Systematic reviews of assessment measures and pharmacologic treatments for agitation

Background: Agitation is a common behavioral emergency associated with high risk of injury to patients and health care professionals. There are a wide variety of approaches to assessing the severity of agitation and the risk of violence/aggression, and many different pharmacotherapies have been used to manage this condition.

Objectives: Two systematic reviews were carried out. The first focused on measures used to assess agitation and predict aggression/violence and/or the need for medication. The second focused on clinical trials of the efficacy and tolerability of pharmacotherapies for agitation.

Methods: Publications relevant to each topic were identified by searches of MEDLINE through December 24, 2009. The search concerning the assessment of agitation included the terms agitation AND assessment AND (scale OR instrument); the search for clinical trials of pharmacotherapies for agitation included the terms agitation and treatment AND (emergency OR acute). Both searches were limited to reports of studies published in English involving patients aged > or =18 years.

Results: The literature search identified 13 scales used to assess the severity of agitation across multiple patient populations; only 3 of these reports involved the prediction of aggression/violence in patients with agitation, and 1 involved prediction of the need for medication. Thirty-one clinical trials of pharmacotherapy for agitation were identified by the literature search. Based on their results, orally administered olanzapine, risperidone, aripiprazole, quetiapine, haloperidol, and lorazepam; intramuscularly administered olanzapine, lorazepam, ziprasidone, haloperidol, aripiprazole, midazolam, and droperidol; and intravenously administered droperidol and lorazepam were effective for the treatment of agitation. The intramuscular route of administration was associated with a more rapid onset of action compared with the oral route (eg, for olanzapine, 30 minutes vs 1 hour, respectively).

Conclusions: Agitation is a common behavioral emergency that may require pharmacotherapy. The management of agitated patients may be improved through the use of easy-to-administer instruments that predict the need for medication and the availability of rapid-acting treatments that are well accepted by patients and health care professionals.