Management of Acute Agitation & Aggression - PowerPoint Presentation

Slide1

Management of Acute Agitation & Aggression

Collin Lueck

PGY4 Psychiatry

August 2018Slide2

Lecture Outline

Defining Agitation

Overview of Commonly-Used Medications

Treatment Approach by EtiologySlide3

Lecture Outline

Defining Agitation

Overview of Commonly-Used Medications

Treatment Approach by EtiologySlide4

Defining Agitation

“A state of anxiety accompanied by motor restlessness”

For the purpose of this lecture, I’ll include aggression and more goal-directed harmful behavior

Some things you’ll see in agitated patients:

Psychomotor agitation

Pacing

Clenching hands

Aimless movement

Vocalization

Impulsivity

Why is this a problem?

Potential for harm to the patient or othersSlide5

Lecture Outline

Defining Agitation

Overview of Commonly-Used Medications

Treatment Approach by EtiologySlide6

Typical Medications for Agitation

Antipsychotics: given because they’re sedating and they can treat psych disorders

First-Generation (haloperidol)

Second-Generation (olanzapine, risperidone, quetiapine)

Benzodiazepines: given because they’re (generally) sedating/calming

Lorazepam is the most common choice (fast onset)

Antihistamines: given because they’re sedating, and because their anticholinergic effects can mitigate side effects of antipsychotics

Diphenhydramine, hydroxyzineSlide7

First Generation/“Typical” Antipsychotics

Antipsychotics originally developed as sedatives

Antagonists at D2 dopamine receptor, which reduces psychotic symptoms

Also antihistaminic, providing

sedation

Generally, the med from this class

will be haloperidol. Avoid

chlorpromazine (Thorazine) –

more/worse side effectsSlide8

Haloperidol (Haldol)

Dose:

2.5mg in small adults/elderly

5mg for most people

Generally, best to give in combination with diphenhydramine – prophylaxis against movement side effects, plus more sedation

Route:

PO/IM: expect effect in 15-30 minutes

IV: expect effect in shorter timespan

ALWAYS

have cardiac monitoring if giving IV

Things to Remember:

Dystonia: give Benadryl

QTc

prolongation: use caution with cardiac arrhythmiaSlide9

Haloperidol (Haldol), cont’d

Side Effects:

Movement disorders (very common: 10-20% in patients treated without an accompanying anticholinergic)

Dystonia: treat with Benadryl 25-50mg IM

Can occur 12-24h post-dose

Akathisia/Restlessness: generally treat with propranolol, consider psych consult

Prolonged QTc

Some controversy over this data, but generally don’t give IV unless you have them hooked up to cardiac monitoringSlide10

Second Generation/“Atypical” Antipsychotics

Developed as drug companies tried to formulate an antipsychotic with low/no movement side effects

Antagonist at D2 receptor; also interacts with other receptors

Movement side effect burden is much lower (1% for single/short-term doses)

Unfortunately, longer time to onsetSlide11

Atypicals

You’ll Likely Use (1/2)

Olanzapine (Zyprexa)

Dose: 5mg – 10mg

Route: PO (also

dissolving:

Zyprexa

Zydis

), IM

Things to Know:

DO NOT GIVE IM ZYPREXA WITH IM ATIVAN

(Respiratory Depression!)

Currently need an

auth

code from psych due to respiratory depression

Risperidone (Risperdal)

Dose: 0.5mg – 2mg

Route: PO (also

dissolving:

Risperdal M-Tab

– but unavailable at present due to shortage)

Things to Know: EPS/movement effects, galactorrheaSlide12

Atypicals

You’ll Likely Use (2/2)

Quetiapine (Seroquel)

Dose: 25mg – 50mg

Route: PO

Things to Know: orthostatic hypotension risk, anticholinergic

Not as effective in psych disorders, so maybe not the best choice up front (they’ll be on a different one later)

Often used as a sedative, or an antidepressant

Ziprasidone (Geodon)

Dose: 50mg

Route: PO, IM

Things to Know:

PO form must be given with food

Greatest QT prolongation of any antipsychoticSlide13

Benzodiazepines

Main one to know:

Lorazepam (Ativan)

Why?

short on, short off. Metabolized in kidney, not liver

(ok for cirrhosis)

Dose: 1mg – 2mg

Route: PO, IM, IV

Things to Know:

DO NOT GIVE IM ATIVAN WITH IM OLANZAPINE/ZYPREXA

(respiratory depression)

Space by 3-4 hours

Avoid giving to:

Elderly (fall risk, delirium risk)

Delirium (worsens/prolongs delirium)

Dementia and Intellectual Disability (

disinhibition

)

Use caution with:

Anyone on opiates (respiratory depression, sedation)Slide14

Antihistamines

Main one to know:

Diphenhydramine (Benadryl)

Dose: 25mg – 50mg

Route: PO, IM, IV (don’t use IV)

Things to Know:

Avoid giving to:

Elderly, Delirium, Dementia (causes/prolongs/worsens delirium)Slide15

*

*

*

*Slide16

Lecture Outline

Defining Agitation

Overview of Commonly-Used Medications

Treatment Approach by EtiologySlide17

Treatment Approach:General Principles

Always use behavioral/environmental interventions first

For a delirious patient: frequent re-orientation, exposure to natural light,

etc

For a personality/impulsive patient: contracting, setting limits,

etc

If that doesn’t work, use meds

If physical restraints are necessary for agitation, there’s

probably

something that could be optimizedSlide18

Treatment Approach:General Principles

NEVER

write IM orders as prn

IM implies medication being given without patient’s consent, for emergency: this is a

physician

-level decision

Only ever write as “ONCE-NOW”

Can write PO agitation meds as prn, since the patient could in principle refuse them

If you give an IM medication, you

must

document the event and your rationale for giving meds without the patient’s consent. Must document that it was an

emergency

(i.e.

imminent risk

of harm to patient or others in the absence of treatment)Slide19

Agitation: How to Classify Intervention

Agitated Patient

Organic (Delirium/Dementia/Substance)

Psychiatric Disorder

Personality/ImpulsivitySlide20

Organic Etiologies

Delirium (Non-Alcohol Withdrawal) and Dementia

Substance-Related

Substance Intoxication

Alcohol WithdrawalSlide21

Organic Etiologies:

Delirium (Non-Alcohol) and Dementia

Avoid benzodiazepines and anticholinergics

These cause/prolong/worsen delirium

General principles: think about “basic brain needs” – circadian rhythm, nutrition,

etc

Frequent orientation

Nutrition: B vitamin/folate supplementation if necessary

Provide familiarity

Provide access to natural light

Assess cognition (

MoCA

) to see if it’s improvingSlide22

Organic Etiologies:

Delirium (Non-Alcohol) and Dementia

Delirium (Non-Alcohol):

always caused by a medical condition +/- new environment

Find/treat underlying medical condition

Even if acute insult is gone, residual disorientation/delirium can last for days or longer

Use low-dose antipsychotics in the short-term to help them sleep at night

Risperidone 0.5mg

qHS

+ 0.25mg prn q8

Quetiapine 50mg

qHS

+ 25mg prn q6

Dementia

Use antipsychotics prn

Try to get them on

memantine

or donepezilSlide23

Organic Etiologies:

Substance-Related

Substance Intoxication

Generally, use benzodiazepines. Can use 5/2/50 too

Unless it’s

alcohol or opiates

, in which case benzos can cause respiratory depression

Use haloperidol +

benadrylSlide24

Organic Etiologies:

Substance-Related

Alcohol Withdrawal

Benzodiazepines: don’t be shy

Nurses are busy and will not always notice withdrawal signs or give it prn. Consider scheduling it with a prn on top

Delirium is correlated with later cognitive decline; may be a serious TBI-

esque

CNS injury

Do what you can to keep them out of delirium

People used to use

chlordiazepoxide

(Librium) but that has a long t

1/2

(commits you to management plan) and is metabolized by liver

Most of them have B12 deficiency

Chart “nutritional deficiency” and give them B vitamins. County gets $$$Slide25

Agitation: How to Classify Intervention

Agitated Patient

Organic (Delirium/Dementia/Substance)

Psychiatric Disorder

Personality/ImpulsivitySlide26

Psychiatric Disorder

Schizophrenia

Tip-offs:

Paranoia/suspiciousness

Obvious delusion

Hearing voices/talking to self

Flat affect

Poor grooming/hygiene/self-care: look at the shoes

Bipolar Mania

Tip-offs:

High amount of energy

Rapid speech

Not sleeping at night, or sleeping very little

Seemingly good self-care: wearing non-dirty clothes, non-tattered shoes

May also have psychosis: delusions/voices/

etcSlide27

Psychiatric Disorder (cont’d)

Consult psych to get recs for long-term management

In the short term,

Both mania and schizophrenia are treated with antipsychotics, so it’s good to use those for agitation (fewer medication classes on board)

Consider:

Haloperidol 5 + lorazepam 2 + diphenhydramine 50 q6h prn

Risperidone 0.5mg q8h prn

Quetiapine 50mg q6h prnSlide28

Agitation: How to Classify Intervention

Agitated Patient

Organic (Delirium/Dementia/Substance)

Psychiatric Disorder

Personality/ImpulsivitySlide29

Violence Risk Factors

Unmodifiable Risk Factors

History

Antisocial behavior (manipulation, crime, history of getting in fights)

Male gender

History of child abuse

Personality disorder diagnosis

Paternal drug use

Modifiable Risk Factors

Unemployment

Violent thoughts

Low SES neighborhood

Postictal

Recent stressor

Command auditory hallucinations

Involuntary hospitalizationSlide30

General Tips for Aggressive Patients

Don’t go near them, even if you’re confident (1.5 leg lengths is appropriate distance)

Stand, don’t sit

If you must stand near them, try to be slightly off to one side rather than fully in front of them

Always have an unobstructed exitSlide31

General Tips for Aggressive Patients

Don’t look away – when exiting, backpedal

Use low/slow voice – more commanding, pressures patient to match

Hands at waist, palms visible to patient

“You’re yelling and people are feeling scared. I think both of us are excited. Why don’t both of us agree to calm down, and I’ll write for some medication that can help feel a little more relaxed”

Try to get them to agree to meds. Easier to treat the willing, even during an episode of aggressionSlide32

General Tips for Aggressive Patients

As with all other forms of patient-related danger…

Behavioral/environmental interventions come first

Limit setting

“Show of force”

Select point person for interaction with the patient

Then medications

Call the code

Never lay hands on the patient yourself

Then restraintsSlide33

Limit Setting:The True Spectrum of Options Available to A Patient

A

D

B

F

G

E

CSlide34

The True Spectrum of Options Available to A Patient in the Hospital

They could…

Accept treatment

Refuse treatment

Accept treatment partially: i.e. accept the scope, but then refuse the bowel prep

Refuse treatment, but then refuse to leave the hospital

Threaten to leave AMA unless treatment goes according to their plans/against your wishes

Threaten/intimidate to obtain treatment according to their plans/against your wishes

Act out violentlySlide35

Limit Setting

A

BSlide36

Limit Setting

“Magician’s Choice”

Frame spectrum of options:

“This is what we want to do”

“If you don’t want to do those things, that’s okay, but then we’d have no reason to keep you in the hospital anymore and you’d have to go home. Can we agree on that?”

If they refuse: “we need to trust each other if we’re going to work together”

Once you’ve set your contract, follow it and refer to the conversation you had previously if the patient accuses you of springing new things on them

Difficult patients will often attempt to split the team: “but the other doctor said something else”

In this case, reinforce team unity: “this is my team and we are all on the same page about this.”

never

say “well I will have to discuss that with them” or “they misspoke”Slide37

Aggressive Patient:

Medication

Step one: call the code

Generally, 5/2/50 is okay

Try to get them to take PO: any buy-in is better than none

Also, med/

surg

nurses are not always accustomed to giving IM meds for sedation

(for example, Benadryl is viscous and takes a long time to draw up)Slide38

Continuum of InterventionSlide39

Questions?