Agitation: Symptoms, Causes and Treatment

Agitation is a complex and often distressing set of symptoms that can affect anyone, from the young to the elderly, and may occur in a wide range of medical and psychiatric conditions. Characterized by feelings of unease, restlessness, and sometimes aggression or violence, agitation can have significant impacts not only on those experiencing it, but also on caregivers, families, and healthcare professionals. Understanding the symptoms, underlying causes, and evidence-based treatment options for agitation is crucial for improving patient outcomes and reducing the burden on society.

Symptoms of Agitation

Agitation manifests in many ways, both physically and emotionally. Recognizing its symptoms is the first step toward effective intervention and management. These symptoms often vary depending on the underlying condition, the person's age, and individual factors, but certain patterns are commonly observed across diverse populations.

Symptom	Description	Severity Spectrum	Source(s)
Restlessness	Inability to stay still; pacing, fidgeting	Mild to severe	1 4 7
Inner tension	Subjective feeling of unease or nervousness	Mild to moderate	1 4
Irritability	Easily annoyed or provoked	Mild to severe	3 4
Aggression	Verbal or physical hostility	Moderate to severe	2 3 4
Verbal agitation	Shouting, complaining, repetitive questioning	Mild to severe	2 8
Sleep disturbance	Trouble falling or staying asleep	Mild to moderate	1 3
Racing thoughts	Rapid, crowded, or overwhelming thoughts	Mild to moderate	1 4
Emotional lability	Rapid mood swings, unpredictable emotions	Moderate	3 4

Table 1: Key Symptoms of Agitation

Understanding Agitation's Symptom Spectrum

Agitation is not a single, uniform experience. Instead, it spans a spectrum from subtle restlessness and anxiety to pronounced aggression and violent outbursts. Let's break down the common symptoms:

Restlessness and Tension

• Restlessness is one of the most frequently reported symptoms. It can manifest as physical movements (pacing, fidgeting) or an inability to sit still 1 4 7.
• Inner tension—a subjective feeling of unease, worry, or nervousness—is often described by those experiencing agitation 4.

Irritability and Emotional Lability

• Irritability means being easily annoyed or provoked, sometimes escalating to anger.
• Emotional lability involves rapid, unpredictable changes in mood, which can add to the unpredictability of agitation episodes 3 4.

Aggression and Verbal Outbursts

• Aggressive behaviors can be either verbal (shouting, threats) or physical (hitting, throwing objects) and are more common in moderate to severe agitation 2 3 4.
• Verbal agitation may also include repetitive questioning, complaining, or persistent demands, particularly in older adults or those with dementia 2 8.

Cognitive and Sleep Disturbances

• Racing or crowded thoughts—often reported in mixed depressive states or bipolar disorder—can make it difficult for individuals to concentrate or communicate clearly 1 4.
• Sleep disturbances—such as trouble falling or staying asleep—can both contribute to and result from agitation 1 3.

Symptom Clusters and Variation

• Agitation can be divided into clusters such as “agitation/aggression” and “behavioral dyscontrol” (including symptoms like disinhibition and sleep disturbance). These clusters may have unique biological underpinnings and require targeted interventions 3.
• Severity ranges from mild (unease, restlessness) to severe (physical aggression, need for hospitalization). Many people experience a mix of symptoms, and the severity can fluctuate over time 4.

Causes of Agitation

Agitation is not a disease in itself, but a symptom arising from a wide range of underlying causes. Identifying the root cause is crucial for effective management and treatment.

Cause Type	Examples/Details	Population/Context	Source(s)
Psychiatric	Schizophrenia, bipolar disorder, depression, anxiety	All ages, esp. adults	1 4 5 7
Neurocognitive	Dementia, Alzheimer’s, delirium	Elderly	2 3 7 8
Medical	Infections, metabolic disturbances, pain, hypoxia	All ages, esp. elderly	6 8
Substance-related	Intoxication, withdrawal (e.g., drugs, alcohol)	Adolescents, adults	9 13
Environmental	Overstimulation, changes in routine, caregiver stress	All, esp. institutionalized	2 7 8
Medication side effects	Antidepressants, antipsychotics, others	All ages	1 6

Table 2: Common Causes of Agitation

Psychiatric and Neurocognitive Disorders

• Psychiatric illnesses such as schizophrenia, bipolar disorder (especially manic or mixed episodes), depressive disorders, and anxiety disorders are leading causes of agitation 1 4 5 7. In these contexts, agitation may arise as part of the core illness or as a reaction to internal distress.
• Neurocognitive disorders like dementia and delirium frequently present with agitation, especially in older adults. Up to 60% of people with dementia will experience agitation at some point, often with devastating consequences for both patients and caregivers 2 3 7 8.

Medical and Physiological Triggers

• Medical conditions such as infections (e.g., urinary tract infections in the elderly), metabolic imbalances (electrolyte disturbances, hypoglycemia), pain, or hypoxia can precipitate agitation 6 8. In the emergency setting, rapid identification and management of these underlying issues is critical.
• Medication side effects—including those from antidepressants, antipsychotics, or other drugs—can paradoxically cause or worsen agitation 1 6. This is particularly relevant in the elderly and those on multiple medications.

Substance Use and Withdrawal

• Substance intoxication and withdrawal, including from alcohol, stimulants, or new psychoactive substances, are increasingly recognized causes of agitation in emergency and psychiatric settings 9 13. These presentations often require specialized management.

Environmental and Psychosocial Factors

• Environmental triggers such as overstimulation, unfamiliar surroundings, or disruptions in routine can provoke or exacerbate agitation, especially in institutionalized or hospitalized patients 2 7 8.
• Caregiver stress and inadequate support structures may also contribute, particularly in home care or long-term care settings.

Neurobiological and Genetic Factors

• Dysregulation of neurotransmitter systems—dopaminergic, serotonergic, noradrenergic, and GABAergic—are implicated in the pathophysiology of agitation, though there is no single unifying pathway 5 7.
• Genetic factors, such as mutations in dopamine-related genes (e.g., COMT), may predispose certain individuals, especially those with psychiatric disorders, to agitation 7.

Treatment of Agitation

The management of agitation requires a tailored, stepwise approach that addresses both the immediate safety concerns and the underlying causes. Treatments range from non-pharmacological strategies to targeted pharmacological interventions, and often involve a combination of both.

Treatment	Examples/Methods	When Used	Source(s)
Non-pharmacologic	Verbal de-escalation, environmental modification, behavior management	First-line, mild-moderate	8 11 14
Pharmacologic	Antipsychotics, benzodiazepines, mood stabilizers, antidepressants	Moderate-severe, refractory	12 13 14
Underlying cause	Treat infection, correct metabolic imbalance, manage pain	Always, if cause identified	6 13
Sequential/algorithmic	Stepwise drug trials, titration, combination therapy	Dementia, refractory cases	14

Table 3: Main Treatment Approaches for Agitation

Non-Pharmacological Interventions

Non-pharmacologic strategies are the foundation of agitation management, especially for mild to moderate symptoms:

• Verbal de-escalation: Engaging the person in calm, supportive conversation, validating their feelings, and redirecting attention can help diffuse agitation 11.
• Environmental modification: Reducing noise, adjusting lighting, removing potential triggers, and ensuring a familiar environment are proven strategies, particularly for older adults and those with dementia 8 11.
• Behavior management techniques (BMT): Structured routines, positive reinforcement, and distraction can reduce agitation, especially in dementia care settings. BMT is associated with fewer adverse events compared to medications 10.

Pharmacologic Treatments

When non-pharmacologic measures are insufficient or when agitation poses a risk to self or others, medication may be required:

• Antipsychotics: Both first- and second-generation antipsychotics (e.g., haloperidol, risperidone, olanzapine, aripiprazole, quetiapine) are effective for acute agitation in psychiatric and neurocognitive disorders. The choice depends on patient profile, side effect risk, and speed of action required 12 13 14.
• Benzodiazepines: Agents like lorazepam are used for rapid calming, especially when agitation is due to withdrawal or when antipsychotics are contraindicated. Caution is needed in elderly patients due to fall risk and confusion 12 13.
• Mood stabilizers and antidepressants: In certain presentations (e.g., mixed depression or bipolar disorder), mood stabilizers (carbamazepine, valproate) and antidepressants (citalopram, trazodone) may be considered 1 14.
• Algorithmic/Sequential therapy: For dementia-related agitation, evidence-based algorithms recommend sequential drug trials (starting with antipsychotics, then mood stabilizers or antidepressants as needed), with adjustments for frailty and comorbidities 14.

Note: Pharmacologic intervention should always be individualized, starting with the lowest effective dose, and physical restraints are considered only as a last resort 11.

Treating Underlying Causes

• Medical evaluation: It is vital to rule out and treat underlying causes such as infection, metabolic imbalance, or pain before or alongside symptom management 6 13.
• Medication review: Discontinuation or adjustment of drugs that may be contributing to agitation is an important step, especially in polypharmacy situations 1 14.

Special Considerations

• Older adults: Geriatric dosing, increased sensitivity to side effects, and a greater risk of delirium or falls require careful selection and monitoring of pharmacologic treatments 8 14.
• Assessment tools: Structured scales and instruments can help clinicians evaluate agitation severity, predict risk, and guide medication need 12.

Conclusion

Agitation is a multifaceted clinical issue that can have serious impacts on individuals, caregivers, and healthcare systems. Recognizing the symptoms, identifying underlying causes, and implementing tailored, evidence-based treatments are key to effective management.

Key Points:

• Agitation presents as a spectrum of symptoms, from restlessness and inner tension to aggression and severe behavioral disturbances 1 2 3 4 7.
• Causes are varied and include psychiatric illnesses, neurocognitive disorders, medical conditions, substance use, environmental factors, and medication effects 1 2 4 5 6 7 8 9 13.
• Management should prioritize non-pharmacologic interventions, address underlying causes, and use pharmacologic treatments judiciously, following evidence-based algorithms where available 8 10 11 12 13 14.
• Special care is required for vulnerable populations—especially the elderly and those with dementia—due to increased risks and unique treatment needs 2 8 14.

By deepening our understanding of agitation and its management, we can improve quality of life for patients and reduce the burdens on caregivers and healthcare systems alike.