Fenomenet agitasjon. Hvorfor - PowerPoint Presentation

Slide1

Fenomenet agitasjon. Hvorfor er dette viktig i klinikken?

Arne Vaaler

Slide2

CoveringWhat

is agitation?Definitions / assessments

.

Epidemiological

aspects

Clinical

consequences

/

burden

of

illness

.

Suicide

and

agitation

Conclusions

.

Slide3

What is agitation?

- «Something every

clinician

know

when

they

see it».

-

Common

component

of

many

disorders

.

-

Seldom

addressed

as a

unique

medical or

psychiatric

entity

.

A

cluster

of

behaviours

occuring

in

a

number

of

clinical

situations

.

A

heterogeneous

,

dimensional

concept

crossing

multiple

diagnostic

areas

in

medicine

and

psychiatry

.

Core

symptoms:

Restlessness

,

excessive

verbal and motor

activity

,

irritability

,

unability

to

cooperate

,

threats

… and violent

incidents

.

Vegetative symptoms as

decreased

sleep

.

Unstable

,

fluctuating

course

with

symptoms

rapidly

changing

over time.

Slide4

Frequent in:

Psychiatric conditions:

Schizophrenia

,

affective

disorders

, ADHD,

personality

,

anxiety

…

Central

nervous

system

diseases

:

Epilepsy

, dementia,

Mb

Parkinson’

Medical

conditions

:

Encephalitis

, diabetes,

thyrotoxicosis

,

brain

trauma.

Substance

abuse

:

Alcohol

,

methamphetamine

, GHB (gamma-

hydroxybutyric

acid)…

Side

effects

medication

:

Antipsychotics

and

antidepressants

.

… and combinations of all.

Slide5

Definitions.A

number of often imprecise

and/or

conflicting

defintions

.

Sachs. J

Clin

Psychiatry

2006.

«

Excessive

motor

activity

associated

with

a feeling of inner

tension

»

APA. DSM-4

.

«

Agitation

is an non-

specific

constellation of

comparatively

unrelated

behaviours

that

possess

a risk to

the

safety

of

the

patient

or caregiver,

impedes

the

process

of care giving or

impairs

a

person’s

function

».

Yildis

et al.

Emerg

Med J

2000

Agitation

is «a

temporary

disruption

of

the

typical

phycisian

–

patient

collaboration

,

which

interferes

with

assessment

and

treatment

, during a

period

when

immediate

assessment

and

treatment

are

needed

».

Allen

. J

Clin

Psychiatry

2000.

Slide6

Definitions – differences and similarities.

Agitation is seen

by

many

specialists

.

Psychiatry

,

emergency

medicine

, GP,

neurology

..

Clinicians

view

agitation

primarily

from

the

perspective

of

own

patient

population

.

-

Emergency

physicians

describe

agitation

in terms of

broader

range of symptoms.

-

Geriatricians

describe

it

reflecting

syndromes

commonly

in

the

elderly

.

The

definitions

in

the

literature

tend

to vary

with

the

illnesses

in

focus

.

Shared

factors

in

the

different

definitions

:

«

Increase

in motor

activity

;

aggression

;

disinhibition

and

impulsivity

;

and

irritable,

anxious

or labile

mood

».

Battaglia

.

Drugs

2005;65.

Slide7

Assessment of agitation.

A number of rating scales

in

use

.

Zeller&Rhoades

.

Clin

Ther

2010.

The

lack

of

precision

in

the

definitions

of

the

clinical

syndrome

is

reflected

in

significant

differences

in

the

assessment

approaches

and

rating

scales

.

Sachs. J

Clin

Psychiatry

2006.

Better

utility

in

the

assessment

of

interventions

than

in

epidemiologic

or

pathophysiologic

research.

Lindenmayer

. J

C

lin

Psychiatry

2000.

Slide8

Severity of agitation.

A spectrum of behaviours from mild to severe..

with

rapid

fluctuations

.

Anxiety

….High

anxiety

…

Agitation

…

Aggression

.

In

some

patients

:

Agitation

a

warning

sign

of

aggression

.

Severity

of

untreated

agitation

increases

with

time.

Violence

in

agitated

patients

preceded

by

increased

pacing and

loud

speech

.

Slide9

Agitation in psychiatric acute and emergency

psychiatry.«Epidemiology»

At present

lack

of

direct

epidemiological

studies

assessing

prevalence

,

clinical

impact

,

short

/ long time

consequences

, and

financial

costs

.

Sachs. J

Clin

Psychiatry

2006

Existing

data

derived

from

patients

visiting

emergency

settings.

Different

populations

,

rating

scales

,

organization

of services…

Severity

of

agitation

.

Studies

with

/

without

informed

consent

.

The

typical contemporary

psychiatric intensive care

patient presents in severe crisis, often complicated by substance use, polypharmacy, behavioural

dyscontrol

and multiple axis

1-2

diagnoses.

Zealberg&Brady

. Emergency Psychiatry 1999.

Present data an

indication

of «

the

burden

of

illness

».

Slide10

Epidemiology / «burden of illness».

Agitated or violent behaviour in 10 %

emergency

psychiatry

visits

worldwide.

Raveendran

et al. BMJ 2007.

McAllister-Williams&Ferrier

.

Br

J

Psychiatry

2002.

Tardiff&Koeningsberg

. Am J

Psychiatry

1985.

Huf

et al.

Cochrane

Database

Syst

Rev 2005.

20 – 50 % of

emergency

patients

in US «at risk» for

agitation

Allen&Currier

. Gen

Hosp

Psych

2005.

21 % of

emergency

visits

may

involve

agitated

patients

with

schizophrenia

. 13 % bipolar

disorders

.

Marco&Vaughan

. Am J

Emerg

Med 2005.

Total

number

of

emergency

visits

in US

potentially

involving

agitation

1.7 million

annually

.

Sachs. J

Clin

Psychiatry

2006

Slide11

«The psychiatric emergency research collaboration-01»

Retrospective, structured chart

review

on

psychiatric

emergency

services

patients

...

the

interface

between

community

and

institution

.

Nine US

sites

.

Agitation

in 52 % of

the

subjects

US.

Specific

anti-

agitation

medication

in 48

%.

Physically

restrained

6 %.

Self

-

harm

ideation

55 %.

Admitted

to

inpatient

unit 45 %.

Boudreaux

et al

.

Gen

Hosp

Psychiatry

2009

.

Slide12

Consequences of agitation.Two

examples.1: Coercive

measures

in

inpatient

care.

Keski-Valkama

et al. «

The

reason

for

using

restraint

and

seclusion

in

psychiatric

inpatient

care: A nationwide 15-year

study

». Nord J

Psychiatry

2010; 64.

Aims

:

- To

study

the

reasons

for

restraint

/

seclusion

, and

changes

in

reasons

over a 15-year

period

.

- Law

revisions

1991 and 2001

with

explicit

aims

to

reduce

restraint

/

seclusion

Method:

- A

structured

postal survey to all

actual

Finnish hospitals in

a

predetermined

week

in 1990, 1991, 1994, 1998 and 2004.

-

Categories

for

reason

:

Actual

violence

;

threatening

violence

;

damaging

property;

threatening

to

damage

property;

agitation

/

disorientation

;

unclass

.

Slide13

Keski-Valkama et al.

Results: - Response

rate 92 –100 %.

- The

use

of

restraint

/

seclusion

did

not

decrease

1990 – 2004.

Reasons

restraint

/

seclusion

:

Agitation

/

disorientation

40.7 – 57.1 %

Actual

violence

15.3 – 26.3 %

Reasons

restraint

only

:

Agitation

/

disorientation

48.0 – 62.8 %

Actual

violence

14.0 – 30.6 %

Brasil: Mignon et al. Gen

Hosp

Psych

2008;30.

US: Simpson et al. Gen

Hosp

Psych

2014;36.

Agitation

main

reason

for

use

of

coercive

measures

in

acute

psychiatry

.

Slide14

2: Prediction of suicide.Retrospective data.

Suicide is difficult to study and to prevent. Suicide attempts

20 times more

frequent

(

Malhi

et al. 2013

)

.

Suicidal ideations

even more frequent

(

Valtonen

et al. 2005

)

.

Most

of the knowledge from completed suicides stems from retrospective case series in various clinical settings. These classical studies are based on informant interviews and medical records (psychological autopsy studies).

The studies have indicated that the patients usually have been psychiatrically ill (>90 %), suffering mostly from affective disorders, schizophrenia and alcoholism. Prior suicide attempts statistically predict an increased risk of suicide.

30-40

% of patients committing

suicide prior

attempts

(

Fawcett

et al. 1987

).

A

lcohol / substances use, male

gender are other examples of statistically significant predictors for suicide. Obviously, these are of very limited value in the emergency setting as the specificity is far too low. Up to 80 % of the patients admitted to Norwegian emergency psychiatry wards are influenced by alcohol or substances at admittance

(

Flovig

et

al. 2009

)

.

Slide15

Prediction of imminent suicidal behaviour.Prospective

data.A

lot of data on

lifetime

/ long-term risk and

prevention

Surprisingly

little is

known

about

the

short

-term, imminent risk of

suicide

.

When

facing

the

single

patient

no

specific

rating

scale

exists

with

clinically

meaningful

predictive

properties.

A

clinically

useful

risk

factor

in

emergency

settings

should

be

1)

able

to

affect

how

we

manage

individual

patients

.

«

shed

some

light

on

the

relatively

imminent risk of

suicide

,

and it

should

be

amenable

to

treatment

».

Goodwin FK. J

Clin

Psychiatry

2003;64.

Busch et al. J

Clin

Psychiatry

2003; 64

Slide16

Prospective studies.1: NIMH prospective

study, depressive disorders,

actual

suicides

:

Robust

acute

predictors

of

suicide

one

year

folllow

up:

Severe

anxiety

and

panic

, global

insomnia

, severe

anhedonia

,

recent

alcohol

abuse

.

Fawcett

et al. Am J

Psychiatry

1987;144.

Busch

et al. J

Clin

Psychiatry

2003; 64

2:

Review

of

charts

from 76

patients

who

committed

suicide

while

in

hospital or

immediately

after

discharge

:

Ratings

the

week

before

suicide

:

1)

S

tandard risk

predictors

.

2)

Presence

and

severity

of symptoms

found

to

correlate

with

acute

risk in

recent

studies

(

specific

items

from

the

Schedule

for

Affective

Disorders

and

Schizophrenia

(SADS)).

Slide17

Results.

- 49 % prior suicide

attempt

.

- 39

%

admitted

for suicidal

ideations

.

-

78

%

denied

suicidal

ideation

in

their

last

communication

about

the

topic

.

79 % met

criteria

for severe or

extreme

anxiety

and/or

agitation

.

Conclusion

:

- Standard risk

assessments

and

precautions

used

were

of limited

value

in

protecting

the

group from

suicide

.

-

Adding

severity

of

anxiety

and

agitation

to

our

current

assessment

may

help

identify

patients

at

acute

risk and

suggest

effective

treatment

interventions

.

- «

Effective

anxiolytic

medication

hardly

used at all».

Slide18

Sani et al. Psychiatr Clin Neurosci

2011.

Aims

:

Identify

predictors

for

completed

suicide

.

Methods:

4441

inpatients

followed

for

some

time during 35

years

.

Mostly

affective

disorders

.

Conclusion

:

«

Suicide

is

likely

to

occur

in a

milieu

of

agitation

,

mixed

anxiety

and

depression

, and

psychosis

».

Severe

agitation

predicts

imminent suicidal

acts

.

Slide19

Agitasjon og suicidMedikamenter: Antidepressiva kan utløse og forsterke agitasjon.

Vaaler&Fasmer

.

Tidsskr

Nor

Legefor

2013

Antidepressiva kan utløse suicidale kriser hos pasienter med

agiterte depresjoner.

Reeves&Ladner

. CNS

Neurosci

Ther

2010.

Primær suicidforebyggende terapi bør fokusere på agitasjon.

Slide20

Den suicidale «prosess».Det er en myte at denne prosessen tar lang tid.> 50 % < ti minutter.

Alvorlige suicidale handlinger er et impulsivt fenomen.

Deisenhammer

et al. J

Clin

Psychiatry

2009.

Goodwin. J

Clin

Psychiatry

2003.

Pearson et al.

Suicide

and life

threat

behav

2002.

«

Attempted

suicide

among

rural

women

in

People’s

Republic

of

China:

possibilities

for

prevention

».

Alvorlig depresjon med agitasjon krever umiddelbar handling!

Slide21

Goodwin. «Preventing inpatient suicide». J

Clin Psychiatry 2003.

Predictors

free

of

recall

bias.

Male,

suicide

ideation

, prior

attempt

not associated

with

acte

risk (first

year

)

A

useful

clinical

predictor

should

indicate

imminent risk,

affect

management, and be

amenable

to

treatment

.

Robuste

acute

predictors

severe

anxiety

,

panic

, global

insomnia

, severe

anhedonia

, and

recent

alcohols

abuse

.

Misleading

: Absence

of

suicidal

ideation

. Prior

attempt

..<

50 %.

Preventive

interventions

: IO 15 min fell

short

(50 %

suicd

). No-harm

contracts

.

What

should

work

: Aggressive

pharmacological

management

of

anxiety

,

panic

,

agitation

and

insomnia

.

Slide22

Språk og holdningerSelvmord vs suicid.

Norsk vs engelsk…?Selvmord assosieres med «selvdrap»?

En aggressiv handling…?

En aggressor.

Overgriper

vs

offer.

Slide23

Conclusions.Regardless of underlaying

etiology, severe agitation is an emergency

.

A

predictor

for

violence

and

use

of

coercive

measures

.

A

very

important

predictor

for

imminent suicidal

acts

.

Immediate

interventions

to

control

symptoms and

prevent

injury

.

Together

with

therapeutic

measures

like «

talking

down

» fast

acting

medication

is

mandatory

.