Prevention, Diagnosis, and Treatment Strategies for the Agitated and Delirium Patient

Transcription

1 Prevention, Diagnosis, and Treatment Strategies for the Agitated and Delirium Patient Todd P. Hill, D.O. Meritas Health Psychiatry (formerly Northland Psychiatric Specialists, LLC) Medical Director Psychiatric Services: North Kansas City Hospital Medical Director: Signature Psychiatric Hospital Assistant Professor, Chairman Department of Psychiatry KCUMB

2 Speakers Bureau: (present): Teva Pharmaceuticals

3 Objectives: 1. Know the differential diagnosis for the delirium/agitated patient. 2. Understand de-escalation techniques 3. Become familiar with the different pharmacological agents used in the treatment of agitation

4 Between 35% and 80% of hospital staff have been physically assaulted at least once and nurses are at great risk for violence while on duty Each year there are an estimated 2,600 nonfatal assaults on hospital staff

5 In 2011, 23 percent of hospitals reported an overall increase in attacks and assaults 10 percent reporting a decrease 34 percent reported a rise in patient and family violence against emergency department 29 percent reported an increase in patient and family violence against other staff

6 Agitated patients are disruptive, dangerous, and usually delirious Agitated patients cause delays in patient recovery, increase expenses, increase anxiety, and can lead to injury

7 Psychiatric illnesses Bipolar mood disorder Schizophrenia; other psychotic illnesses Personality disorders Antisocial Borderline

8 Non-psychiatric causes: Medical: infection, CVA, metabolic encephalopathy, pain, traumatic brain injury Dementia Medications Alcohol or drug withdrawal Intoxication

9 Thirty-three to 50% of acute TBI survivors will encounter emotional lability Posttraumatic agitation Aggression Akathisia Disinhibition

10 Reversible, acute onset of impaired cognition, attention, consciousness, perception, sleep patterns (ie. day/night reversal), or emotional states that fluctuate over the course of the day Delirium is often misdiagnosed or unrecognized and thus inappropriately treated or untreated

11 Cognitive impairment Sensory impairment Severity of illness Dehydration Malnutrition Metabolic disturbances Intoxication Approximately 7 of 10 ICU patients experience delirium.

12 Delirium is associated with an increased mortality risk in patients 65 and older 38% had an increased risk for death 27.5% for controls Increased risk for institutionalization 33.4% of patients with delirium vs. 10.7% of controls 62.5% had an increased risk for dementia compared with 8.1% of controls

13 Confusion Assessment Method (CAM) 1. Is there an acute onset of mental status change? 2. Does the patient have difficulty focusing, ex. easily distracted or difficulty keeping track of what is being said? 3. Is the patient s thinking disorganized or incoherent, i.e. rambling or irrelevant conversation, unclear or illogical flow of ideas, unpredictable switching from subject to subject? 4. Overall how would you rate the patient s level of consciousness? Diagnosis of Delirium if questions 1 and 2 are yes with either a yes for question 3 or anything other than Alert in question 4.

14 History Patient with a well known history vs. the acutely agitated patient brought in to the hospital Almost half of the patients with schizophrenia have a drug and/or alcohol abuse problem Patient assessment may be difficult if someone is a trauma victim, acutely agitated and is an immediate danger to self or others

15 Interview should be private but not isolated The patient should NOT sit between the physician and the exit Removal of objects that could be used as weapons Security staff members available Code word or panic button to call for security

16 Remember to rule out medical conditions prior to initiating additional treatment Past history of violence may be a good predictor of future violent behavior Disorders of thought content (ie. Delusions) have also been linked to violence

17 Non-Violent/Non-Self-Destructive: Drug/ETOH withdrawal Delirium Mechanical ventilated patients Alzheimer s dementia TBI

18 Violent/Self-Destructive Patient Suicidal Homicidal Biting, kicking, scratching

19 The prevention of violence is best accomplished by developing a system that includes ongoing staff education, adequate personnel, and a well-designed physical structure.

20 Tone is set in the first few minutes Offer something to eat or drink Helps to build trust and appeals to basic human needs Sense of concern rather than confrontation Specific inquiry about patient s needs Calm and soothing tone of voice Non-confrontational, attentive and receptive Ventilation of the patient s feeling may be needed Maintain patient dignity

21 Avoid sudden movements or approaching the patient from behind Stand at least one arm s length away Never turn your back Stating the obvious, You look angry may help the patient share their emotions Do not criticize, interrupt, or respond defensively Never lie to a patient

22 Use restraints as a last resort only when: Alternative interventions have failed Imminent harm to self or others Disruption of important treatment Never to be used for convenience or punishment

23 If restraints must be used: Protect the patient s rights and dignity Choose the least restrictive method Explain to patient/family the purpose of the restraints (patient/staff safety, NOT a form of punishment or behavioral modification) Document each occurrence of restraints used Only properly trained and authorized staff may apply and remove restraints

24 Medications used to manage a patient s behavior, freedom of movement, and are not part of patient s standard treatment May be used with or without physical restraints Anticipate the need early in the clinical course to reduce the need for physical restraints If the patient becomes more agitated, no additional agents from this class should be given

25 Assessed by a clinician with documentation The reason should be clearly documented Responsible for the well-being of the patient Physical restraints should be removed as soon as possible

26 Restraining a patient who is capable of making decisions and poses no threats is false imprisonment or battery (which is not covered by malpractice) Required to warn a person who is in danger from a combative patient

27 Rapid onset, effective regardless of route of administration, minimal side effects The degree of sedation required must be balanced against potential side effects Benzodiazepines, typical antipsychotics and atypical antipsychotics, new agents (Precedex, ketamine) As a last resort, sedation with endotracheal intubation

28 Agitation from an unknown cause Agitation from drug or alcohol intoxication or withdrawal Avoid use in most delirium patients Lorazepam: rapid onset, effectiveness, short half-life mg every 30 minutes Half-life hours IV, PO, or IM SE: respiratory depression, excessive somnolence, paradoxical disinhibition

29 Haloperidol Oral: 5-10 mg (0.5-1mg. 1-2mg, 2-5mg doses used in geriatric patients) q hour IM/SC/IV: 2-5 mg usually every 4 hours (can be as often a 1 hour) Average Total Dose: mg (lower for geriatric patient) Decrease the dose by ½ in the elderly Repeat doses every 30 minutes; SE: QT prolongation, torsades de pointes (with IV) Possible slight increased risk of NMS in TBI patients, especially when used in high doses First line due to its efficacy, relative safety, and versatility Combination therapy with lorazepam achieves a more rapid sedation and minimizes any extra-pyramidal adverse effects

30 Olanzapine IM 10 mg Q2-4H (Max 30 mg/day) May calm agitated patients without causing excessive sedation Watch for excessive sedation if used with lorazepam Black Box: Elderly patients with dementia are at an increased risk of death Ziprasidone IM 10 mg Q2H or 20 mg Q4H (Max 40 mg/day) SE: QTc prolongation Black Box: Elderly patients with dementia are at an increased risk of death

31 The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) set standards for monitoring pain and anxiety assessment These practice guidelines established preferences for sedation in providing the calmest, least agitated, and easily aroused patients Minimizing agitation and anxiety has been shown to reduce ICU length of stay

32 Dexmedetomidine (Precedex) a selective alpha 2-adrenoceptor agonist, is an effective sedative agent for critically ill patients The recommended maintenance dose ranges from 0.2 to 0.7 ug/kg For conscious intubations, 0.5 ug/kg per hour is typically used initial loading dose, if required, is 1 ug/kg over 10 minutes with a normal response within 6 minutes following IV administration infusion pump should be used to control the dosage to the desired level of clinical sedation.

33 Dexmedetomidine (Precedex) Hypertension has occurred with the loading dose Hypotension with the maintenance infusion Bradycardia and cardiac arrhythmias Not to be used for more than 24 hours Advised not to use with lorazepam Ketamine low doses used in TBI patients less chance of increased intracranial pressures

34 Severely violent patients Haloperidol and lorazepam Agitation from drug intoxication or withdrawal Benzodiazepine Avoid haloperidol in alcohol and benzodiazepine withdrawal (mainly if history of seizures) Undifferentiated agitation Benzodiazepines or typical antipsychotics Agitated patients with psychiatric disorder Typical/atypical antipsychotics and benzodiazepines Avoid use of benzodiazepines in geriatric patients

35 44 y/o C.F. admitted following an overdose of Trazodone and Seroquel and. Pt was slightly agitated in the ED but then fell asleep. In ICU was confused and combative for 5 days Required 4-point restraints, high doses of haldol and lorazepam.

36 20 y/o C.F brought to the ED by police for anger outbursts and stating I would rather die than walk in the snow. While in the ED pt became agitated and was throwing objects at staff. Personality Disorder: impulsive, minimal insight Ziprasidone IM and lorazepam very effective

37 37 y/o C.M. came into the ED stating I ve killed several people referring to being HIV+. Pt attempted to jump out of a moving vehicle on the way to the ED. Pt attempted to leave the ED and had to be restrained. Pt has been on a 2-3 week methamphetamine binge. Pt has been disoriented and having auditory hallucinations Olanzapine 10mg IM effective

38 83 y/o C.F. admitted for agitation and fighting with nursing home staff. Pt becomes agitated in the evenings, pulling at her heart monitor and IV. Avoid benzodiazepines mg Risperdal in the evening

39 69 y/o C.M. with increased agitation, confusion, disorientation, and hallucinations. Pt. had multiple medical comorbidities Pt. did have episodes of delirium at an outside facility where he was receiving Zyprexa and Ativan. Pt. remained combative along with hallucinations and confusion, neither were effective Haloperidol was effective in this patient

40 42 year old male, admitted for surgery, family neglected to inform staff of alcohol use Severe delirium tremens, sending 3 staff members to the ED Adding scheduled haldol to lorazepam was effective Librium usually a better choice if taking PO and no severe liver disease

41 Double blind, comparison trial of haloperidol, chlorpromazine, and lorazepam involving 30 patients lorazepam alone was ineffective in treating delirium and sometimes made it worse Haloperidol and chlorpromazine were both effective in controlling symptoms of delirium and even improving cognitive functioning within the first 24 hrs

42 Breitbart, W., Alici, Y., (2008). Agitation and delirium at the end of life. JAMA, 300, Kunik, M.E., Snow, A. L., Davila, J.A., McNeese, T., Steele, A. B., Balasubramanyam, V., Morgan, R. O. (2010). Consequences of aggressive behavior in patients with dementia. Journal of Neuropsychiatry and Clinical Neurosciences, 22, Moore, G., & Pfaff, J. (2010). Assessment and management of the acutely agitated or violent adult. Up To Date. Salzman, C., Jeste, D. V., Meyer, R. E., Cohen-Mansfield, J., Cummings, J., Grossberg, G.T., Zubenko, G.S. (2008). Elderly patients with dementia-related symptoms of severe agitation and aggression. Journal of Clinical Psychiatry, 69, Servis, M. (1996). Managing agitated patients in a general hospital. WJM, 164 (3),

43 van Gool, Willem A. MD PhD. Delirium Linked to Death and Other Poor Outcomes in Elderly Patients JAMA. 2010;304: Health Facilities Management. October 2011 Emerg Med Clin N Am 28 (2010) The Journal of TRAUMA Injury, Infection, and Critical Care. 2009;66: The Journal of TRAUMA Injury, Infection, and Critical Care. 2008;65:34 41 I Was Stabbed By A Psychotic Patient. KCVA. October Todd P. Hill. D.O. (unpublished for now)