Behavioral Activity Rating Scale (BARS)
A 1-item rating scale to quantify a patient's level of agitation in acute care or psychiatric settings.
Provided by
EVAL FoundationInstructions
- Observe the patient's behavior and level of activity.
- Select the one description from the list that best matches the patient's current state.
- The tool will provide the corresponding BARS score, which quantifies the level of agitation.
- BARS can be reassessed at multiple time points after an intervention for agitation.
The Behavioral Activity Rating Scale (BARS) is a single-item, 7-point, clinician-observed rating scale designed to quantify a patient's level of agitation. It provides a quick and reliable method for assessing agitation, particularly in emergency or psychiatric settings, and for monitoring the patient's response to treatment.
When to Use
The BARS is intended for use by healthcare professionals to assess patients exhibiting signs of agitation. It is useful for initial assessment, tracking changes in agitation levels over time, and evaluating the efficacy of interventions aimed at calming the patient.
Scoring and Interpretation
The scale consists of seven distinct behavioral anchor points. The clinician selects the single best description of the patient's state:
| Score | Description |
|---|---|
| 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 activity (physical or verbal), calms with instructions |
| 6 | Extremely or continuously active, not requiring restraint |
| 7 | Violent, requires restraint |
A score of 4 is considered a normal level of activity. Scores above 4 indicate increasing levels of agitation, while scores below 4 indicate increasing levels of sedation.
Results
- BARS Score 1-3: Additional medical workup may be needed.
- BARS Score 4: Likely normal behavioral activity, intervention not needed.
- BARS Score 5-6: Indicates the need for verbal de-escalation or other behavioral interventions.
- BARS Score 7: Likely to require pharmacologic intervention and/or physical restraints. May required additional medical workup.
Evidence and Validation
The BARS was validated in a study by Swift et al. (2002) involving patients with acute agitation. The study demonstrated the scale's validity, reliability, and sensitivity to change. Key findings include:
- Inter-rater Reliability: The BARS showed excellent inter-rater reliability (weighted kappa = 0.90), indicating that different clinicians are likely to assign the same score to a patient.
- Concurrent Validity: The BARS was highly correlated with other established measures of agitation, including the Positive and Negative Syndrome Scale-Excited Component (PANSS-EC) (r=0.88) and the Clinical Global Impression-Severity of Illness (CGI-S) (r=0.83).
- Sensitivity to Change: The scale was effective in detecting changes in agitation levels following treatment with intramuscular ziprasidone.
The authors concluded that the BARS is a 'valid and reliable, single-item global rating scale of agitation that is quick to administer and sensitive to change.' Its simplicity makes it a practical tool for busy clinical environments.
All questions & possible results
Behavioral Activity Rating Scale (BARS)Title not visible
Select the best description of the patient's behavior:
Select one option:
- 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 activity (physical or verbal), calms with instructions
- 6: Extremely or continuously active, not requiring restraint
- 7: Violent, requires restraint
Possible results
BARS Score 3: Additional medical workup may be needed.
- Broaden the differential diagnosis to include possible medical causes of sedation or agitation in patients with BARS 1-3 or 7.
- BARS 1 requires close monitoring regardless of the etiology of their behavioral state.
- Although BARS can assess the behavioral response to acute interventions, it does not distinguish between medical and psychiatric etiologies of agitation.
- Suggested actions in response to BARS scores are based on expert consensus guidelines from the American Association of Emergency Psychiatry.
- BARS can be reassessed at multiple time points after an intervention for agitation.
Findings that require immediate evaluation by a clinician:
Symptoms
- Loss of memory, disorientation
- Severe headache
- Extreme muscle stiffness or weakness
- Heat intolerance
- Unintentional weight loss
- Psychosis (new onset)
- Difficulty breathing
Signs
- Abnormal vital signs: pulse, blood pressure, or temperature
- Overt trauma
- One pupil larger than the other
- Slurred speech
- Incoordination
- Seizures
- Hemiparesis
Factors that could indicate serious, possibly life-threatening, conditions:
- New onset at age >45 years
- Abnormal vital signs
- Focal neurological findings
- Evidence of head injury
- Substance intoxication
- Substance withdrawal
- Exposure to toxins or drugs
- Decreased awareness with attentional problems
BARS Score 7: Likely to require pharmacologic intervention and/or physical restraints. May required additional medical workup.
- Broaden the differential diagnosis to include possible medical causes of sedation or agitation in patients with BARS 1-3 or 7.
- BARS can be reassessed at multiple time points after an intervention for agitation.
- Although BARS can assess the behavioral response to acute interventions, it does not distinguish between medical and psychiatric etiologies of agitation.
- Suggested actions in response to BARS scores are based on expert consensus guidelines from the American Association of Emergency Psychiatry.
Findings that require immediate evaluation by a clinician:
Symptoms
- Loss of memory, disorientation
- Severe headache
- Extreme muscle stiffness or weakness
- Heat intolerance
- Unintentional weight loss
- Psychosis (new onset)
- Difficulty breathing
Signs
- Abnormal vital signs: pulse, blood pressure, or temperature
- Overt trauma
- One pupil larger than the other
- Slurred speech
- Incoordination
- Seizures
- Hemiparesis
Factors that could indicate serious, possibly life-threatening, conditions:
- New onset at age >45 years
- Abnormal vital signs
- Focal neurological findings
- Evidence of head injury
- Substance intoxication
- Substance withdrawal
- Exposure to toxins or drugs
- Decreased awareness with attentional problems
BARS Score 4: Likely normal behavioral activity, intervention not needed.
- Although BARS can assess the behavioral response to acute interventions, it does not distinguish between medical and psychiatric etiologies of agitation.
- Suggested actions in response to BARS scores are based on expert consensus guidelines from the American Association of Emergency Psychiatry.
- BARS can be reassessed at multiple time points after an intervention for agitation.
Findings that require immediate evaluation by a clinician:
Symptoms
- Loss of memory, disorientation
- Severe headache
- Extreme muscle stiffness or weakness
- Heat intolerance
- Unintentional weight loss
- Psychosis (new onset)
- Difficulty breathing
Signs
- Abnormal vital signs: pulse, blood pressure, or temperature
- Overt trauma
- One pupil larger than the other
- Slurred speech
- Incoordination
- Seizures
- Hemiparesis
Factors that could indicate serious, possibly life-threatening, conditions:
- New onset at age >45 years
- Abnormal vital signs
- Focal neurological findings
- Evidence of head injury
- Substance intoxication
- Substance withdrawal
- Exposure to toxins or drugs
- Decreased awareness with attentional problems
BARS Score 6: Indicates the need for verbal de-escalation or other behavioral interventions.
- Attempt verbal de-escalation with patients with BARS 5-6 before resorting to pharmacologic or physical restraints.
- Although BARS can assess the behavioral response to acute interventions, it does not distinguish between medical and psychiatric etiologies of agitation.
- Suggested actions in response to BARS scores are based on expert consensus guidelines from the American Association of Emergency Psychiatry.
- BARS can be reassessed at multiple time points after an intervention for agitation.
Findings that require immediate evaluation by a clinician:
Symptoms
- Loss of memory, disorientation
- Severe headache
- Extreme muscle stiffness or weakness
- Heat intolerance
- Unintentional weight loss
- Psychosis (new onset)
- Difficulty breathing
Signs
- Abnormal vital signs: pulse, blood pressure, or temperature
- Overt trauma
- One pupil larger than the other
- Slurred speech
- Incoordination
- Seizures
- Hemiparesis
Factors that could indicate serious, possibly life-threatening, conditions:
- New onset at age >45 years
- Abnormal vital signs
- Focal neurological findings
- Evidence of head injury
- Substance intoxication
- Substance withdrawal
- Exposure to toxins or drugs
- Decreased awareness with attentional problems
BARS Score 2: Additional medical workup may be needed.
- Broaden the differential diagnosis to include possible medical causes of sedation or agitation in patients with BARS 1-3 or 7.
- BARS 1 requires close monitoring regardless of the etiology of their behavioral state.
- Although BARS can assess the behavioral response to acute interventions, it does not distinguish between medical and psychiatric etiologies of agitation.
- Suggested actions in response to BARS scores are based on expert consensus guidelines from the American Association of Emergency Psychiatry.
- BARS can be reassessed at multiple time points after an intervention for agitation.
Findings that require immediate evaluation by a clinician:
Symptoms
- Loss of memory, disorientation
- Severe headache
- Extreme muscle stiffness or weakness
- Heat intolerance
- Unintentional weight loss
- Psychosis (new onset)
- Difficulty breathing
Signs
- Abnormal vital signs: pulse, blood pressure, or temperature
- Overt trauma
- One pupil larger than the other
- Slurred speech
- Incoordination
- Seizures
- Hemiparesis
Factors that could indicate serious, possibly life-threatening, conditions:
- New onset at age >45 years
- Abnormal vital signs
- Focal neurological findings
- Evidence of head injury
- Substance intoxication
- Substance withdrawal
- Exposure to toxins or drugs
- Decreased awareness with attentional problems
BARS Score 5: Indicates the need for verbal de-escalation or other behavioral interventions.
- Attempt verbal de-escalation with patients with BARS 5-6 before resorting to pharmacologic or physical restraints.
- Although BARS can assess the behavioral response to acute interventions, it does not distinguish between medical and psychiatric etiologies of agitation.
- Suggested actions in response to BARS scores are based on expert consensus guidelines from the American Association of Emergency Psychiatry.
- BARS can be reassessed at multiple time points after an intervention for agitation.
Findings that require immediate evaluation by a clinician:
Symptoms
- Loss of memory, disorientation
- Severe headache
- Extreme muscle stiffness or weakness
- Heat intolerance
- Unintentional weight loss
- Psychosis (new onset)
- Difficulty breathing
Signs
- Abnormal vital signs: pulse, blood pressure, or temperature
- Overt trauma
- One pupil larger than the other
- Slurred speech
- Incoordination
- Seizures
- Hemiparesis
Factors that could indicate serious, possibly life-threatening, conditions:
- New onset at age >45 years
- Abnormal vital signs
- Focal neurological findings
- Evidence of head injury
- Substance intoxication
- Substance withdrawal
- Exposure to toxins or drugs
- Decreased awareness with attentional problems
BARS Score 1: Additional medical workup may be needed.
- Broaden the differential diagnosis to include possible medical causes of sedation or agitation in patients with BARS 1-3 or 7.
- BARS 1 requires close monitoring regardless of the etiology of their behavioral state.
- Although BARS can assess the behavioral response to acute interventions, it does not distinguish between medical and psychiatric etiologies of agitation.
- Suggested actions in response to BARS scores are based on expert consensus guidelines from the American Association of Emergency Psychiatry.
- BARS can be reassessed at multiple time points after an intervention for agitation.
Findings that require immediate evaluation by a clinician:
Symptoms
- Loss of memory, disorientation
- Severe headache
- Extreme muscle stiffness or weakness
- Heat intolerance
- Unintentional weight loss
- Psychosis (new onset)
- Difficulty breathing
Signs
- Abnormal vital signs: pulse, blood pressure, or temperature
- Overt trauma
- One pupil larger than the other
- Slurred speech
- Incoordination
- Seizures
- Hemiparesis
Factors that could indicate serious, possibly life-threatening, conditions:
- New onset at age >45 years
- Abnormal vital signs
- Focal neurological findings
- Evidence of head injury
- Substance intoxication
- Substance withdrawal
- Exposure to toxins or drugs
- Decreased awareness with attentional problems
Citation
Swift RH, Harrigan EP, Cappelleri JC, Kramer D, Chandler LP. Validation of the behavioural activity rating scale (BARS): a novel measure of activity in agitated patients. J Psychiatr Res. 2002 Mar-Apr;36(2):87-95. doi: 10.1016/s0022-3956(01)00052-8. PMID: 11777497.
Literature
- Validation of the behavioural activity rating scale (BARS): a novel measure of activity in agitated patients. J Psychiatr Res. 2002 Mar-Apr;36(2):87-95. doi: 10.1016/s0022-3956(01)00052-8. PMID: 11777497. — Swift RH, Harrigan EP, Cappelleri JC, Kramer D, Chandler LP.
- Translation, cross-cultural adaptation, and validation of the Behavioral Activity Rating Scale (BARS) for the Brazilian population. Trends Psychiatry Psychother. 2023;45:e20210310. doi: 10.47626/2237-6089-2021-0310. Epub 2022 Feb 7. PMID: 35129902; PMCID: PMC9991416. — Pereira LA, da Silva AG, Hemanny C, de Jesus R, Moromizato M, Vieira T, Souza M, Lima MG, Baldaçara L.
- Medical evaluation and triage of the agitated patient: consensus statement of the american association for emergency psychiatry project Beta medical evaluation workgroup. West J Emerg Med. 2012 Feb;13(1):3-10. doi: 10.5811/westjem.2011.9.6863. PMID: 22461915; PMCID: PMC3298208. — Nordstrom K, Zun LS, Wilson MP, Stiebel V, Ng AT, Bregman B, Anderson EL.
