A side from posing a psychiatric emergency, agitation can also signal a potentially serious medical problem (Box). After the patient’s behavior is stabilized, a medical evaluation may be necessary. The letters that spell “agitation” remind us to watch for these problems:
Alcohol dependence, intoxication, or withdrawal can lead to agitation even when obvious signs or symptoms of alcohol use are not present.1 Watch for nausea, vomiting, tremors, sweating, auditory or visual hallucinations, headaches, and abnormal vital signs. Also watch for confusion, which may precede delirium.
Genetics. Agitation is a presenting symptom in several congenital diseases, such as Huntington’s disease.2 Look for Huntington’s chorea, psychotic symptoms, and family history of a congenital disease associated with agitation.
Infections. Agitation in patients with systemic, local, or CNS infections may be seen as psychogenic, thereby delaying medical evaluation.3 Watch for abnormal vital signs, especially fever or sweating. General achiness could signal meningitis, a viral infection prodrome, or tetanus infection.
Tumors. Patients with primary cancer with CNS metastasis or primary CNS tumors may present with agitation but no other symptoms or signs of cancer.4 Find out if the patient has a personal or family history of cancer. Watch for unexplained pain that cannot be adequately controlled.
Akathisia. Inner psychological restlessness and observable movements associated with akathisia can manifest as agitation.5 Ask whether the patient is using illicit drugs or medications (eg, some antipsychotics) that may cause akathisia.
Trauma. Agitated patients with brain injuries caused by surgery, burns, or heatstroke usually present with obvious clinical signs. However, persons with asymptomatic, undiagnosed bone and skull fractures may also become agitated.6 Elderly and frail persons and patients with a past head injury also are at risk for trauma-related agitation.
Potential sources of agitation
- Alcohol dependence/intoxication/withdrawal
- Genetic diseases
- Infection
- Tumors
- Akathisia
- Trauma
- Illicit drug use
- Other predisposing medical factors
- Neuropsychiatric conditions
Illicit drugs. Agitation may point to drug intoxication, addiction, or withdrawal. Do a urine and blood screen to check for use of stimulants, anabolic steroids, ketamine, phencyclidine (PCP), or “club drugs” such as methylenedioxymethamphetamine (MDMA, or Ecstasy) and gamma hydroxybutyrate (GHB).7
Other predisposing medical factors for agitation include chronic pain, respiratory distress, and endocrine and metabolic abnormalities.1,2,7,8 Refer the patient for a medical workup, including laboratory and diagnostic tests based on lab results.
Neuropsychiatric conditions. Agitation may be the main presenting symptom of seizures, as well as:
- degenerative CNS diseases such as Parkinson’s disease, multiple sclerosis, and dementias, especially the Alzheimer’s type
- Tourette syndrome
- a pervasive developmental disorder
- inherited movement disorders, such as Wilson’s disease or Hallervorden-Spatz syndrome.2,8-10
Get a detailed patient and family history, then refer the patient for comprehensive physical and neurologic examinations.
Acknowledgments
The authors thank Leonard D. Williams, PA, and Drs. Nestor Manzano, Craig Campbell, Scott Ahles, Robert Hierholzer, and Avak Howsepian for their help.