Management of Acute Agitation & Aggression

Presentation on theme: "Management of Acute Agitation & Aggression"— Presentation transcript:

1 Management of Acute Agitation & Aggression
Collin Lueck PGY4 Psychiatry August 2018

2 Lecture Outline Defining Agitation
Overview of Commonly-Used Medications Treatment Approach by Etiology

3 Lecture Outline Defining Agitation
Overview of Commonly-Used Medications Treatment Approach by Etiology

4 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 others Agitation, sometimes a behavioral emergency, is a critical situation that demands immediate, effective attention so as to minimize danger to the patient and others, frequently in the absence of complete data. It is characterized by a constellation of signs and symptoms that may include psychomotor activation; affective lability; verbal abuse; catatonic excitement; and aggression to property.

5 Lecture Outline Defining Agitation
Overview of Commonly-Used Medications Treatment Approach by Etiology

6 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, hydroxyzine

7 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 effects

8 Haloperidol (Haldol) Dose: Route: Things to Remember:
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 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 arrhythmia

9 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 monitoring

10 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 onset

11 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, galactorrhea

12 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 antipsychotic

13 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)

14 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)

15 * * * * Medications are available in various formulations. There are oral / oral fast-dissolving tablets, IM, and IV formulations. There are some discrepancies in the literature re: pharmacokinetics of oral vs. IM formulations. However, IM injection enables direct entry of the active agent into the systemic circulation through the muscle’s vasculature, providing the potential for rapid onset of action. When delivered via IM injection, peak plasma levels of haloperidol are reached in about 20 minutes. The * above indicates a discrepancy between this chart and more recent literature.

16 Lecture Outline Defining Agitation
Overview of Commonly-Used Medications Treatment Approach by Etiology

17 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 optimized

18 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)

19 Agitation: How to Classify Intervention
Organic (Delirium/Dementia/Substance) Agitated Patient Psychiatric Disorder Personality/Impulsivity

20 Organic Etiologies Delirium (Non-Alcohol Withdrawal) and Dementia
Substance-Related Substance Intoxication Alcohol Withdrawal

21 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 improving

22 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 mg prn q8 Quetiapine 50mg qHS + 25mg prn q6 Dementia Use antipsychotics prn Try to get them on memantine or donepezil

23 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 + benadryl

24 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 t1/2 (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 $$$

25 Agitation: How to Classify Intervention
Organic (Delirium/Dementia/Substance) Agitated Patient Psychiatric Disorder Personality/Impulsivity

26 Psychiatric Disorder Schizophrenia Bipolar Mania Tip-offs:
Paranoia/suspiciousness Obvious delusion Hearing voices/talking to self Flat affect Poor grooming/hygiene/self-care: look at the shoes Bipolar Mania 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/etc

27 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 prn

28 Agitation: How to Classify Intervention
Organic (Delirium/Dementia/Substance) Agitated Patient Psychiatric Disorder Personality/Impulsivity

29 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 hospitalization Recognizing a gap in the abilities of mental health professionals to accurately assess the risk of “dangerousness to others,” the MacArthur Violence Risk Assessment Study was designed to produce a violence risk assessment tool. Several predictors for a high risk of violence were identified.

30 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 exit

31 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 aggression

32 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 restraints

33 Limit Setting: The True Spectrum of Options Available to A Patient
D C F E

34 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 violently

35 Limit Setting A B

36 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”

37 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)

38 Continuum of Intervention

39 Questions?