The role of restraint in fatal excited delirium: a research synthesis and pooled analysis

Forensic Sci Med Pathol. 2020 Dec;16(4):680-692. doi: 10.1007/s12024-020-00291-8. Epub 2020 Aug 22.


The purpose of the present study was to perform a comprehensive scientific literature review and pooled data risk factor analysis of excited delirium syndrome (ExDS) and agitated delirium (AgDS). All cases of ExDS or AgDS described individually in the literature published before April 23, 2020 were used to create a database of cases, including demographics, use of force, drug intoxication, mental illness, and survival outcome. Odds ratios were used to quantify the association between death and diagnosis (ExDS vs. AgDS) across the covariates. There were 61 articles describing 168 cases of ExDS or AgDS, of which 104 (62%) were fatal. ExDS was diagnosed in 120 (71%) cases, and AgDS in 48 (29%). Fatalities were more likely to be diagnosed as ExDS (OR: 9.9, p < 0.0001). Aggressive restraint (i.e. manhandling, handcuffs, and hobble ties) was more common in ExDS (ORs: 4.7, 14, 29.2, respectively, p < 0.0001) and fatal cases (ORs: 7.4, 10.7, 50, respectively, p < 0.0001). Sedation was more common in AgDS and survived cases (OR:11, 25, respectively, p < 0.0001). The results of the study indicate that a diagnosis of ExDS is far more likely to be associated with both aggressive restraint and death, in comparison with AgDS. There is no evidence to support ExDS as a cause of death in the absence of restraint. These findings are at odds with previously published theories indicating that ExDS-related death is due to an occult pathophysiologic process. When death has occurred in an aggressively restrained individual who fits the profile of either ExDS or AgDS, restraint-related asphyxia must be considered a likely cause of the death.

Keywords: Agitated delirium; Choke hold; Epidemiology; Excited delirium; Restraint asphyxia.

Publication types

  • Meta-Analysis
  • Review

MeSH terms

  • Asphyxia / etiology
  • Asphyxia / mortality
  • Delirium / mortality*
  • Humans
  • Psychomotor Agitation / mortality*
  • Restraint, Physical / adverse effects*
  • Substance-Related Disorders / complications