BARS: Easy Tool to Assess for Agitation in Patients for Occupational Therapy

Introduction

One way to communicate to other staff a patient’s level of agitation for occupational therapy such as in psychiatric settings like locked units is with an objective scale. A scale like the Behavioral Activity Rating Scale (BARS) can be used to measure agitation and also to help reduce defensive behaviors from staff, which can result in worse outcomes.

Best Practices

A scale like the BARS should be used as early as possible to establish a baseline. If used when a patient appears agitated, it may not be as useful as there is nothing to compare the score to. An example of a good time is to measure BARS before even arriving at the facility. For the BARS, a score higher than a 4 may warrant evaluation by a clinician and the proper precautions taken place.[1]Richmond, J. S., Berlin, J. S., Fishkind, A. B., Holloman Jr, G. H., Zeller, S. L., Wilson, M. P., … & Ng, A. T. (2012). Verbal de-escalation of the agitated patient: consensus statement of … Reference List An example may be having the patient removed from room with neighbors, having a sitter in the room, alerting the staff and physician, consider medications, restraints, and other protocols set in place by the facility within the law.

Behavioral Activity Rating Scale (BARS)

  1. Difficult or unable to rouse
  2. Asleep but responds normally to verbal or physical contact
  3. Drowsy, appears sedated
  4. Quiet and awake (normal level of activity)
  5. Signs of overt (physical or verbal) activity, calms down with instructions
  6. Extremely or continuously active, not requiring restraint
  7. Violent, requires restraint*

*chemical and/or physical

Causes of Acuity Changes

Although the scale seems pretty straightforward, both the occupational therapist as well last the staff should apply clinical reasoning as to why the patient may be behaving the way that they are, such as backtracking staff interactions, medications, medical changes, poor sleep, changes in routine, etc.

  • Cognitive (e.g., attention)
  • Neurological (e.g., stroke, seizures, dementia, sundowning)
  • Psychosocial, e.g., depression, bipolar
  • Physical, e.g., shock
  • PTSD
  • Fear
  • Cultural and/or language barriers
  • Trauma (Consider Trauma Informed Care, TIC)
  • Staff manipulation, e.g., staff splitting, faking of symptoms
  • Malnutrition
  • Hypoglycemia (diabetes)
  • Intoxication or drug’s effects
  • Drug withdrawal from drug abuse (also use CIWA)
  • Unintended withdrawal effects from opioid reversal medication such as Naloxone (Narcan)
  • Medications side effects
  • Pain (acute, chronic)
  • Infection, e.g., UTI
  • Poor rest and sleep; insomnia
  • Psychosis (hallucinations; positive AND negative psychosis)
  • Suicide ideation
  • Social factors, e.g., perceived racism from staff, mistreatment by staff, shift changes
  • Crowds, numerous new admissions
  • Institutional factors, e.g., being handcuffed
  • Personality disorders
  • Environmental, e.g., loud annoying sounds, noxious smells
  • Sensory integration dysregulation
  • Lack of locus of control or freedom
  • Deviation from routine, unpredictability
  • Time: anniversaries
  • Historical or recent events
  • Family or domestic dispute and abuse

Other Scales

  • Overt Aggression Scale
  • Scale for the Assessment of Aggressive and Agitated Behaviors
  • Staff Observation Aggression Scale

References

References
1 Richmond, J. S., Berlin, J. S., Fishkind, A. B., Holloman Jr, G. H., Zeller, S. L., Wilson, M. P., … & Ng, A. T. (2012). Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. Western Journal of Emergency Medicine, 13(1), 17.