal for the different diagnoses related to confusion is unknown. It will be important to identify nursing interventions that decrease the probability of the occurrence of agitated episodes. A general rule is to remain aware of the contributing factors and to work to minimize their effects. Acceptance of a standard operational definition for agitation could facilitate both research and clinical practice in the future.
There is a dearth of information about agitation in the elderly. The results presented are a baseline towards future research for this complex-variable phenomenon - agitation. Defining agitation behaviors will aid researchers in pursuing the causes and consequences of agitation. Future research should ultimately investigate possible nursing interventions to prevent or minimize agitation episodes in the cognitively impaired elderly patient.
- 1 . Barnes R, Raskind M: Strategies for diagnosing and treating agitation in the aging. Geriatrics 1985; 35:111-114.
- 2. Shevitz S: The agitated patient. J Fam Pract 1979;9:305-311.
- 3. Pfeiffer E: A short portable mental status questionnaire for assessment of organic brain deficit in elderly patients. J Am Geriatr Soc 1979; 23:433-436.
- 4. Wolanin MO, Phillips LR: Confusion: Prevention and Care. St. Louis, CV Mosby, 1981.
- 5. Mohs RC, Rosen WG, Davis KL: The Alzheimer's disease assessment scale: An instrument for assessing treatment efficacy. Psychopharmacol 1983; 19:448-449.
- The authors express appreciation to Joan LaSage, PhD, RN, chairperson of Gerontological Nursing at the Johnston R. Bowman Center for the Elderly in Chicago, Illinois, for her expertise and support in preparation of this article. We would also like to acknowledge the gerontological nurses who facilitated our research and assisted in data collection.
DESCRIPTION OF THE SAMPLE
AGITATION EPISODES AND ACTION TAKEN
PATIENT BEHAVIORS OBSERVED BY NURSES