Reliability and validity of the Overt Agitation Severity Scale in adult psychiatric inpatients

Managing acute agitation and aggression in the world of drug shortages

Acute agitation and aggression create safety risks for both patients and staff, often leading to psychiatric emergencies. Quick and appropriate treatment is necessary to achieve safe and effective outcomes. Unfortunately, there are several factors that hinder timely interventions, such as medication shortages and delay in staff preparedness. Ultimately, the goal of managing acute agitation and aggression in the clinical setting is to de-escalate the situation and prevent harm to patients and staff. This article will explore useful interventions in realizing treatment goals for the management of agitation and aggression in adults while navigating limitations faced in practice.

Safety and efficacy of pharmacologic agents used for rapid tranquilization of emergency department patients with acute agitation or excited delirium

Introduction: Management of patients with acute agitation or aggressive behavior can pose a significant challenge to health-care providers in emergency departments. Areas covered: This article provides a comprehensive review of the pharmacologic properties, efficacy, and safety profiles of select intramuscular (IM) sedative agents (i.e., antipsychotics, benzodiazepines, and ketamine) for rapid tranquilization. Expert opinion: Using antipsychotics and benzodiazepines - whether a single agent or combined - will have similar efficacy in producing sedation. But there are differences in the time to sedation depending on which agent is used. Based upon the available studies, droperidol (5-10 mg IM) and midazolam (5-10 mg IM) have the fastest onset of sedation when either is used as a single agent. When combination therapy is used, using midazolam with an antipsychotic agent, instead of lorazepam, may result in faster sedative effect. QT prolongation and torsades de pointes are uncommon adverse drug effects of antipsychotic administration. Ketamine is often reserved as a second-line agent when antipsychotics and benzodiazepines fail to produce the desired tranquilization. However, ketamine (5 mg/kg IM) is more frequently associated with airway compromise requiring endotracheal intubation. A low-dose of ketamine (2 mg/kg IM) may reduce the risk of airway compromise while providing adequate sedation.

Asenapine: an atypical antipsychotic with atypical formulations

Asenapine is a second-generation (atypical) antipsychotic medication not available in a pill that can be swallowed; rather, it is commercialized in sublingual and transdermal formulations. This is a consequence of extensive first-pass metabolism if ingested. The sublingual formulation is approved in many jurisdictions for the treatment of schizophrenia and manic or mixed episodes associated with bipolar I disorder and is available generically. The efficacy profile is well characterized in a number of clinical trials, including an off-label use for the management of agitation. Obstacles to its use include food and drink restrictions, twice-daily dosing and adverse effects such as dysgeusia (distorted, altered, or unpleasant taste) and oral hypoesthesia (numbness). Transdermal asenapine was approved by the US Food and Drug Administration in 2019 for the treatment of schizophrenia in adults. Efficacy was established in a registrational study examining acutely ill inpatients with schizophrenia. The patch needs to changed once daily. Obstacles to its use include the potential for skin reactions such as erythema and pruritis, and being a branded product, it is more costly than other options. This is a narrative review of the chemistry and pharmacokinetics/pharmacodynamics of asenapine, as well as summarizing the efficacy and tolerability of both sublingual and transdermal asenapine, and its possible place in treatment.

Approach to the Agitated Emergency Department Patient

BACKGROUND

Acute agitation is a common occurrence in the emergency department (ED) that requires rapid assessment and management.

OBJECTIVE

This review provides an evidence-based summary of the current ED evaluation and management of acute agitation.

DISCUSSION

Acute agitation is an increasingly common presentation to the ED and has a broad differential diagnosis including metabolic, neurologic, infectious, toxicologic, and psychiatric etiologies. Missed diagnosis of a dangerous etiology of the patient's agitation may result in severe morbidity and mortality. Assessment and management of the agitated patient should occur concurrently. Focused history and physical examination are recommended, though control of the patient's agitation may be required. All patients should receive a point-of-care glucose test, with additional testing depending upon the specific patient presentation. Initial management should involve verbal de-escalation techniques, followed by pharmacologic interventions, with physical restraints reserved as a last resort. Pharmacologic options include first-generation antipsychotics, second-generation antipsychotics, benzodiazepines, and ketamine. Finally, the management of pediatric, pregnant, and elderly patients warrants special consideration.

CONCLUSION

Acute agitation is an important presentation that requires prompt recognition and treatment. A focused and thorough examination coupled with appropriate management strategies can assist emergency clinicians to safely and effectively manage these patients.

Management of acute agitation in psychosis: an evidence-based approach in the USA

Agitation in psychiatric settings, particularly in psychosis, presents a staggering challenge for clinicians, who must both manage the patient's acute symptoms and simultaneously make an accurate diagnosis. Too often, the management of the former confounds the latter. Patients are very often sedated medically, which masks their underlying condition, rendering accurate diagnosis delayed and inherently difficult. Significant data are available regarding both pharmacological and non-pharmacological interventions for agitation that maximise symptom control while minimising confounding side-effects. In this article, a review of the historical evolution of agitation management in psychotic illness is presented, followed by an evidence-based clinical guideline for managing agitation in psychosis in the USA.

Efficacy and Safety of Levosulpiride Versus Haloperidol Injection in Patients With Acute Psychosis: A Randomized Double-Blind Study

BACKGROUND

Injectable antipsychotics are frequently required for controlling agitation and aggression in acute psychosis. No study has examined the use of injectable levosulpiride for this indication.

OBJECTIVE

To compare the efficacy and safety of injectable levosulpiride and haloperidol in patients with acute psychosis.

METHODS

This was a randomized, double-blind, parallel-group study in which 60 drug-naive patients having acute psychosis were randomly assigned to receive either intramuscular haloperidol (10-20 mg/d) or levosulpiride (25-50 mg/d) for 5 days. All patients were rated on Brief Psychiatric Rating Scale (BPRS), Overt Agitation Severity Scale (OASS), Overt Aggression Scale-Modified (OAS-M) scores, Simpson Angus Scale (SAS), and Barnes Akathisia Rating Scale (BARS).

RESULTS

Repeated-measures ANOVA for BPRS scores showed significant effect of time (P < 0.001) and a trend toward greater reduction in scores in haloperidol group as shown by group × time interaction (P = 0.076). Repeated-measures ANOVA for OASS showed significant effect of time (P < 0.001) but no group × time interaction. Repeated-measures ANOVA for OAS-M scores showed significant effect of time (P < 0.001) and greater reduction in scores in haloperidol group as shown by group × time interaction (P = 0.032). Lorazepam requirement was much lower in haloperidol group as compared with those receiving levosulpiride (P = 0.022). Higher rates of akathisia and extrapyramidal symptoms were noted in the haloperidol group.

CONCLUSIONS

Haloperidol was more effective than levosulpiride injection for psychotic symptoms, aggression, and severity of agitation in acute psychosis, but extrapyramidal adverse effects were less frequent with levosulpiride as compared with those receiving haloperidol.

Managing Agitation Associated with Schizophrenia and Bipolar Disorder in the Emergency Setting

Introduction

Patient agitation represents a significant challenge in the emergency department (ED), a setting in which medical staff are working under pressure dealing with a diverse range of medical emergencies. The potential for escalation into aggressive behavior, putting patients, staff, and others at risk, makes it imperative to address agitated behavior rapidly and efficiently. Time constraints and limited access to specialist psychiatric support have in the past led to the strategy of “restrain and sedate,” which was believed to represent the optimal approach; however, it is increasingly recognized that more patient-centered approaches result in improved outcomes. The objective of this review is to raise awareness of best practices for the management of agitation in the ED and to consider the role of new pharmacologic interventions in this setting.

Discussion

The Best practices in Evaluation and Treatment of Agitation (BETA) guidelines address the complete management of agitation, including triage, diagnosis, interpersonal calming skills, and medicine choices. Since their publication in 2012, there have been further developments in pharmacologic approaches for dealing with agitation, including both new agents and new modes of delivery, which increase the options available for both patients and physicians. Newer modes of delivery that could be useful in rapidly managing agitation include inhaled, buccal/sublingual and intranasal formulations. To date, the only formulation administered via a non-intramuscular route with a specific indication for agitation associated with bipolar or schizophrenia is inhaled loxapine. Non-invasive formulations, although requiring cooperation from patients, have the potential to improve overall patient experience, thereby improving future cooperation between patients and healthcare providers.

Conclusion

Management of agitation in the ED should encompass a patient-centered approach, incorporating non-pharmacologic approaches if feasible. Where pharmacologic intervention is necessary, a cooperative approach using non-invasive medications should be employed where possible.

Assessment and management of agitation in psychiatry: Expert consensus

BACKGROUND

Psychomotor agitation is associated with different psychiatric conditions and represents an important issue in psychiatry. Current recommendations on agitation in psychiatry are not univocal. Actually, an improper assessment and management may result in unnecessary coercive or sedative treatments. A thorough and balanced review plus an expert consensus can guide assessment and treatment decisions.

METHODS

An expert task force iteratively developed consensus using the Delphi method. Initial survey items were based on systematic review of the literature. Subsequent surveys included new, re-worded or re-rated items.

RESULTS

Out of 2175 papers assessing psychomotor agitation, 124 were included in the review. Each component was assigned a level of evidence. Integrating the evidence and the experience of the task force members, a consensus was reached on 22 statements on this topic.

CONCLUSIONS

Recommendations on the assessment of agitation emphasise the importance of identifying any possible medical cause. For its management, experts agreed in considering verbal de-escalation and environmental modification techniques as first choice, considering physical restraint as a last resort strategy. Regarding pharmacological treatment, the "ideal" medication should calm without over-sedate. Generally, oral or inhaled formulations should be preferred over i.m. routes in mildly agitated patients. Intravenous treatments should be avoided.

Medical evaluation and triage of the agitated patient: consensus statement of the american association for emergency psychiatry project Beta medical evaluation workgroup

Numerous medical and psychiatric conditions can cause agitation; some of these causes are life threatening. It is important to be able to differentiate between medical and nonmedical causes of agitation so that patients can receive appropriate and timely treatment. This article aims to educate all clinicians in nonmedical settings, such as mental health clinics, and medical settings on the differing levels of severity in agitation, basic triage, use of de-escalation, and factors, symptoms, and signs in determining whether a medical etiology is likely. Lastly, this article focuses on the medical workup of agitation when a medical etiology is suspected or when etiology is unclear.

Managing dementia agitation in residential aged care

Agitation is a widespread and challenging problem among aged care residents with dementia. This article draws on empirical and theoretical literature to propose a model for preventing and treating agitation non-pharmacologically. A literature review finds agreed, coherent definition and measurement of agitation to be absent despite numerous agitation remedies having been suggested, yet sufficient material to support evidence-based care planning. Agitation is revealed as resulting from a resident’s interactions with the environment or their internal state, giving rise to unmet needs that attentive care can treat. Agitation treatments are reviewed to find no single effective remedy and a lack of quality evaluation. A higher-order, problem-solving approach is proposed. The described system consists of sequential diagnosis, decision making and treatment options, commencing with individualized and institutional preventative measures removing environmental triggers, followed by individual remediation, with residents’ unmet needs receiving priority consistent with patient-centred care.

Clinical characteristics of inpatient adolescents with severe obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a common disorder in adolescents, usually treated in the outpatient setting. Our aim in this study was to evaluate the clinical characteristics of adolescents with severe OCD that required hospitalization. A total of 342 patients consecutively admitted to a psychiatric adolescent inpatient unit and 87 healthy volunteers were assessed by a semistructured interview for clinical diagnosis, suicide risk factors, aggression, ego defense mechanisms, and intelligence. Patients with OCD (n=40) were compared to other four diagnostic patient groups with psychotic, affective, conduct, and eating disorders, as well as to normal controls. Adolescent inpatients with OCD experienced less separation anxiety than all the other psychiatric groups (P < .01) and were less impulsive than controls (P < .001). They differed in aggressive/impulsive traits and hospital-related behaviors from other diagnostic groups. Adolescent inpatients with OCD consist of a unique subgroup in the inpatient unit in terms of their clinical characteristics and risk factors for suicide. These characteristics should be taken into account when developing a treatment plan for these difficult-to-treat inpatients.

Measuring aggression in older adults: a latent variable modeling approach

This cross-sectional measurement study demonstrates a technique for combining information from several aggression scales into one aggression score using latent variable modeling. Participants included male patients (n = 49) with a DSM-IV diagnosis of dementia at The Veterans Affairs Medical Center Outpatient Geriatric Psychiatry Clinic. Data from seven aggression scales were used to indicate the latent aggression variable. Results provided evidence that a unidimensional latent variable model of aggression adequately represented the data. Reliability of the aggression latent variable was estimated as 0.90, whereas reliability of the separate scales estimated with this sample were less than 0.84. Our findings suggest that combining multiple scales into one aggression score using latent variable modeling results in comprehensive and reliable aggression scores that offer researchers several advantages over current methods for measuring aggression.