Patients with acute psychomotor agitation are commonly attended in medical and psychiatric clinical settings. Agitation is a heterogeneous concept without a uniformly accepted definition; however, it is generally considered as a state of cognitive and motor hyperactivity characterized by excessive or inappropriate motor or verbal activity with marked emotional arousal (1–3). While it is difficult to estimate the prevalence of acute agitation episodes due to the scarcity of epidemiological studies, it is widely recognized that agitation is a common phenomenon, both in medical and psychiatric emergency and inpatient settings. Acute episodes of psychomotor agitation account for 900,000 annual visits to psychiatric emergency services (4) and represent a total of 1.7 million emergency department visits per year in the USA (5). Furthermore, it is estimated that up to 10% of psychiatric emergencies attended at emergency services involve an acute agitation episode (6–8). Agitation is frequently associated with an underlying psychiatric disorder, particularly schizophrenia, bipolar disorder, personality disorders, Alzheimer’s disease, or other types of dementia, among others (6, 9, 10). In cases of dementia, there are multiple factors that can precipitate or worsen psychomotor agitation, such as medical problems, drug adverse events, sleep abnormalities, delirium, depression, or environmental and social factors, but it is mostly linked to the severity of the neurocognitive disorder (11). Treatment of the agitated patient is complex, due to the status of the patient, the involvement of multiple healthcare professionals (HCPs), and the ethical/legal concerns on the different management procedures.

Various guidelines are available providing guidance on the medical and psychiatric assessment and the pharmacological and non-pharmacological management of the patient presenting with an episode of agitation, including the recent guidelines from Austrian Society for Neuro-Psychopharmacology and Biological Psychiatry (12), the recommendations from the World Federation of Societies of Biological Psychiatry (WFSBP) regarding management of acute agitation in schizophrenia (13), the Project BETA (Best practices in Evaluation and Treatment of Agitation) guidelines from the American Association for Emergency Psychiatry (2, 14–17), the Clinical Policy for Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department from the American College of Emergency Physicians’ (18), the guideline for Violence: the short-term management of disturbed/violent behavior in inpatient settings and emergency departments—CG25—issued by the United Kingdom National Institute for Health and Care Excellence (NICE) in 2005 (19) or the standards in Restraint and Seclusion proposed by the Joint Commission on Accreditation of Healthcare Organizations and the Centers for Medicare and Medicaid (20). In addition, the Expert consensus paper on the assessment management of agitation in psychiatry from the WFSBP has recently compiled the state-of-art of the assessment and management of agitation (21). In spite of all these guidelines, care of the agitated patient remains often suboptimal, partly as a result of the failure to implement updated consensus recommendations and treatment algorithms, and partly due to the heterogeneous etiology and complexity of the clinical presentation of the episode of agitation. An agreement for clearer patient-centered protocols that can be followed by all HCPs involved in the management of agitated patients in any clinical setting is an important unmet need.

A group of 20 experts from nine different countries across Europe and South America with an interest and large experience in the clinical management of agitated patients met in Madrid for the 1st International Experts’ Meeting on Agitation. This independent expert panel was set up to identify the difficulties and barriers HCPs face in daily clinical practice in the assessment and management of agitated patients in emergency and inpatient settings and to discuss practical recommendations to best improve them. Timely evaluation of precipitating factors and a prompt intervention are crucial to prevent escalation to violent behaviors and potentially dangerous situations. The objectives of the expert meeting and the present document is to increase awareness on the adequate assessment, early identification and on the optimal and most efficient individualized therapeutic interventions of an episode of agitation. The key topics addressed in this statement are as follows: (1) definition and identification of agitation, (2) current management practices of an episode of agitation, (3) ideal treatment interventions, and (4) current barriers and potential solutions for better management and treatment practices of agitated patients.

The present document is the result of a full-day meeting held in October 2016 in Madrid in which the need for improved communication and a practical consensus statement were identified. The meeting was attended by 20 Psychiatry experts actively involved in the clinical management of agitated patients from Argentina, Austria, Finland, France, Germany, Greece, Italy, Norway, Spain, and Sweden. The meeting was organized in different sections, where participants had the opportunity to discuss different concepts in groups using Workmats^® (22) and then shared the results with the rest of the groups to start a debate and reach conclusions. Workmat^® methodology consists in exercises presented in a poster format designed to maximize the interaction among participants and sharing of ideas to reach agreements and conclusions on a specific subject (22). The present document that has been reviewed and discussed within the expert group is the result of the debates during the meeting and the exchange of information and proposals prior and after the meeting. Following this process, the final document was circulated for written approval by all members of the Expert Group. For the preparation of the document, non-systematic search for clinical studies, randomized controlled trials, and reviews was performed from Medline, as well as from cross-referencing and identification by the participating experts. Details of the clinical presentation, assessment, and management of agitated patients were further informed by clinical expertise. Results and conclusions shown here represent the general views agreed by the experts group for episodes of agitation. Regarding the treatment, the discussion focused primarily on the pharmacological options. This practical consensus statement is written for specialists in psychiatry but is also intended to increase the understanding of acute agitation episodes from other healthcare providers.

Episodes of psychomotor agitation represent a significant challenge in the emergency department and inpatient settings, both for non-psychiatric and psychiatric clinical staff, as well as for patients and caregivers. Furthermore, agitation and most of the interventions and treatment strategies have consequences beyond the actual episode. Management of agitation has been associated with greater use of healthcare resources, increased length of inpatient stay, more hospital readmissions, and higher medication use, as well as raised burden and management costs (27–29). Therefore, one of the conclusions and agreements reached at this expert consensus meeting was recognizing the need of improving interaction, collaborative work, discussion, and agreements among experts involved in the management of patients with episodes of psychomotor agitation in order to share clinical experiences, and address and solve unmet needs. Furthermore, participants acknowledged the opportunity to discuss with colleagues from other settings and countries the experiences, difficulties, barriers, as well as commonalities and disparities in the different approaches in daily practice for managing episodes of psychomotor agitation in various clinical settings. It was also an opportunity to discuss local and international guidelines, and best clinical practice recommendations available locally or internationally to aid in the management of the agitated patient (2, 14–17, 21, 30).

In daily clinical practice, the three aspects that were discussed by the expert group, namely early identification, adequate management, and pharmacological treatment of agitation, are tightly intertwined. Thus, improvement of one of these areas may have a positive impact on the other ones. The potential for agitation to escalate into aggressive behavior, putting patients, staff, and others at risk, highlights the importance to address the behavior early, rapidly, and efficiently relying on the most adequate and effective pharmacological and non-pharmacological interventions for each patient to ensure the safety of everyone involved (6, 31). At the meeting, some solutions were identified by the expert participants to reduce the current barriers and, consequently, optimize the procedures and interventions for managing the agitated patient. However, such potential solutions did not target directly these three aspects of agitation but rather proposed more practical solutions that could be implemented in the day-to-day practice. An action plan is presented here (Figure 4) based on the discussion of the solutions at the meeting.

During the meeting, the workgroup agreed that it would be highly recommendable for the appropriate management of agitation to rely on standardized protocols at each center, particularly so, as treatment protocols and guidelines are commonly regarded as gold standards of care. In this context, an example of the updated treatment algorithm from the Hospital Clinic of Barcelona was presented and discussed (32). Such algorithm may be used as a starting point and adapted to each specific center. This would help the different members of multidisciplinary teams involved in the assessment and management of agitated patients to have a clearer understanding of the procedures to follow. Having standardized protocols would also help educate, train, and engage non-specialized and new staff in the early identification and management of the agitated patient. Since any protocol would have multiple decision choices, it is very important to keep track of the different procedures, so that the efficiency of each one can be measured. This would also provide evidence to guide any needed amendment to the original protocol.

The following strategic triad is highly relevant to advance the understanding of the most adequate management of agitation. The relevance lies on the continued improvement of the working flow: standardized protocols will improve an adequate assessment process, including methods of identification, management, and treatment of agitation. This will improve educational and training tools that will make a more efficient individual and team work possible. Standard procedures and trained professionals would allow an accurate registry of the agitation cases and analysis of the optimal actions. And closing the circle, this analysis will help improving the current protocols and algorithms, making possible a working method design that will allow updated optimal care of the agitated patient. This working plan requires some time and effort but may provide great improvements in the experience for patients, caregivers, and HCPs in the management of an episode of agitation, as well as a more efficient use of the economic and personal resources at each individual center.

JM-R moderated the meeting and overviewed the writing of the manuscript. All the authors contributed significantly to the discussion, ideas and conclusions presented here and reviewed critically, and approved the manuscript.

GDS has received honoraria (speaker/advisory board) from Angelini, Otsuka, Janssen; RF has been speaker for some workshops/seminars for Lilly, Otsuka, Lundbeck, Janssen, and Bristol-Myers-Squibb; MG has received funding for research projects and/or honoraria as a consultant or speaker for Ferrer, Janssen, Lundbeck and Instituto de Salud Carlos III; GG has received honoraria from Laboratories Bago, Otsuka, Laboratories Baliarda, Roemers, Casasco, Ferrer, Bayer, Baguete Engineering in Anesthesiology and Pfizer; KGK received speaker honoraria by Eli Lilly, neuraxpharm, Servier and Trommsdorf; JK has received financial support for IIT studies from Medtronic EuropeSARL (Meerbusch, Germany) and he has occasionally received honoraria from Lundbeck, Otsuka, Servier, Janssen, Trommsdorff, and Schwabe for lecturing at conferences; KP has received honoraria from AOP Orphan, Eli Lilly, and Ferrer; FR from Ferrer for the work under consideration for publication (non-financial support); AR has received financial compensation from Ferrer, Lundbeck, Janssen-Cilag S.A., Lilly, Pfizer, and Otsuka and has collaborated with Elan Corporation and Cephalon Inc.; GS has received honoraria as a consultant or speaker for Ferrer, Janssen, Lundbeck, and Adamed; JS has received travel grants and speakers honoraria from AOP Orphan, Janssen, G.L.Pharma, and Lundbeck. The rest of the authors have declared no conflicts of interest.