Cause Of Agitation Research Articles

How are agitated patients dealt with in internal medicine departments?

Studies on agitation in internal medicine departments are scarce, especially regarding how doctors and nurses act in these situations. The objective of this study was to clarify how agitation is dealt with in these departments. This prospective observational study was performed in the internal medicine departments of four Portuguese hospitals. The researchers at each hospital contacted the nursing team that identifies patients who were agitated in the previous shifts. The researcher reviewed these patients' files, recording the research protocol's parameters. During the study period, 331 patients were observed; 177 (54%) were female, and the median age was 80 years (19-99). Episodes of agitation occurred in 69 patients (21%); of them, 44 (64%) were female, and the median age was 84 years (31-98). In the first episode of agitation, the doctor on duty was called in 49 times (71%). These doctors prescribed a new medication for the crisis in 30 cases (43%). After the crisis, the assistant doctor recorded the episode in the patient file in 41 cases (59%). According to the medical notes, after the acute phase, in only 21 patients (30%), there was an attempt to clarify the cause of agitation. The prescription after the crisis was regular medication in 32 cases (46%), rescue medication in 27 (39%), and physical restraint in 9 (13%), isolated or in various combinations. This study suggests that there is room to improve how agitated patients are managed in internal medicine departments.

FDA Approves Rexulti for Agitation Associated With Dementia Due to Alzheimer’s Disease

Back to table of contents Next article Clinical & ResearchFull AccessFDA Approves Rexulti for Agitation Associated With Dementia Due to Alzheimer’s DiseaseMark MoranMark MoranSearch for more papers by this authorPublished Online:12 May 2023https://doi.org/10.1176/appi.pn.2023.07.7.17AbstractOne expert called the approval a “positive step” for the treatment of agitation associated with dementia in Alzheimer’s but cautioned against using the drug as a panacea for all behavioral symptoms of dementia.The U.S. Food and Drug Administration (FDA) this week approved the expanded use of Rexulti (brexpiprazole) for the treatment of agitation associated with dementia due to Alzheimer’s disease (AD).“Agitation associated with dementia due to Alzheimer’s disease is a common neuropsychiatric symptom that is reported in approximately half of all patients with Alzheimer’s dementia,” wrote Otsuka Pharmaceutical Co. Ltd. and Lundbeck LLC, makers of the medication, in a press release. The symptoms cover “a large group of behaviors occurring in patients with Alzheimer’s disease, such as pacing, gesturing, profanity, shouting, shoving, and hitting.”Brexpiprazole was first approved by the FDA in 2015, as an adjunctive therapy to antidepressants in adults with major depressive disorder and as a treatment for adults with schizophrenia. In 2021, the FDA expanded the use of the medication for the treatment of adolescents over the age of 13 with schizophrenia. Earlier this year, Otsuka and Lundbeck announced that the FDA would review the companies’ supplemental New Drug Application for brexpiprazole for the treatment of agitation associated with AD.In a hearing last month, the FDA’s Psychopharmacologic Drugs Advisory Committee and the Peripheral and Central Nervous System Drugs Advisory Committee voted 9-1 in favor of the approval of brexpiprazole for the new indication, noting the data presented by Otsuka and Lundbeck suggested that the benefits of the medication outweighed the risks for patients with these symptoms.A briefing document released prior to the April FDA hearing describes some of the data presented by the manufacturers, including several phase 3, 12-week, randomized, placebo-controlled studies. “Results from Studies 331-12-283 and 331-14-213 suggest that brexpiprazole exhibited a statistically significant treatment effect in the reduction of agitation over a 12-week treatment period, while also showing a similar safety profile relative to its use in adults with schizophrenia and major depressive disorder,” the document stated. “[B]rexpiprazole’s effect on mortality appears to be consistent with the known risk with other antipsychotics in elderly patients with dementia.”Rajesh Tampi, M.D., M.S., said it is important that physicians determine the cause of agitation in patients with Alzheimer’s disease before prescribing Rexulti.The approval of Rexulti “is a positive step for the treatment of agitation associated with dementia related to Alzheimer’s Disease,” said Rajesh Tampi, M.D., M.S., a professor and chair of the Department of Psychiatry at Creighton University and a past president of the American Association for Geriatric Psychiatry. “This is the first drug to be approved for agitation. The manufacturers were persistent and had solid data to support efficacy,” he told Psychiatric News.Tampi cautioned that agitation is just one of many noncognitive behavioral symptoms of dementia that patients may experience. “Brexpiprazole should absolutely not be assumed to treat all of those symptoms,” he said. “For instance, the most important behavioral symptom of dementia is apathy, and brexpiprazole should not be used to treat apathy.”He noted that only a minority of patients with dementia are treated by geriatric psychiatrists; most see their primary care physician (or other physicians who are not psychiatrists) for care. “My worry is that some will use the medication as a panacea for every behavioral symptom,” he said.According to the updated medication label, Rexulti is to be taken daily. The medication is not approved for the treatment of Alzheimer’s patients with dementia-related psychosis without agitation.“Physicians need to make a good assessment of whether the agitation is a result of dementia related to AD or due to other causes—for example, a medical condition or a psychiatric condition like bipolar disorder or schizophrenia,” Tampi said.Inappropriate use of brexpiprazole “will only raise the risk of adverse events associated with antipsychotic treatments—sedation, risk of falls, stroke and death,” he said.The most common side effects of Rexulti reported during the clinical trials by patients with agitation associated with dementia due to Alzheimer’s disease include headache, dizziness, urinary tract infection, nasopharyngitis, and sleep disturbances, according to an FDA release. “Rexulti will retain the Boxed Warning for medications in this class that elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death,” the agency noted. ■ResourcesFDA Approves First Drug to Treat Agitation Symptoms Associated with Dementia due to Alzheimer’s DiseaseFDA Briefing Document ISSUES NewArchived

Restraint asphyxia. An analysis of the circumstances and mechanism of death in agitated, physically restrained individuals.

Recent years saw frequent media reports of young people who die while they are being arrested by the police. Death in these circumstances affects people who are agitated and restrained with the use of force, with their autopsies indicating no unequivocally traumatic cause of death. The goal of this study was to identify the mechanism and circumstances of sudden deaths in agitated individuals who are being restrained. Ten cases evaluated at our center since 2010 were included in this study: nine involved forensic postmortem examination and one involved casefile analysis. In each case there was sudden cardiac arrest or at least a loss of consciousness, and the cardiopulmonary resuscitation proved ineffective. In six cases the cause of agitation was acute psychosis, in four it was an effect of narcotics, usually in high concentration. Conjunctival petechiae were detected in only five cases. The most probable cause of death in the evaluated cases was the combination of physical exertion caused by pathological psychomotor agitation and forcible restraint, hindering the function of the respiratory system. This mechanism is known as restraint asphyxia.

Diagnosis and Initial Management of Agitated Patients in a General Hospital

Objective: To examine the characteristics, diagnosis and management of agitated inpatients before psychiatric consultation in a general hospital.Methods: A retrospective chart review of inpatients aged 18 years or older that were referred for psychiatric consultation due to agitation in a general hospital in Thailand.Results: Of the 188 patients, confusion was the most commonly detected early sign of agitation (63;33.5%), while fidgeting was the most common symptom/behavior that led to psychiatric consultations (94;50.0%). The average onset time of agitation after admission was 62 hours 48 minutes. The most common cause of agitation was delirium due to a medical condition (89;47.3%). Primary psychiatric disorders were only found in 9 (4.8%) of agitated patients. There was a low diagnostic concordance between attending physicians and psychiatrists (Cohen’s Kappa=0.32). Physical restraints were used in 109 (58.0%) patients, whereas 166 (88.3%) were prescribed with sedatives. Attending physicians prescribed benzodiazepine to ameliorate agitation in 32 (36.0%) of patients with delirium. However, 4 (7.3%) patients with alcohol-withdrawal delirium were untreated initially with benzodiazepine.Conclusion: Medical conditions are more common causes of agitation than psychiatric illness. There is poor diagnostic concordance between attending physicians and psychiatrists, and high rates of physical restraints and benzodiazepine injection were found. Medical education on the detection and management of agitation and the appropriate use of sedative medications and restraints is needed.

Severe Agitation in Dementia: An Explorative Secondary Data Analysis on the Prevalence and Associated Factors in Nursing Home Residents.

Background:The phenomena of severe agitation is not well understood and often not adequately treated.Objective:This article determines the prevalence and associated factors of severe agitation in nursing home residents with dementia.Methods:Secondary data analysis within an observational study in German nursing homes with n = 1,967 participants. We assessed severity of agitation with the Neuropsychiatric Inventory Questionnaire (NPI-Q) and defined the construct of agitation as a composite score of the NPI-Q items agitation/aggression, disinhibition, and irritability/lability; the dependent variable of severe agitation was considered as being present in residents who scored ‘severe’ in at least one of these symptoms. A binary logistic regression model was calculated to estimate associations.Results:The prevalence of severe agitation was 6.3% (n = 124). The strongest associations were found for elation/euphoria (OR 7.6, CI 3.1–18.5), delusions (OR 7.3, CI 4.0–13.2), apathy/indifference (OR 2.8, CI 1.7–4.7), anxiety (OR 2.2, CI 1.2–3.8), nighttime behaviors (OR 2.4, CI 1.4–4.2), motor disturbances (OR 2.4, CI 1.4–4.1), and male sex (OR 2.4. CI 1.3–4.2).Conclusion:Severe agitation in nursing home residents with dementia is a relevant clinical issue as approximately 70% of residents have a dementia. Residents with elation/euphoria and delusions may have a stronger risk of showing severe agitation. We consider delusions as a possible cause of agitation and therefore a prelude to agitation. Although it might be possible that elation/euphoria follows from agitation, we hypothesize that the residents first experience elation/ euphoria and exhibit agitation afterwards.

The Characteristics and Prevalence of Agitation in an Urban County Emergency Department

We seek to determine the characteristics and prevalence of agitation among patients in an urban county emergency department (ED). This was a prospective observational study of ED patients at an urban Level I trauma center. All ED patients were screened during daily randomized 8-hour enrollment periods. Adult agitated patients, defined as having an altered mental status score greater than 1, were included. Trained research volunteers collected demographics and baseline data, including the presenting altered mental status score, use and type of restraints, and whether any initial sedative was given. The alteredmental status score, vital signs, and any medications or treatments given were recorded every 5 minutes thereafter until the patient had an altered mental status score less than 1. Providers were asked to describe clinical events resulting in an intervention occurring during the patient course, including hypotension, vomiting, increased monitoring, use of supplemental oxygen or airway adjunct, or intubation. The provider also completed a checklist to determine the presence of delirium symptoms. A total of 43,838 patients were screened (45.1% women; median age 33 years; range 0 to 102 years). The prevalence of agitation was 2.6% (1,146/43,838; median altered mental status score 2). Of these patients, 84% (969/1,146) required physical restraint and 72% (829/1,146) required sedation with an intramuscular injection. Sedative agents were olanzapine in 39% of patients (442/1,146), droperidol in 20% (224/1,146), haloperidol in 20% (226/1,146), a benzodiazepine in 6% (68/1,146), and ketamine in 5% (52/1,146). Delirium characteristics were observed in 0.6% of patients (260/43,838), representing 23% of agitated patients in the ED. Clinical events were observed in 13% of agitatedpatients (114/866) without delirium symptoms and 26% (68/260) with delirium symptoms. Characteristics associated with a clinical event included delirium symptoms (odds ratio [OR] 1.6; 95% confidence interval [CI] 1.2 to 2.4), a cause related to a drug other than alcohol (OR 1.7; 95% CI 1.1 to 2.9), or a nondrug-induced cause of agitation (OR 3.5; 95% CI 2.3 to 5.6). The prevalence of agitation in the ED was 2.6%. Agitated patients frequently required restraint and sedation, with significant rates of clinical events requiring intervention.

Ból jako przyczyna pobudzenia u osób starszych z zaburzeniami funkcji poznawczych

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Nowak T, Neumann-Podczaska A, Wieczorowska-Tobis K. Pain as a cause of agitation in older subjects with cognitive impairment. Neuropsychiatria i Neuropsychologia/Neuropsychiatry and Neuropsychology. 2018;13(4):128-134. doi:10.5114/nan.2018.83036. APA Nowak, T., Neumann-Podczaska, A., & Wieczorowska-Tobis, K. (2018). Pain as a cause of agitation in older subjects with cognitive impairment. Neuropsychiatria i Neuropsychologia/Neuropsychiatry and Neuropsychology, 13(4), 128-134. https://doi.org/10.5114/nan.2018.83036 Chicago Nowak, Tomasz, Agnieszka Neumann-Podczaska, and Katarzyna Wieczorowska-Tobis. 2018. "Pain as a cause of agitation in older subjects with cognitive impairment". Neuropsychiatria i Neuropsychologia/Neuropsychiatry and Neuropsychology 13 (4): 128-134. doi:10.5114/nan.2018.83036. Harvard Nowak, T., Neumann-Podczaska, A., and Wieczorowska-Tobis, K. (2018). Pain as a cause of agitation in older subjects with cognitive impairment. Neuropsychiatria i Neuropsychologia/Neuropsychiatry and Neuropsychology, 13(4), pp.128-134. https://doi.org/10.5114/nan.2018.83036 MLA Nowak, Tomasz et al. "Pain as a cause of agitation in older subjects with cognitive impairment." Neuropsychiatria i Neuropsychologia/Neuropsychiatry and Neuropsychology, vol. 13, no. 4, 2018, pp. 128-134. doi:10.5114/nan.2018.83036. Vancouver Nowak T, Neumann-Podczaska A, Wieczorowska-Tobis K. Pain as a cause of agitation in older subjects with cognitive impairment. Neuropsychiatria i Neuropsychologia/Neuropsychiatry and Neuropsychology. 2018;13(4):128-134. doi:10.5114/nan.2018.83036.

EFFECTS OF ACUPRESSURE ON AGITATION AND STRESS IN NURSING HOME RESIDENTS WITH DEMENTIA

Agitation is prevalent in nursing home residents with dementia and has negative impacts on the PWD and their caregivers. Non-pharmacological interventions (NPI) offer promise for managing agitation. However, no NPIs have been proven to be effective across cultures. Acupressure is derived from Traditional Chinese Medicine. It has been used, particularly in Chinese communities, to manage agitation in PWD because it is safe and inexpensive. However, its effect on agitation and at the biochemical level is uncertain. The aim of this study was to examine the effect of acupressure on those with agitation and stress, and to test whether acupressure reduces agitation by mediating stress. This RCT was conducted in 12 nursing homes in Hong Kong. CMAI was used to measure the effect of acupressure on agitation, and salivary cortisol the effect on stress, measured at baseline (T0) and in the 3rd (T1), 5th (T2), and 8th (T3) weeks. The participants, who were agitated nursing home residents with dementia, were randomly allocated into three groups. In the acupressure group (n=39), acupressure was performed by trained laypeople for nine minutes per session; on five acupoints: Baihui (GV20), Shenman (HT7), Yingtang (EX-HN3), Fengchi (GB20), and Neiguan (PC6); for 10 minutes per session, for two sessions per day; and for 20 sessions within two weeks. In the sham group (n=41), the intervention was the same as in the acupressure group, except that five non-acupoints were employed. In the usual-care group (n=39), only the usual care was provided. Significant interaction effects between groups and time points were observed on the level of salivary cortisol (p=0.022) but not on agitation (p=0.052). The mediation effect of salivary cortisol between intervention and agitation was insignificant. Intervention fidelity was 100% and compliance was 91.9%. Acupressure can be accurately implemented by trained laypeople and complied with by agitated Chinese PWD. Its effect at reducing salivary cortisol in PWD merits further research on how acupressure works on the HPA axis. Its insignificant effect at reducing agitation may be related to the inadequate sample size. Physiological stress may not be the cause of agitation in PWD.

USING ANTHROPOLOGICAL METHODS TO UNDERSTAND STAFF EXPERIENCES OF TERMINAL AGITATION IN A HOSPICE

IntroductionTerminal agitation is a well recognised phenomenon. Unlike other symptoms at the end of life its pathophysiological basis is not well understood. Its presence may be disputed and it is...

PAIN MANAGEMENT, END-OF-LIFE CARE AND DEMENTIA: ADDRESSING THE GAPS BETWEEN THEORY AND PRACTISE

BackgroundPain is frequently an undetected cause of agitation and distress in dementia; and thus often a cause of behavioural and psychological symptom of dementia (BPSD). Despite a plethora of tools...

Psychiatric evaluation of the agitated patient: consensus statement of the american association for emergency psychiatry project Beta psychiatric evaluation workgroup.

It is difficult to fully assess an agitated patient, and the complete psychiatric evaluation usually cannot be completed until the patient is calm enough to participate in a psychiatric interview. Nonetheless, emergency clinicians must perform an initial mental status screening to begin this process as soon as the agitated patient presents to an emergency setting. For this reason, the psychiatric evaluation of the agitated patient can be thought of as a 2-step process. First, a brief evaluation must be aimed at determining the most likely cause of agitation, so as to guide preliminary interventions to calm the patient. Once the patient is calmed, more extensive psychiatric assessment can be completed. The goal of the emergency assessment of the psychiatric patient is not necessarily to obtain a definitive diagnosis. Rather, ascertaining a differential diagnosis, determining safety, and developing an appropriate treatment and disposition plan are the goals of the assessment. This article will summarize what components of the psychiatric assessment can and should be done at the time the agitated patient presents to the emergency setting. The complete psychiatric evaluation of the patient whose agitation has been treated successfully is beyond the scope of this article and Project BETA (Best practices in Evaluation and Treatment of Agitation), but will be outlined briefly to give the reader an understanding of what a full psychiatric assessment would entail. Other issues related to the assessment of the agitated patient in the emergency setting will also be discussed.

The “Caliphate Question”

This paper examines British approaches to the caliphate from the beginning of the First World War to the aftermath of its dissolution in 1924. Background will be given as to how the Islamic conception of the caliphate shifted over time. British use of the caliphate as a political tool in the nineteenth century is also examined, especially with regards to how strong British-Ottoman ties prior to the First World War affected India’s Muslims. The primary focus, however, will be on British ties with King Hussein of the Hejaz. British suggestions of an Arab caliphate encouraged the idea that Hussein should assume the title of caliph, which would later be a cause of agitation and concern for British policy in the British Empire. This is especially true with regards to India, as fear of Indo-Muslim opinion would deeply influence British policy when it came to the Ottoman Empire’s position in the post-bellum period. With the creation of the Turkish Republic and the subsequent disestablishment of the Ottoman caliphate, Hussein, sharif of the Hejaz, would officially announce his claim to the title. This dismayed the British foreign policy establishment, which strove to avoid suggestions of complicity lest further anti-British activity be encouraged in India. Eventually, the end of Hussein would come from Ibn Saud, his principle rival in the Arab world. Despite Hussein’s status as a British ally, the widespread anger against him in the Islamic world over the caliphate would persuade the British to distance themselves from him and his religious pretensions.

The “Caliphate Question”

This paper examines British approaches to the caliphate from the beginning of the First World War to the aftermath of its dissolution in 1924. Background will be given as to how the Islamic conception of the caliphate shifted over time. British use of the caliphate as a political tool in the nineteenth century is also examined, especially with regards to how strong British-Ottoman ties prior to the First World War affected India’s Muslims. The primary focus, however, will be on British ties with King Hussein of the Hejaz. British suggestions of an Arab caliphate encouraged the idea that Hussein should assume the title of caliph, which would later be a cause of agitation and concern for British policy in the British Empire. This is especially true with regards to India, as fear of Indo-Muslim opinion would deeply influence British policy when it came to the Ottoman Empire’s position in the post-bellum period. With the creation of the Turkish Republic and the subsequent disestablishment of the Ottoman caliphate, Hussein, sharif of the Hejaz, would officially announce his claim to the title. This dismayed the British foreign policy establishment, which strove to avoid suggestions of complicity lest further anti-British activity be encouraged in India. Eventually, the end of Hussein would come from Ibn Saud, his principle rival in the Arab world. Despite Hussein’s status as a British ally, the widespread anger against him in the Islamic world over the caliphate would persuade the British to distance themselves from him and his religious pretensions.

The Treatment of Acute Agitation in Schizophrenia

AbstractAcute agitation is a nonspecific term applied to an array of syndromes and behaviors. It is frequently defined as an increase in psychomotor activity, aggression, disinhibition/impulsivity, and irritable or labile mood. Etiologies of acute agitation include medical disorders, delirium, substance intoxication or withdrawal, psychiatric disorders, and medication side effects. Treatment of acute agitation requires both environmental and pharmacologic intervention. Patients should be calmed with sedating agents early in the course of treatment, allowing for diagnostic tests to take place. Failure to correctly diagnose causes of agitation may lead to delayed treatment for serious conditions, and can even exacerbate agitation.The most common cause of agitation in patients with schizophrenia is psychotic relapse due to medication nonadherence. Pharmacologic treatment options for these patients include lorazepam and antipsychotic agents. Lorazepam causes nonspecific sedation and treats some substance withdrawal, but has little effect on psychosis. First-generation antipsychotics treat psychosis and, at high enough doses, cause sedation, but may induce extrapyramidal side effects (EPS). Some second-generation antipsychotics have been approved for the treatment of agitation in schizophrenia. These agents treat psychosis with a favorable EPS profile, but are comparatively expensive and cause risks such as hypotension. However, avoiding EPS may reduce patients' resistance to antipsychotic treatment.In this expert roundtable supplement, Joseph Battaglia, MD, provides an overview of the definition of acute agitation. Next, Delbert, G. Robinson, MD, outlines evaluation methods for actue agitation. Finally, Leslie Citrome, MD, MPH, reviews interventions for acute and ongoing management of agitation.

Agitation in the medically ill elderly

Agitation is a common and significant problem in the medically ill elderly. It is responsible for diminished quality of life for not only the patient, but the caregivers as well as the patient's relatives. This paper will illustrate the concept of agitation and different modes of classification. The major emphasis will be placed on discussing prompt, correct diagnosis of the underlying cause of agitation and effective treatment of both the cause of agitation and the symptoms of agitation itself.

Ziprasidone Pretreatment Attenuates the Lethal Effects of Cocaine in a Mouse Model

Cocaine intoxication is a common cause of agitation in emergency department patients. Ziprasidone, an atypical antipsychotic, is being increasingly used for sedation of agitated patients in the emergency department. To provide preliminary animal data on the efficacy of ziprasidone for the treatment of acute cocaine poisoning. This was a randomized, blinded comparison of ziprasidone and placebo for the prevention of seizures and apparent lethality in a mouse model of cocaine intoxication. Animals were assigned to either placebo or 0.4 mg/kg or 1.2 mg/m(2) of ziprasidone intraperitoneally 30 minutes prior to administration of 105 mg/kg of cocaine. Study outcomes were the proportions of animals having seizures and the apparent lethality. 1.2 mg/m(2) of ziprasidone decreased the lethal effects of cocaine by 50%, while 0.4 mg/kg decreased lethality by 13%. There was no effect on seizures at either dose. Ziprasidone pretreatment decreased lethality in this mouse model of severe cocaine intoxication.

Intramuscular antipsychotics: Clinical experience review

Acute agitation is a therapeutic dilemma. Rapid control of agitation is necessary to minimize danger both to recipients of care and to caregivers. Although a comprehensive assessment may ultimately be necessary to determine the cause of agitation and to identify or exclude underlying medical illness, it is often imperative to treat agitation immediately. In this imperfect clinical world, it is essential to have treatments that are both safe and effective for patients with a wide variety of causes of agitation.

Management of sedation in mechanically ventilated patients.

There are many new and exciting studies in the sedation literature. Recent studies of new scoring systems to monitor sedation, new medications, and new insights into post-intensive care unit (ICU) sequelae have brought about interesting ideas for achieving an adequate level of sedation of our patients while minimizing complications. The recent literature focuses on monitoring the level of a patient's sedation with new bedside clinical scoring systems and new technology. Outcomes studies have highlighted problems with both inadequate sedation and excessive sedation in regard to patients' post-ICU psychological health. More insight into drug withdrawal and addiction as complications of ICU care were examined. A new medication for sedation in the ICU has been approved for use, but its role is not yet defined. Many patients in the ICU receive mechanical ventilation and will require sedative medications. A frequently overlooked cause of agitation in the ventilated patient is pain, and assessing the adequacy of analgesia is an important part of the continuous assessment of a patient. The goal of sedation is to provide relief while minimizing the development of drug dependency and oversedation. Careful monitoring with bedside scoring systems, the appropriate use of medications, and a strategy of daily interruption can lead to diminished time on the ventilator and in the ICU.

Influence of clinicians' values and perceptions on use of clinical practice guidelines for sedation and neuromuscular blockade in patients receiving mechanical ventilation

Although popular, clinical practice guidelines are not universally accepted by healthcare professionals. To compare nurses' and physicians' actual and perceived rates of adherence to practice guidelines used in sedation of patients receiving mechanical ventilation and to describe nurses' and physicians' perceptions of guideline use. Pairs of fellows and nurses caring for 60 eligible patients were asked separately about their rationale for medicating patients, effectiveness of medication, and their perceived adherence to the guidelines. Actual adherence was determined independently by review of medical records. An additional 18 nurses and 11 physicians were interviewed about perceptions of guideline use. Use of mechanical ventilation was the most common reason given by physicians (53%) and nurses (48%) for medicating patients, although reasons for administering medication to a given patient differed in up to 30% of cases. Physicians and nurses disagreed on the effectiveness of medication in 42% (P = .01) of cases. Physicians reported following guidelines in 69% of cases, but their actual adherence rate was only 20%. Clinicians sometimes had difficulty distinguishing among anxiety, pain, and delirium. Clinicians justified variations from guidelines by citing the value of individualized patient care. Nurses and physicians sometimes had different goals in the use of sedation. Physicians may think they are following sedation guidelines when they are not, and they may prescribe incorrect medications if the cause of agitation is misdiagnosed. Differences between physicians and nurses in values and perceptions may hamper implementation of clinical practice guidelines.