Behavioral Emergencies & Violence Risk

"Agitated individuals can be dangerous to themselves and others, making agitation an emergency." StatPearls separates the two words: acute agitation is "a state of unease or inner tension with or without excessive motor activity," while aggression is the "behavioral expression of severe agitation with the potential to cause harm to oneself or others." Project BETA describes the path between them: "Agitation exists on a continuum, eg, from anxiety to high anxiety, to agitation, to aggression." The practical point is that there is time on that continuum, and each step has its own signs. "Violence typically erupts after a period of mounting tension. In a typical scenario, the client first becomes angry, then resists authority, and finally becomes confrontational. However, violent behavior may erupt without warning, especially when caused by medical illness or dementia."

Open RN divides crisis into four phases, and each calls for a different nursing move. In Phase 1, "Individuals are rational and in control of their behavior and emotions." In Phase 2 (rising anxiety), "Problem-solving techniques do not relieve the stressor," and "Their voice pitch may be higher with a more rapid speech pattern. Nervous habits such as finger or foot tapping may occur." In Phase 3, "Capacity to reason becomes significantly diminished, and behaviors become more disruptive. Communication processes may include yelling and swearing. Individuals may become very argumentative or use threats. Individuals may pace; clench their fists; perspire heavily; or demonstrate rapid, shallow, panting breaths." In Phase 4 (crisis), "Individuals experience unbearable anxiety, increased feelings of panic, and disordered thinking processes," and "some individuals at this level of crisis may be a danger to themselves and others."

Crisis itself has a shape and an end. "A crisis can be broadly defined as the inability to cope or adapt to a stressor," and "A crisis state is time-limited, usually lasting several days but no longer than four to six weeks." The goals of crisis intervention are three: ensure safety, provide support to return the person "to a prior level of functioning as quickly as possible," and lessen the negative impact on future mental health. Project BETA’s four objectives for the agitated patient say the same thing in emergency language: "(1) ensure the safety of the patient, staff, and others in the area; (2) help the patient manage his emotions and distress and maintain or regain control of his behavior; (3) avoid the use of restraint when at all possible; and (4) avoid coercive interventions that escalate agitation."

Agitation is a bottom-up surge meeting a top-down brake that is not holding. Restlessness arises from "disturbances in the limbic and striatal sensorimotor pathways," and "This bottom-up activation occurs in the setting of insufficient top-down inhibition and control normally exerted by higher cortical regions." The amygdala is the alarm: "Insufficient amygdalar modulation by higher cortical regions and subsequent hyperactivity can lead to overestimating threats and misinterpreting environmental stimuli. External stress can contribute to the activation of these pathways by reducing inhibition from the prefrontal cortex." That is the patient who hears a routine request as an attack.

The chemistry depends on the cause. Norepinephrine "is implicated in aggression, as it is thought to be involved in the hyperactivation of the amygdala and other pathways involved in the" fight-or-flight response. "In psychosis and substance use, particularly stimulant-induced psychosis, agitation is often associated with a hyperdopaminergic state, with increased norepinephrine and reduced GABAergic tone". Low levels of the serotonin metabolite 5-HIAA in cerebrospinal fluid "have been associated with aggressive personality traits as well as suicide attempts using more violent means." One cause is iatrogenic: "Akathisia can lead to agitation and is believed to be modulated by increased dopamine blockade in striatal neurons due to antipsychotic medications" — so the drug given for agitation can itself produce restlessness.

Why force tends to make it worse. "When staff members physically intervene to subdue a patient, it tends to reinforce the patient’s idea that violence is necessary to resolve conflict," and "using medication too quickly may seem dismissive, rejecting, or humiliating to the patient." In dementia, aggressive behaviour is better understood as a response to something in the patient’s internal or external environment — "Intimate care was identified as the primary factor precipitating aggressive behavior, with hallucinations and delusions as secondary contributors."

The rule is federal regulation, not preference. Under the CMS hospital Condition of Participation, "All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time." It "may only be used when less restrictive interventions have been determined to be ineffective," and the type used "must be the least restrictive intervention that will be effective." A restraint is any method or device that "immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely," or "A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition." Seclusion is "the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving," and may only be used "for the management of violent or self-destructive behavior."

Orders have hard limits (42 CFR 482.13). "Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN)." For violent or self-destructive behaviour each order may be renewed "for up to a total of 24 hours" in blocks of "(A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1 hour for children under 9 years of age," and after 24 hours a physician or other licensed practitioner "must see and assess the patient" before a new order. The patient "must be seen face-to-face within 1 hour after the initiation of the intervention" by a physician or other licensed practitioner or a "Registered nurse who has been trained" to the regulation’s standard. And the time on the order is a ceiling, not a target: "Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order." The limits apply "Unless superseded by State law that is more restrictive."

Restraint is not treatment. The American Nurses Association holds that "a restraint-free environment is the standard of care"; StatPearls reports that "There is no evidence-based research supporting the idea that restraints and seclusion are therapeutic or diminish aggression," and that posttraumatic stress disorder after restraint and seclusion has been estimated at 25% to 47%. The physical risks are real: "patient falls, pressure injuries, positional asphyxiation, musculoskeletal injuries, drug reactions, and even death." Programs such as Safewards and the Six Core Strategies exist to reduce restraint use.