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Published in Andrew Schofield, Paul Schofield, The Complete SAQ Study Guide, 2019
Andrew Schofield, Paul Schofield
Delirium is a common sight on acute medical and surgical wards. Delirium is an organic condition characterised by an impaired consciousness over the course of hours and days. The causes are many, including infection, metabolic disturbance, hypoxia, sedative medications and sensory impairment. Delirium should be differentiated from anxiety by history and dementia by time of onset. Delirium can occur in the setting of a chronic cognitive impairment such as Alzheimer’s dementia, and indeed these patients are more at risk, being in new and distressing environments. Treatment should focus on the cause, and this should be investigated with FBC, U&E, glucose, PaO2, microbiology cultures and appropriate imaging. In the interim patients should be nursed in a calm environment, and non-pharmacological treatments should be employed. In extreme circumstances, medications such as haloperidol or lorazépam can be used to treat agitation. Delirium is a reversible process, but may complicate hospital stays and increase morbidity and mortality.
Medications That May Be Useful in the Management of Patients with Chronic Intractable Pain
Published in Michael S. Margoles, Richard Weiner, Chronic PAIN, 2019
Do not use for severe depression of either exogenous or endogenous origin. It may lower the seizure threshold in patients with a history of seizures. Use cautiously in patients with hypertension. Patients with an element of agitation may react adversely. Perform periodic complete blood count and differential and platelet counts during prolonged therapy.
Neurointensive care: Sedation and analgesia in the ICU
Published in Hemanshu Prabhakar, Charu Mahajan, Indu Kapoor, Essentials of Geriatric Neuroanesthesia, 2019
Nonpharmacological strategies to manage agitation should begin with therapies targeting the cause of distress in the patient. This may include reassurance, frequent orientation, frequent communication with the patient, regular family visits, and establishment of wake-sleep cycles and quiet ICU hours (4–6). One trial randomly assigned patients who were mechanically ventilated to receive either a strategy of no sedation followed by continuous verbal reassuring versus continuous sedation using pharmacological agents (6). The trial found that patients managed with a strategy of no sedation had a decrease in ICU length of stay, decrease in hospital length of stay, and decrease in the risk of delirium. In addition, there was no difference in post-traumatic stress disorder, quality of life, or depression in the two groups (6).
A 2023 update on the advancements in the treatment of agitation in Alzheimer’s disease
Published in Expert Opinion on Pharmacotherapy, 2023
Daniel Lee, Emily D. Clark, Inga M. Antonsdottir, Anton P. Porsteinsson
Before a consensus diagnostic definition was established, agitation was largely characterized by symptoms of emotional distress, psychomotor activity, aggressive behaviors, disruptive irritability, and disinhibition [11]. To facilitate research in agitation, the International Psychogeriatric Association (IPA) convened a group of experts to develop and publish a provisional consensus clinical and research definition of agitation in cognitive disorder broadly defined as follows: (1) occurring in patients with a cognitive impairment or dementia syndrome; (2) exhibiting behavior consistent with emotional distress; (3) manifesting excessive motor activity, verbal aggression, or physical aggression; and (4) evidencing behaviors that cause excess disability and are not solely attributable to another disorder (psychiatric, medical, or substance related) [12]. In 2023, the IPA provisional diagnostic criteria for agitation in cognitive disorders were updated and finalized so the provisional disclaimer could be removed. While both definitions are largely similar, this update and the final definition provide modifications to address special circumstances, clarify that behaviors may be associated with excess distress or produce excess disability and reiterate the need to address delirium [13].
Sublingual dexmedetomidine: repurposing an anesthetic as an anti-agitation agent
Published in Expert Review of Neurotherapeutics, 2023
Justin Faden, Meghan Musselman, Leslie Citrome
Acute agitation is broadly defined as abnormal and excessive motor and verbal activity, including feelings of restlessness, inner tension, hypervigilance, hyperarousal, and irritability [1,2]. It is not synonymous with aggression or violence, though if left untreated, it can evolve into it[3]. The etiology of agitation is multifactorial, including, but not limited to, substance intoxication or withdrawal, dementia, neurologic and metabolic conditions, traumatic brain injury, delirium, anxiety, and personality disorders[4]. Other common causes include schizophrenia and bipolar disorder. Individuals with schizophrenia may be predisposed to episodes of agitation and aggression due to low frustration tolerance, irritability, limited coping skills, persecutory delusions, or command hallucinations to harm others, whereas individuals with bipolar disorder may exhibit agitation or aggression due to emotional lability, alterations in energy levels, impulsivity, or irritability[5]. In presentations to the emergency department (ED) for agitation, bipolar disorder and schizophrenia have been estimated to be the underlying cause in 13% and 21% of occurrences, respectively[6]. More broadly, agitation is a common clinical presentation occurring in approximately 2.6% of ED presentations and 4.3% to 10% of psychiatric ED presentations [7–9].
Risks and benefits of current and novel drugs to treat agitation in Alzheimer’s disease
Published in Expert Opinion on Drug Safety, 2022
Nathan Herrmann, Hui Jue Wang, Bing Xin Song, Kritleen K. Bawa, Krista L. Lanctôt
Agitation, in particular, is a challenging NPS that affects up to 50% of patients with AD and becomes increasingly prevalent in the advanced stages of the disease [6,7]. According to the International Psychogeriatric Association’s (IPA) consensus definition of agitation in cognitive disorders, agitated behaviors manifest in three forms: excessive motor activity (e.g. pacing, rummaging), physical aggression (e.g. punching, kicking), and verbal aggression (e.g. screaming, cursing) [8]. Agitation may interfere with the individual’s interpersonal relationships, social functioning, and ability to perform activities of daily living [8]. Agitation constitutes a major source of distress for patients and caregivers alike and has been linked to a wide array of negative health outcomes including decreased quality of life, greater caregiver burden, earlier admission to long-term care, and increased mortality [8–10].