Warning signs
| Pacing | Flushed skin |
| Delusions | Problems focusing |
| Rubbing forehead | Red eyes |
| Mood changes | Confusion |
| Furrowing eyebrows | Flared nostrils |
| Scowling | Clenched fists |
| Deep breaths in or accelerating breathing | Cupping fist |
| Grinding teeth | Swearing |
| No eye contact | Sighing |
| Disorganized thinking | Sarcasm |
| Crying | Muttering |
| Shaking or trembling | Slurred speech |
| Criticizing | Talking louder |
| Demanding | Sweating |
| Hallucinating | Staring |
Medications used for mood stabilisation or to prevent agitation_
| Type of medication | Medications | Comments/ Evidence |
|---|---|---|
| Atypical Anti-psychotics | Quetiapine | Impact neurotransmitters such as dopamine, serotonin and noradrenaline. |
| Typical antipsychotics | Haloperidol | Two studies identified that haloperidol was not effective in behaviour management post-traumatic brain injury but increased duration of post-traumatic amnesia and length of stay (Rao et al., 1985; Anderson et al., 2016). Should be avoided in the older population due to side effects of dyskinesia. |
| Benzodiazepines | Lorazepam | Benzodiazepines work by enhancing the action of gamma-aminobutyric acid (GABA) which has an inhibiting effect on the central nervous system. These medications can help abort seizures. They are quick to work but can cause oversedation and respiratory compromise. Chronic use can cause dependence, (Zareifopoulos & Panayiotakopoulos; 2019) |
| Beta-blockers | Propranolol | Caution with bradycardia and hypotension with higher dosages (Rahmani et al., 2021). |
| Antiepileptics | Valproic acid, Sodium | For mood stabilisation. |
| Antidepressants | Sertraline | For improved mood or cognition or treatment of depression but no studies demonstrated significant reduction in agitation (Rahmani et al., 2021). |
| Hormone | Melatonin | Regulates the sleep-wake cycle. |
| Dopamine agnostic | Amantadine | A prescription of Amantadine 100 milligrams twice daily has been reported to be effective and safe for use in patients displaying irritability or aggression after a traumatic brain injury in the chronic phase as long as creatinine clearance has been established (Ter Mors, Backx, Spauwen et al., 2019; Neumann et al., 2017). Amantadine may increase the risk of agitation in the critically ill (Williamson et al., 2019). |
Examples of unmet needs
| Sleep deprivation – not being addressed | Inadequate nutrition or fluids |
| Pain that is uncontrolled | Side effects of medications |
| Nausea and vomiting -uncontrolled | Noisy environment |
| Constipation that is unmanaged | Wants to smoke or vape |
| Urinary retention or urgency | Wants a single room vs a shared room |
| An infection that is not healing | Wants light on /off |
| Electrolyte imbalances | Wants to get up and walk by self |
| Metabolic abnormalities | Wounds that are sore or require dressing |
Recommendations for a safe, patient centred, environment (In acute/sub-acute areas)
| Provide natural light and access to views of nature | Provide comfortable seats for patients |
| Provide low stimulus environment | Provide interesting visual and sensory stimuli |
| Provide open areas for patients to ambulate freely and for family to visit | Allow access to privacy- single room with access to a bathroom |
| Provide consistent and well-trained staff | Ensure there is adjustable temperature and lighting |
| Minimise movement in and out of the patient’s room at night | Provide adequate signage for bathrooms, open shared areas, etc |
| Reduce objects in the room that could cause harm to the patient or others | Provide open outdoor area for recreational activities |
| Implement falls risk strategies (bed to the lowest level, consider removal of medical devices if appropriate, video monitoring) | Reduce stimulation overnight where clinically appropriate, including nursing assessment, medication administration, ambient hallway noise and removal of waste. Cluster activities during day time hours where appropriate |
| Provide orientation board that includes name, place, time | Promote environmental stimuli such as family pictures or personal possessions |
| Provide access to a clock to support orientation | Ensure music therapy is adjusted to the patient’s preference |
Some helpful de-escalation phrases are below:
| I can’t imagine what you are going through, but I would like to understand a little more about it, can you help me to understand? |
| I can see you have some pain, can I get you something to help? |
| I can see you are upset, I am here to help, what can I do for you? |
| I am (name) and I am (role) and I am here to help you |
| I can understand your frustration and it is a difficult environment for you, let me understand how I can help you. |
| I am sorry I understand you are upset but when you speak to me like that I feel scared (boundaries). Can you take a seat in your chair or on your bed (options) and then we can talk about how I can help (identifying unmet need and showing empathy). |
Useful tips for verbal de-escalation as developed from Richmond’s (2012) ten domains of de-escalation:
| Communication | One person should be the main communicator with the patient to build rapport (as much as possible). |
| Listen to the patient | Establish what they need or want |
| Set boundaries | Explain what is acceptable behaviour |
| Introduce others in the room | Identify who needs to be in the room, can some people leave? Explain why the people are in the room and what they are there to do. |
| Reduce stimulation | Remove objects from room that are not needed |