Understanding Agitation

Agitation

Serina Michaud
&
Jessica Katz
York University

Table of Contents
Defining
Agitation...3
Causes of
Agitation.3
Agitation Levels
5
Management.
6
Examples...
7
References.
9

Agitation
2

Defining Agitation
Understanding what agitation is will help you seek further
information about the cause, which will lead to management of the
behaviour.
According to Johns Hopkins Medicine, Agitation is defined as,
A non-specific symptom of one or more physical, or psychological
processes in which screaming, shouting, complaining, moaning,
cursing, pacing, fidgeting or wandering pose risk or discomfort,
become disruptive or unsafe or interfere with the delivery of care.

Causes of Agitation

Physical and
Medical

Complications
Environmental

Stresses
Sleep disturbances
Psychiatric
Syndromes

Residents with dementia often display symptoms of

irritability, restlessness, repetitive behaviour, and explosive
behaviour that are all part of the overall behaviour of agitation.
Agitation is more frequently displayed in a person with dementia
because of the changes occurring internally; there are changes in
the brain physically causing changes in the functioning of mind.
Symptoms of agitation can be demonstrated internally or outwardly
leading to disruptive and even harmful behaviour to the resident
and those around them.
Some

common symptoms:
Irritability
Frustration
Excessive anger
Demands for attention or reassurance
Repetitive questions or comments
Stubborn refusal to do things or participate
Explosive behaviour
Constant pacing
Searching/wandering
Rummaging
Verbal outburst (yelling, screaming, cursing, threats)
Physical violence (hitting, scratching, biting, kicking)

These behaviours stem from somewhere beyond what we can see.

There are many causes of agitation and in order to assist the
residents we must look beyond the surface and discover what is
really causing the behaviour.

Causes
Physical/Medical Complications

Agitation

Agitation is often demonstrated in a change of behaviour.

When you notice changes the initial cause to check for is a
change in their health status. Sudden illnesses can further
weaken in the brain due to the immune system working
harder than usual to fight against the infecting illness. The
most common medical problems are urinary tract infections,
bladder infections, cold, flu, bronchitis, pneumonia, injuries

Environmental Stresses
The most appropriate environment is one that is calming, comforting, light and clear. Ones
that are noisy, poorly lighted, too cold or hot can lead to agitated behaviour. It is helpful to
have a routine for residents because changes in routines, schedules or environment can
lead to anxiety, frustration or fear, which can result in agitated behaviour.
It is important for residents to feel like they are not alone and they feel safe and comforted
with the staff around them. The environment is a balancing technique; residents being left
alone for too long or having too many people around can both have an effect on agitation
levels.
Sleeping Problems
Dementia has an effect on the sleeping patterns of person. Many residents with dementia
find it challenging to sleep does to the diseases effect on the brain. Finding out the reason
behind the sleep disturbances can help the staff correct the problem. Some examples of
reasons resident may not sleep are too much activity before bed, caffeine, drinking to many
fluids, sleeping too much during the day, depression or physical pain. However, there are
many times that the cause is just unknown.
Sundowning is a common sleep problem amongst this population. It is when residents are
confused, disorientated and agitated during the evening and night. Dementia often causes
damage to the functioning of our internal clock. This controls the brains ability to sense day
and night, as well as when we should sleep and when we should wake.
Psychiatric Syndromes
Agitated behaviour may be caused by an underlying psychiatric condition such as
psychosis, aggression, anger, depression and anxiety
Psychosis is displayed through two kinds of symptoms: delusions and hallucinations.
Delusions are when the resident has a belief that incorrect. Hallucinations are when the
resident is seeing, hearing, smelling, communicating, and feeling things that are not really
there. These commonly present in residents and staff will often hear things such as that
they are unwelcome guests in their home, that family members are imposters, spouses are
unfaithful, people are trying to harm them, timeline in their lives is inaccurate (children are
not that old), seeing people that are not really there, etc.
Aggression/Anger is common in residents with dementia, because the disease affects
their ability to control their impulsive behaviour. This loss of control is often described as
disinhibiting. Aggressive behaviour can become dangerous because these residents have
tendencies to be verbally and physically violent as well as destroying objects. It is important
to find out the reason of behind the aggressive behaviour. Often these feelings stems from
misunderstanding, misinterpreting, feelings of loneliness, anxiety, frustration, feeling
incapable or dependent, feelings of insignificance or mistreatment. Anger tends to lead to
more verbal out bursts and isolation. Screaming, yelling, cursing, refusals, insults,
accusations, violence to others or themselves are signs of these syndromes. Once this
behaviour occurs making changes and managing the situation is important for everyones
safety.
Depression is portrayed in residents as sad feelings, tearful, isolated, not enjoying
activities, discouraged, failure, feel like a burden, or even suicidal thoughts. Physical
symptoms are loss of appetite, changes in weight, sleeping changes, and complaints of
pain. Depression can be linked to many other causes of agitation.
Anxiety can be seen as nervousness, fidgeting, shaky, frightened, and fearful. These
behaviours can be due to changes the resident is feeling from the disease or their

Agitation
4

Resident Agitation Scale

Rating

Based on the Pittsburgh Agitation Scale

Resident Signs

1-2

Resident exhibits ONE or TWO of the following signs:

3-4

Resident exhibits THREE of the signs in level 1-2 OR

Resident exhibits ONE or TWO of the following signs:

5-6

Vocalization: low volume, not disruptive (includes crying)

Motor Agitation: pacing/moving in chair at normal rate while seeking
comfort/moving purposelessly/spouse-seeking
Aggressiveness: ONLY aggressive when resisting care
Resisting Care: Procrastination/avoidance

Vocalizations: Louder than conversational, mildly disruptive but

redirectable
Motor Agitation: Increased rate of movements, mildly intrusive but
redirectable
Aggressiveness: Verbal threats AND/OR threatening gestures
Resisting Care: Verbal or physical gesture (brushing the caregiver off
without striking out at them) of refusal
Resident exhibits THREE of the signs in Level 3-4 OR
Resident exhibits ONE or TWO of the following signs:
Vocalizations: Loud, disruptive difficult to redirect
Motor Agitation: Rapid movements, moderately intrusive or
disruptive, difficult to redirect
Aggressiveness: Physical acts against property (throwing, breaking,
etc.)
Resisting Care: Pushing caregiver away to avoid task

7-8
910

Resident exhibits ONE of the following signs:

Borderline risk of hurting self or others
Vocalizations: Extremely loud, screaming or yelling, highly disruptive,
unable to redirect
Motor Agitation: Intense movements that are extremely intrusive or
disruptive and not redirectable verbally
Aggressiveness: Physical towards self or others
Resisting Care: Striking out at caregiver
Resident exhibits TWO or more of the following signs:
This is a level of unsafety; resident is at risk of hurting self or
others
Vocalizations: Extremely loud, screaming or yelling, highly disruptive,
unable to redirect
Motor Agitation: Intense movements that are extremely intrusive or
disruptive and not redirectable verbally
Aggressiveness: Physical towards self or others; unsafe, presents risk
of hurting self or others
Resisting Care: Striking out at caregiver
5

High
Risk
Low Risk

Leve
l 1-2

Leve
l 3-4

Leve
l 5-6

Agitation Levels

Leve
l 7-8

Leve
l 910

Providing the right

Environment
Evaluate the environment.
Consider things like are their
changes from their normal
schedule, is there enough
light, too much noise, too cold
or to hot, too many people,
not enough people, are they
comfortable, etc.

Management of Agitation
1. Providing the right environment
2. Supervising activities
3. Learning to communicate with a person who has
dementia
4. Getting support and improving coping skills
5. Medication
Supervising Activities
Residents with dementia often need supervision
and assistance with their daily routine and
activities. Structured routines and activities can
limit the occurrence of anxiety, anger, and overall

Medication
Medications are used to help
control these behaviours that
are beyond the efforts of the
staff to provide a ideal
environment. Mediation is not
a cure to this disease; it is
used to help manage the
symptoms.

Support and Coping

Work as a team and be
supportive of each other as
caregivers. Share ideas with
one another and
communicate. Many staff will
feel stressed; have anxiety
and depression when working
with this population.
Remember this behaviour is
caused by the disease; not the
person.

agitation. Some examples are:

Pleasant activities
Avoid complex tasks
Giving them simple task (redirection)
Distraction (music, television, snack)
Flexibility (staff must be willing to adjust to
changing circumstances)
Soothing environment
Communication
Learning to communicate can be challenging due
to the changes of verbal abilities. Some people
will use gestures or expressions to communicate.

Some helpful suggestions are:

Be understanding to changing emotions
Always identify yourself and use the name of the
person you are talking to (avoid asking if they

remember you?)
Speaking slowly and distinctively
Use gestures, visual cues, and the five senses

Agitation

Examples
Resident R
Resident R is a relatively new resident at Sage Care. She exhibits agitation
that presents itself in outbursts where Resident R demands attention from
staff and residents and becomes aggressive, and she is often disruptive
during group activities. Resident R's agitation stems from a need for control.
In her earlier life, Resident R was a highly successful real estate agent who
did a significant amount of charity work caring for the poor. While her
professional life was always a success, she was a perfectionist, and did not
always have a harmonious home life. Her children do not all get along and
she was often perceived by her children as 'stuck up' in her views on high
class clothing and decorum. Resident R has some elements of frontal lobe
dementia, which impacts her ability to control herself and the things that she
says; overall, it makes her impulsive. When Resident R gets agitated, she will
sometimes call out fellow resident, Resident G, as a "homeless person" that
she once helped and who never thanked her. Rhoda tends to get agitated
when environmental stressors are present. For Resident R, these stressors
tend to include busy times when the recreation programs are running but
they are not all about her. She also experiences Sundowning now that it is
getting dark earlier, related to disruptions in her internal clock due to her
dementia. Managing Resident R's agitation should include providing the right
environment, which means that if Resident R is feeling undervalued because
the focus is not on her, a staff member should (if feasible) spend one-to-one
time with her, re-affirming her importance in society and the value of her life.
Resident R has a lot of paranoia, so staff should be careful not to talk about
her while she is in earshot, to avoid setting off her paranoia. In cases of
Sundowning, Resident R requires a well-lit room and re-orientation to the
time of day that it is. Resident R responds particularly well to being made to
feel important and as though her feelings are valued. Always INVITE her to
participate and express your desire to hav her as a part of your program,
rather thanG
TELLING her what to do.
Resident
Resident G is a former Rabbi's wife. She is excellent at carrying on
conversations and making you feel as though you've connected with her, but
once you end a conversation with her, you realized she didn't really let you
"in", even though she talked with you about many aspects of life. In her
former life, Resident G lived with a lot of anxiety and anger. Resident G once
trashed a room in a previous care facility in fury, according to her children.
Resident G's form of agitation is exit seeking, and she has threatened
physical abuse when angry, and has threatened to throw a chair in the past.
Resident G has had many sleeping problems, and it is important to balance
her medications so that she is sleeping well at night, which will help minimize
her agitation during the day. Since Resident G has a history of anxiety and
confusion, a good intervention is to help her to relax by using calming music,
white noise, massage and one-to-one calming conversation to re-orient her.
Maintaining an environment where Resident G does not feel confused is if of
utmost importance, so sitting her next to people who she likes and is familiar
with (and keeping her away from Resident R, who may stress her out by
calling her a homeless person) are important. We may never know what
psychoogical trauma Residen G carries from her past life, but we must make
an oingoing effort to reduce her anxiety and confusion at Sage Care.

Resident H
H
Resident H w as a pharm acist who was m arried and has children, w ith whom
she w as alw ays very affectionate. She cam e to Sage Care as her cognitive
decline and aphasia worsened and the care provided by her retirem ent hom e
w as not enough. Resident H expresses her anxiety through scream ing, as she
is no longer able to com m unicate effectively using w ords. The exact source of
her agitation is unknow n as she does not seem to have any significant
traum a from her previous life that m ay be causing anxiety, fear or distress.
We do know , however, that Resident H is used to having control and being
specific and on-point, since she w as a pharm acist, which is detail-oriented
w ork that requires order. H owever, Resident H has a history of Urinary Tract
Infections and other sources of pain and m edical issues (particulary sciatica
in her back), all of w hich can cause agitation. A m ulti-faceted approach is
best to m anage Helen's agitation episodes. The first step is to perform
regular tests for UTIs and treat appropriately and prom ptly. Next is to ensure
that Helen's m edications are in balance and to m inim ize her pain, m axim ize
her night-tim e sleep, and aim for general com fort during her w aking hours.
W hen agitation episodes do occur, Helen m ay be helped by calm ing m usic,
one-to-one concersation, gentle m assage, and w hite noise. M anaging
Resident H 's agitation requires trial-and-error and interveing early is key.
Resident H benefits from a recreation program that does not over-stim ulate
her and m akes her feel as though she has som e control over her
environm ent.

References
Alzheimers Association. (2012). Alzheimers Disease Facts and Figures. Alzheimers
Association. Retrieved from www.alz.org/downloads/facts_figures_2012.pdf
Johns Hopkins Medicine. (2012). Health Library Glossary. Retrieved from:
http://www.hopkinsmedicine.org/healthlibrary/conditions/nervous_system_disorders/gloss
ary_-_nervous_system_disorders_85,P00781/
Pittsburgh Agitation Scale. (1994). Retrieved from: www.dementiaassessment.com/au/symptoms/Pittsburgh_Agitation_Scale.pdf
Sage Care. (2004). Sage Care Residence. Retrieved from:
http://www.sagecareonline.ca/homestor.htm
University of California Davis Alzheimers Disease Research Center. (2005). Treatment of
Dementia and Agitation: A Guide for Families and Caregivers. Expert Consensus
Guideline Series. Retrieved from
http://alzheimer.ucdavis.edu/careg/media/pdf/dementiahandout.pdf