Management Of Agitation Research Articles

Pharmacological emergency management of agitation in children and young people: protocol for a randomised controlled trial of oral medication (PEAChY-O)

IntroductionAcute severe behavioural disturbance (ASBD) is a condition seen with increasing frequency in emergency departments (EDs) in adults and young people. Despite the increasing number of presentations and significant associated...

Pharmacological Emergency management of Agitation in Children and Young people: protocol for a randomised controlled trial of intraMuscular medication (PEAChY-M)

IntroductionAcute severe behavioural disturbance (ASBD) is a condition seen with increasing frequency in emergency departments (EDs) in adults and young people. Despite the increasing number of presentations and significant associated...

The pharmacological management of acute behavioural disturbance in pregnancy

SUMMARYAcute behavioural disturbance is relatively common during the perinatal period. The management of agitation in pregnant women is similar to that in the general population, although with some additional considerations, such as modifications to restraint techniques, careful medication selection, monitoring of maternal and fetal well-being and the importance of a debrief. There are benefits of agreeing a pre-determined care plan for women who are at risk.

Critical Issues in the Management of Agitation, Aggression, and End-of-Life in Delusional Disorder: A Mini-Review

Background: Compared to other psychotic disorders, there is little information about staging care in delusional disorder (DD). Unlike schizophrenia, this is a disorder that begins in middle age, a time at which chronic medical comorbidities have already begun to impact global functioning. With age, the combination of psychological and somatic conditions leads to new behaviours, e.g., agitation, aggression, and behaviours that require specific preventive and interventive measures. With further age, knowledgeable end-of-life care becomes necessary for this population. Aim: The aim of this article was to review existing evidence on the management of these successive phases. Methods: We conducted a narrative review using PubMed and ClinicalTrials.gov and searched for the following terms: (agitation OR aggressivity OR aggression OR palliative OR "end-of-life") AND ("delusional disorder"). Results: We found that the literature was sparse. Existing evidence suggests that medical causes are frequently at the root of agitation and aggression. With respect to management, de-escalation strategies are generally preferred over pharmacotherapy. Specific delusional syndromes, e.g., de Clérambault, Othello, Capgras, Fregoli, as well as folie à deux, are associated with aggression. The somatic subtype of DD is the one most often requiring palliative care at the end of life. Conclusions: We conclude that insufficient attention has been given to the care needs of the accelerated aging process in DD.

Management of Agitation in Behaviours That Challenge in Dementia Care: Multidisciplinary Perspectives on Non-Pharmacological Strategies.

NICE guidelines recommend non-pharmacological interventions as the first-line approach for the management of behaviours that challenge. Recent work, however, highlights dissatisfaction with the lack of detailed guidance in the national guidelines regarding non-drug interventions. This study examines the views of practitioners regarding non-pharmacological treatments. It further explores perspectives on non-pharmacological strategies used in the management of agitation occurring within episodes of behaviours that challenge. Forty-two experienced practitioners attended a workshop where behaviours that challenge were described as occurring in three phases of agitation, using a framework adapted from the Positive Behaviour Support framework (pre-agitation, triggering and escalating, high level). The participants were asked to populate a template derived from the adapted framework. The completed templates recorded the clinical strategies the participants found useful to (i) prevent the occurrence of agitation, (ii) de-escalate distress and (iii) deal with perceived high levels of agitation. The Positive Behaviour Support conceptual framework was perceived by participants as helpful in organising their clinical work. A number of interventions were suggested as preventative strategies: music therapy, doll therapy, physical activity and generic person-centred communication skills to enhance wellbeing. In contrast, de-escalation strategies identified by the participants focused on reducing emotional distress. The approaches for dealing with continued high levels of agitation involved a number of "control and restraint" techniques as well as medication. The template allowed specialist multidisciplinary professionals to identify skills for the management of distress and agitated behaviour linked to the respective phase of arousal. The template has scope to guide practitioners to identify the detail needed for the management of behaviours that challenge. The findings have the potential to influence the contents of forthcoming guidelines on alternatives to psychotropics in dementia care.

Sublingual dexmedetomidine: repurposing an anesthetic as an anti-agitation agent

ABSTRACT Introduction Especially when acutely ill, individuals with schizophrenia and bipolar disorder can present with agitated behavior. The initial approach to agitation management are non-pharmacologic strategies such as verbal de-escalation techniques; however, pharmacologic interventions may be needed. Dexmedetomidine is a selective alpha-2 adrenergic receptor agonist, and a sublingual formulation has been approved in the US for the treatment of agitation associated with schizophrenia and bipolar disorder in adults. Areas covered The authors review the published literature on sublingual dexmedetomidine using the US National Library of Medicine’s PubMed.gov resource. Pharmacodynamics, pharmacokinetics, and efficacy and tolerability findings are summarized. The authors also provide a discussion to its potential place in the treatment armamentarium. Expert opinion Sublingual dexmedetomidine is an effective and well-tolerated pharmacologic option for the treatment of agitation associated with schizophrenia and bipolar disorder. The sublingual method of administration allows for a rapid onset of action with treatment effects beginning as early as 20 minutes after administration. Adverse effects include somnolence, hypotension, oral paresthesia, hypoesthesia, and dry mouth. Further study will be needed to evaluate sublingual dexmedetomidine in real-world patients receiving concomitant psychotropic medications.

Prehospital Use of Ketamine versus Benzodiazepines for Sedation among Pediatric Patients with Behavioral Emergencies

Introduction Ketamine is an emerging alternative sedation agent for prehospital management of agitation, yet research is limited regarding its use for children. Our objective was to compare the effectiveness and safety of ketamine and benzodiazepines when used for emergent prehospital sedation of pediatric patients with behavioral emergencies. Methods We performed a retrospective review of 9-1-1 EMS records from the 2019-2020 ESO Data Collaborative research datasets. We included patients ≤18 years of age who received ketamine or benzodiazepines for EMS primary and secondary impressions indicating behavioral conditions. We excluded patients with first Glasgow Coma Scale (GCS) scores ≤8, those receiving ketamine or benzodiazepines prior to EMS arrival, those receiving both ketamine and benzodiazepines, and interfacility transfers. Effectiveness outcomes included general clinician assessment of improvement, decrease in GCS, and administration of a subsequent sedative. Safety outcomes included mortality; advanced airway placement; ventilatory assistance without advanced airway placement; or marked sedation (GCS ≤8). Chi-square and t-tests were used to compare the ketamine and benzodiazepines groups. Results Of 57,970 pediatric patients with behavioral complaints and GCS scores >8, 1,539 received ketamine (13.3%, n = 205) or a benzodiazepine (86.7%, n = 1,334). Most patients were ≥12 years old (89.2%, n = 1,372), predominantly Caucasian (48.3%, n = 744), and were equally distributed by sex (49.7% male, n = 765). First treatment with ketamine was associated with a greater likelihood of improvement (88.8% vs 70.5%, p < 0.001) and a greater average GCS reduction compared to treatment with benzodiazepines (-2.5 [SD:4.0] vs −0.3 [SD:1.7], p < 0.001). Fewer patients who received ketamine received subsequent medication compared to those who received benzodiazepines (12.2% vs 27.0%, p < 0.001). Marked sedation was more frequent with ketamine than benzodiazepines (28.8% vs 2.9%, p < 0.001). Provision of ventilatory support (1.5% vs 0.5%, p = 0.14) and advanced airway placement (1.0% vs 0.2%, p = 0.09) were similar between ketamine and benzodiazepine groups. No prehospital deaths were reported. Conclusion In this pediatric cohort, prehospital sedation with ketamine was associated with greater patient improvement, less subsequent sedative administration, and greater sedation compared to benzodiazepines. Though we identified low rates of adverse events in both groups, ketamine was associated with more instances of marked sedation, which bears further study.

They're Dying. Now What? The Impact of a 2-Hour End-of-Life Educational Intervention on Bedside Nurse Self-efficacy, Knowledge, and Clinical Practice.

The palliative care team identified a lack of knowledge and confidence for nurses providing end-of-life care in a hospital. The team completed a quality improvement project establishing significant improvement in knowledge and self-efficacy after a 2-hour educational intervention. The next step was to study the impact on practice. Clinical management of pain, dyspnea, secretions, and agitation was compared for a 3-month period before and after intervention. Thirty-six patients were identified in the preintervention group, and 46 patients were in the postintervention group. A 2-sample proportion Z test ( α = .05, 2-tailed) showed no statistical significance in the number of doses of opioids administered between preintervention and postintervention groups; however, the number of patients in the postintervention group that received an opioid orally was significantly greater ( z = -2.098, P = .0357). A significantly lower proportion of the postintervention group received benzodiazepines ( z = -4.334, P < .00001). The postintervention group had a statistically significant lower proportion of anticholinergics administered ( z = -4.189, P < .00001). Significantly more patients in the postintervention group had oxygen titrated ( z = -3.196, P = .0014) and were on room air at the time of death ( z = -3.891, P = .0001). A 2-hour training led to statistically significant changes in the use of evidence-based interventions.

Updates in the Assessment and Management of Agitation.

Agitated patients can be dangerous to themselves and others. In fact, severe medical complications and death can occur with severe agitation. Because of this, agitation is considered a medical and psychiatric emergency. Regardless of the treatment setting, identifying the agitated patient early is a necessary skill. The authors review relevant literature regarding the identification and management of agitation and summarize current recommendations for adults, as well as children and adolescents.

Survey of Guideline Compliance and Attitude Toward Symptom Management in Japanese Intensive Care Units.

The Clinical Practice Guideline for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit (ICU) was revised in 2018 to include sleep disruption and immobility. Inadequate management of these symptoms can lead to negative consequences. A 2019 survey in Japan found that the guideline was recognized but needed to be consistently implemented. This study aimed to examine compliance with the guideline for symptom management of pain, agitation, delirium, and sleep in Japanese ICUs. This study included all ICUs in Japan and asked one representative from each unit to respond to the web survey from January 2022 to February 2022. Of a potential 643 units, 125 respondents from the ICU were included in the analysis (19.4% response rate). Compared to the guideline's recommendations, (a) pain assessment was performed in 86.3% of patients who could self-report, and in 72.0% of those who could not self-report; (b) agitation and sedation assessment was performed in 99% of patients; (c) only 66.1% of nurses reported assessing sleep quality on the units, and 9.1% performed the subjective sleep quality assessment; (d) the use of the recommended risk factor of the delirium assessment tool was low (9.6%). Additionally, according to the survey respondents, contrary to the guideline, many units administered medications to prevent and treat delirium, and approximately 30% used multiple non-drug interventions. The data are expressed as numbers and percentages. Some datasets were incomplete due to missing values. Most units used drugs for delirium prevention and treatment, and only a few used non-drug interventions. There is a need to popularize the assessment of sleep and delirium risk factors and use non-drug interventions to promote patient-centered care in the future.

Legal Considerations in Emergency Psychiatry.

Emergency psychiatry stands at the fulcrum between the general principles of autonomy and liberty balanced against illnesses that both subvert autonomy and amplify risks for violence and suicide. Although all specialties of medicine must operate in adherence with the law, emergency psychiatry is particularly constrained and guided by state and federal laws. Routine matters of emergency psychiatric care-including involuntary assessment, admission and treatment, management of agitation, medical stabilization and transfer, confidentiality, voluntary and involuntary commitment, and duties to third parties-all occur within carefully delimited legal boundaries, rules, and processes. This article provides a basic overview of critical legal principles relevant to the practice of emergency psychiatry.

Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry.

Agitation in children and adolescents in the emergency department (ED) can be dangerous and distressing for patients, family and staff. We present consensus guidelines for management of agitation among pediatric patients in the ED, including non-pharmacologic methods and the use of immediate and as-needed medications. Using the Delphi method of consensus, a workgroup comprised of 17 experts in emergency child and adolescent psychiatry and psychopharmacology from the the American Association for Emergency Psychiatry and the American Academy of Child and Adolescent Psychiatry Emergency Child Psychiatry Committee sought to create consensus guidelines for the management of acute agitation in children and adolescents in the ED. Consensus found that there should be a multimodal approach to managing agitation in the ED, and that etiology of agitation should drive choice of treatment. We describe general and specific recommendations for medication use. These guidelines describing child and adolescent psychiatry expert consensus for the management of agitation in the ED may be of use to pediatricians and emergency physicians who are without immediate access to psychiatry consultation.Reprinted from West J Emerg Med 2019; 20:409-418, with permission from the authors. Copyright © 2019.

Haloperidol-Midazolam vs. Haloperidol-Ketamine in Controlling the Agitation of Delirious Patients; a Randomized Clinical Trial.

Agitation management in delirious patients is crucial in a crowded emergency department (ED) for both patient and personnel safety. Benzodiazepines, antipsychotics, and newly derived ketamine are among the most commonly used drugs in controlling these cases. This study aimed to compare the effectiveness of haloperidol-midazolam with haloperidol-ketamine combination in this regard. In this double-blind randomized clinical trial, delirious patients with agitation in ED were randomly assigned to a group: group A: haloperidol 2.5 mg IV and midazolam 0.05 mg/kg IV or group B: haloperidol 2.5 mg IV and ketamine 0.5 mg/kg IV. Sedative effects as well as side effects at 0, 5, 10, 15, 30 minutes and 1, 2, 4 hours after the intervention were compared between the 2 groups. We enrolled 140 cases with Altered Mental Status Score (AMSS)≥+2 and mean age of 52.819.4 years (78.5% male). Agitation was significantly controlled in both groups (p<0.05). In group B, AMSS score was more significantly and rapidly reduced 5 (p = 0.021), 10 (p = 0.009), and 15 (p = 0.034) minutes after drug administration. After intervention, oxygen saturation was significantly decreased in group A 5 (p = 0.031) and 10 (p = 0.019) minutes after baseline. Time required to the maximum effect was significantly lower in group B versus group A (p=0.014). Less patients in group B had major side effects (p=0.018) and needed physical restraint (p=0.001). Haloperidol-ketamine can control agitation in delirium more rapidly than haloperidol-midazolam. This combination had lower adverse events with lower need for physical restraint.

Recommendations for non-pharmacological management of patient agitation in the adult ICU

Recommendations for non-pharmacological management of patient agitation in the adult ICU

Clinical Practice Guidelines for Assessment and Management of Patients with Substance Intoxication Presenting to the Emergency Department.

Clinical Practice Guidelines for Assessment and Management of Patients with Substance Intoxication Presenting to the Emergency Department.

Evidence-Based Guideline: Individualized Music for Persons with Dementia (7th Edition) — Non-Pharmacological Intervention for Agitation

Individualized music is a non-pharmacological intervention for the management of agitation in persons with dementia. It is supported by the Middle-Range Theory of Individualized Music Intervention for Agitation (IMIA), including testable propositions. The Evidence-Based Guideline: Individualized Music for Persons with Dementia (PWD) was originally published in 1996, has recently been updated and is now in its 7th edition. The current edition is 81 pages in length and includes 144 references. This guideline provides the culmination of over 30 years of research and clinical implementation. The guideline provides a grading schema for the strength and consistency of evidence, with a step-by-step description of the intervention to insure consistency in implementation and evaluation of outcome measures. The intervention is individualized at multiple levels, and is more than simply playing preferred music for the PWD. The intervention emphasizes personhood by including the role of music in the person’s life prior to the onset of cognitive impairment. This includes the role of music in the person’s ethnic identity and religious practice. The intervention has been empirically and clinically tested by scholars in an expanding number of countries. Individualized music is versatile and has been successfully used in home care, adult day care, assisted living, longterm care, post-acute care, and palliative care. As with previous editions, the 7th edition is available, along with all supporting documents and forms, as a free downloadable pdf.

Special Circumstances: Agitation with Dementia in Emergency Departments

AbstractBackgroundOlder persons presenting to the emergency department (ED) with agitation have a high prevalence of cognitive impairment which may not have been previously diagnosed.. Agitation in the ED may have many causes, one of the most prominent of which is delirium which occurs in 8–10% of older persons in the ED, and is often not diagnosed till hospital admission . The recently developed IPA algorithm for diagnosis and management of agitation in dementia is applicable to the ED environment particularly as it applies to delirium.MethodThis abstract describes the application of the IPA algorithm to the ED settingResultsOne of the major challenges of agitation management in the ED is taking a history, particularly for patients coming from a LTC environment. LTC staff can readily describe the index episode of agitation, but what is often missing is understanding the timeframe of agitation, including provoking and mitigating factors and any history of prior episodes and their causes. This makes it difficult to know if cognitive impairment is chronic or acute, the hallmark of delirium. A systematic approach to diagnosis and management is required. EDs are making increased use of well‐validated delirium screening assessments such as the Confusion Assessment Method (CAM). Other useful tools for management of delirium in the ED include ADEPT and the Delirium Triage Screen (DTS).Nonpharmacologic strategies have an important role in treatment of agitated patients in the ED. Interventions to prevent or reduce delirium in acute care environments are becoming increasingly effective: a recent Cochrane review supported the effectiveness of interventions including re‐orientation (including use of familiar objects), cognitive stimulation, sleep hygiene, attention to nutrition and hydration, oxygenation, medication review, assessment of mood, and bowel and bladder care. EDs increasingly incorporate these interventions into routine care including the use of delirium‐focused order sets and deployment of geriatric management teams which have been shown to reduce 30‐day ED readmission rates.ConclusionFurther studies should integrate diagnostic workflows and algorithms for behavioral interventions developed for both agitation and delirium management in the ED.

Non‐Pharmacologic management: Considerations for Family Caregivers

AbstractBackgroundAgitation is a common symptom of dementia, estimated to occur in upwards of 30% of patients.1 Family caregivers are often the frontline when it comes to management of agitation given that many patients with dementia live at home, and often bear the brunt of caregiver burden. In spite of existing research, which non‐pharmacological interventions should be used when is unclear.MethodThis abstract describes the application of the IPA algorithm to the family‐caregiver setting.ResultThe current IPA algorithm for agitation emphasizes the importance of non‐pharmacological interventions integrated with pharmacological interventions and adapted in an iterative manner dependent on patient response. Data on non‐pharmacological interventions in the family caregiver setting, though sparse, suggest a couple of key themes. Most interventions, including analyses of data from social media platforms, Long Term Care data and clinical trial data emphasize the importance of patient engagement.2 Planning appropriate activities, problem‐solving and teaching communication skills is also paramount. Finally, modification of the environment, reminiscence and engagement with outside support networks is critical. Individualized approaches with multiple components and modified based on follow up are particularly effective. Review of clinical trial data in fact suggests effect sizes comparable to that achieved with medication without the concomitant side effects.2 Finally, interventions that focus on the well‐being of the caregiver and emphasize enhanced self‐efficacy are particularly important, given caregiver burden in family caregivers often exceeds that of professional caregivers. Studies have been limited by lack of standardization, small sample sizes and limited follow‐up.ConclusionFurther rigorous studies are required to establish which approaches are most effective in family caregivers and how they relate to pharmacological interventions, though data to date suggest interventions that work in other setting (such as Long Term Care) may be adaptable to the family setting.1. Carrarini C, Russo M, Dono F, et al. Agitation and Dementia: Prevention and Treatment Strategies in Acute and Chronic Conditions. Front Neurol 2021; 12: 644317.2. Brodaty H, Arasaratnam C. Meta‐analysis of nonpharmacological interventions for neuropsychiatric symptoms of dementia. The American journal of psychiatry 2012; 169(9): 946‐53.

Reduction and Prevention of Agitation in Patients with Neurocognitive Disorders: An International Psychogeriatric Association Consensus Algorithm

AbstractBackgroundThe International Psychogeriatric Association (IPA) extends its commitment to serving those with psychiatric and behavioral manifestation in the presence of cognitive impairment and dementia with this introduction of an agitation reduction and prevention algorithm that builds on the definition of agitation developed by IPA.MethodThis presentation describes a review of literature, treatment guidelines, to recommend an algorithm for care and a reiterative integration of expert opinion within the context of an IPA Agitation Work group, a panel of international experts on agitation. The outcome is an integration of available information into a comprehensive algorithm.ResultThe IPA Agitation Work Group recommends the Investigate, Plan, and Assess (IPA) approach to agitation reduction and prevention. A thorough investigation of the behavior is followed by planning and implementation with an emphasis on shared decision‐making; the success of the plan in assessed and adjusted as needed. The process is repeated until agitation is reduced to an acceptable level and prevention of recurrence is optimized. Nonpharmacologic interventions are part of every plan and are continued throughout the process. Pharmacologic interventions are organized into panels of choices for nocturnal agitation, mild‐moderate agitation or agitation with prominent mood features, moderate‐severe agitation, and severe agitation with threatened harm to the patient or others. Therapeutic alternatives are presented for each panel. The occurrence of agitation in a different venues is considered (home, nursing home, emergency depaThe IPA definition of agitation is operationalized into an agitation management algorithm emphasizing the integration of non‐pharmacologic and pharmacologic interventions, reiterative assessment of response to treatment, adjustment of therapeutic approaches to reflect the clinical situation, and shared decision‐making. rtment, hospice), with adjustments to the therapeutic approach.ConclusionThe IPA definition of agitation is operationalized into an agitation management algorithm emphasizing the integration of non‐pharmacologic and pharmacologic interventions, reiterative assessment of response to treatment, adjustment of therapeutic approaches to reflect the clinical situation, and shared decision‐making.

A retrospective cohort study of pre-hospital agitation management by advanced paramedic practitioners in critical care.

Pre-hospital clinicians can expect to encounter patients with agitation, including acute behavioural disturbance (ABD). These situations carry significant risk for patients and emergency medical services. Advanced paramedics within the London Ambulance Service (LAS) are frequently tasked to these incidents. At present, little evidence exists regarding clinical decision-making and management of this patient group. We sought to explore the demographics of patients presenting with potential ABD and quantify the degree of agitation, physical restraint, effectiveness of chemical sedation and any associated complications. A retrospective analysis of pre-hospital clinical records for patients coded with ABD and attended by LAS advanced paramedics between 1 October 2019 and 30 September 2020. Sedation assessment tool (SAT) scores were used as the primary outcome measure. A total of 237 patient records were identified. Of the patients, 147 (62%) were physically restrained and 104 (44%) were chemically sedated. Sedation was more commonly administered where patients were exposed to physical restraint. High SAT scores were associated with the administration of sedative agents and at higher doses. Of patients undergoing sedation, 89 (85%) had a SAT score reduction of 2 points or a final score ≤ 0. The mean SAT score reduction was 2.72. Three cases of minor injury were reported following physical restraint. Advanced paramedics undertook sedation in less than half the cohort, suggesting that other strategies such as communication and positioning were utilised. Most patients were managed into a state between being restless and rousable, largely negating the need for ongoing physical restraint during hospital transfer. Appropriately trained advanced paramedics can utilise sedation safely and effectively in selected cases.