Agitation

Physical Restraint and Associated Factors in Adult Patients in Intensive Care Units: A Cross-sectional Study in North of Iran

Background/aim

Patients in the intensive care units (ICUs) are at high risk of developing delirium and agitation. Physical restraint (PR) has increased to control these patients which accompanies by adverse consequences. The aim was to determine the PR use and associated factors in patients hospitalized at the ICUs in the North of Iran.

Materials and methods

In this cross-sectional study, a total of 272 patients in 3 ICUs of 5 Azar referral hospital affiliated to Golestan University of Medical Sciences (Gorgan, Iran) in 2018 were included. Confusion assessment method for the ICU (CAM-ICU), Richmond Agitation-Sedation Scale (RASS), acute physiology and chronic health evaluation II (APACHE II), and Glasgow Coma Scale (GCS) were used to evaluate delirium, sedation level, disease severity, and level of consciousness, respectively. Analysis was done by STATA version 14.2 (StataCorp LP, College Station, Texas), univariate and multiple analyses.

Results

Data from 272 patients were analyzed (mean age of 45.8 ± 21.3 years). PR was used for 74.5% of patients. Restrained patients had more severe disease [mean of APACHE II score, 20.20 (7.5) vs 11.6 (7.1)], longer length of stay [mean of 10 (5.5) vs 5.5 (4.6) days], and lower level of consciousness [mean of GCS score, 8.7 (3.5) vs 13.5 (3.3)] than patients without it. CAM-ICU was positive in majority of patients (79.5 vs 10.4%) and agitation level of RASS score was higher in restrained patients (31.7 vs 3.0%). Associated factors in multiple analysis were use of sedative and psychoactive drugs [odds ratio (OR), 2.85; 95% confidence interval (CI): 1.04–7.82], presence of delirium (OR, 15.13; 95% CI: 4.61–49.65), deep sedation (OR, 0.04; 95% CI: 0.00–0.45), and GCS score (OR, 0.69; 95% CI: 0.53–0.9).

Conclusion

This study revealed the high use of PR in the ICUs, and use of sedative and psychoactive drugs, presence of delirium, deep sedation, and GCS score were such associated factors.

How to cite this article

Nomali M, Ayati A, Yadegari M, Nomali M, Modanloo M. Physical Restraint and Associated Factors in Adult Patients in Intensive Care Units: A Cross-sectional Study in North of Iran. Indian J Crit Care Med 2022;26(2):192–198.

Group music interventions for dementia-associated anxiety: A systematic review

OBJECTIVE

This systematic review examines the few published studies using group music interventions to reduce dementia-associated anxiety, the delivery of such interventions, and proposes changes to nursing curriculum for the future.

DESIGN

Literature review.

METHODS

All quantitative studies from 1989 to 2014 were searched in CINAHL and PubMed databases. Only published articles written in English were included. Studies excluded were reviews, non-human subjects, reports, expert opinions, subject age less than 65, papers that were theoretical or philosophical in nature, individual music interventions, case studies, studies without quantification of changes to anxiety, and those consisting of less than three subjects. Components of each study are analyzed and compared to examine the risk for bias.

RESULTS

Eight articles met the inclusion criteria for review. Subject dementia severity ranged from mild to severe among studies reviewed. Intervention delivery and group sizes varied among studies. Seven reported decreases to anxiety after a group music intervention.

CONCLUSIONS

Group music interventions to treat dementia-associated anxiety is a promising treatment. However, the small number of studies and the large variety in methods and definitions limit our ability to draw conclusions. It appears that group size, age of persons with dementia and standardization of the best times for treatment to effect anxiety decreases all deserve further investigation. In addition, few studies have been conducted in the United States. In sum, while credit is due to the nurses and music therapists who pioneered the idea in nursing care, consideration of patient safety and improvements in music intervention delivery training from a healthcare perspective are needed. Finally, more research investigating resident safety and the growth of nursing roles within various types of facilities where anxiety is highest, is necessary.

The more physical inactivity, the more agitation in dementia

Epidemiological studies show a close relationship between physical activity and cognition. A causal relationship between physical activity and cognition has been observed in children, adolescents, older people without dementia, and in older people in a very early stage of dementia. Considering these positive effects, we argue that a decline in physical activity has a detrimental effect on cognition and behavior in patients with dementia. Merely living in a nursing home reduces the level of physical activity. The level of physical activity may even be reduced to a minimum when physical restraints are applied. The use of physical restraints coincides with stress, further aggravating the already existing neuropathology, which may increase stress and agitation even more. Exercise may reduce stress and agitation.

Multicentre study of delirium in ICU patients using a simple screening tool

Traditionally, intensive care unit (ICU) delirium was viewed as benign and was under-diagnosed in the absence of ICU-appropriate screening tools. Research suggests that up to half of all ICU patients experiencing delirium will continue to do so after discharge to the ward, and half of those experiencing delirium in the ward will die within 1 year of delirium diagnosis. ICU-specific screening tools are now available. The purpose of this study was to identify the incidence of delirium in ICU and explore its associations to clinical factors and outcomes. A secondary aim was to evaluate the usefulness of the intensive care delirium screening checklist (ICDSC). A total of 185 patients in six ICUs in Australia and New Zealand were screened for delirium using the ICDSC over two 12-hour periods per day for the duration of their ICU admission. Some 84 patients (45%) developed delirium. Development of delirium was associated with increased severity of illness (acute physiology and chronic health evaluation--APACHE II--and sequential organ failure assessment--SOFA), ICU length of stay (LOS), and use of psycho-active drugs. Delirious patients showed no statistically significant difference in ICU and hospital mortality rates, nor prolonged hospital LOS. The ICDSC was found to be user-friendly. The incidence of delirium, observed characteristics and outcomes for patients admitted to Australian and New Zealand ICUs for > 36 hours without any history of altered mental state fell in the mid-range and were generally consistent with previous literature. An ICU-specific delirium assessment, such as the ICDSC, should be included in routine ICU observations to minimise under-diagnosis of this serious phenomenon.

The use of physical restraint in critical care

Critically ill patients are at high risk for the development of delirium and agitation, resulting in non-compliance with life-saving treatment. The use of physical restraint appears to be a useful and simple solution to prevent this treatment interference. In reality, restraint is a complex topic, encompassing physical, psychological, legal and ethical issues. This article briefly discusses the incidence of delirium and agitation in critically ill patients and examines in detail the method of physical restraint to manage treatment interference. The historical background of physical restraint is discussed and the prevalence of its use in critical care units across the world examined. Studies into the use of physical restraint are analysed, and in particular the physical effects on patients discussed. The use of physical restraint raises many legal, ethical and moral questions for all health care professionals; therefore, this study aims to address these questions. This article concludes by emphasizing areas of future practice development in intensive care units throughout the UK.

Delirium in the postoperative cardiac patient: a review

BACKGROUND AND AIM OF REVIEW: Cardiac surgery is increasingly common and relatively safe, but there are frequent reports of neuropsychiatric sequelae occurring in the postoperative period. One of the most common neuropsychiatric presentations of cardiac surgery is delirium, also called postcardiotomy delirium (PCD). Despite the vast numbers of cardiac surgeries performed today, there is a paucity of data on risk factors and management options of PCD available to the clinician. This review aims to summarize available information, increase clinicians' awareness of PCD and suggest effective management of this illness.

METHODS

Our literature search was completed using the databases Medline and CINAHL; it was limited to human and English language studies from 1964 to the present. Search terms included "delirium," "agitation," "postoperative," "cardiac," "neuropsychiatric," "neuroleptics," "psychosis," "surgery," "treatment," "postcardiotomy," and "pharmacotherapy."

RESULTS

Our review of the literature revealed several risk factors for PCD, as well as various options for its pharmacological management.

CONCLUSIONS

A multifactorial model should be applied when considering risk stratification for and prevention of delirium postoperatively. Pharmacologically, conventional antipsychotic agents, such as haloperidol, have long been used to manage delirium. In light of haloperidol's side effects, particularly those applicable to the cardiac patient, further research is required into the role of second generation antipsychotics. These agents are common in clinical use, and may be the preferred medications.

Agitation in dementia: concept clarification

AIM

The aim of this paper is to clarify the concept of agitation in dementia through analysing definitions, critical attributes, components, boundaries, antecedents and consequences of agitation.

BACKGROUND

The concept of agitation is not well defined. In addition, there exists much confusion about the characteristics and boundaries of agitation, as well as the distinction between agitation and related concepts. Recently developed theoretical models for agitation in dementia require new interpretation and conceptualization of agitation.

METHODS

Morse's method of critical appraisal of the literature was used. In addition, some parts of Rodgers' evolutionary method were employed. Data were selected using six electronic databases and the key words 'agitation', 'agitated', 'dementia', 'demented' and 'Alzheimer'. The analysis included 86 empirical or theoretical papers and one book.

RESULTS

A transition from the observer's perspective to the patient's perspective in the interpretation of agitation was found. Five critical attributes of agitation in dementia were identified: excessive, inappropriate, repetitive, non-specific and observable. Patient factors, interpersonal factors, environmental factors and restraint were identified as precipitating antecedents. Mediating antecedents included discomfort, unmet need and misinterpretation. Consequences of agitation were identified at the levels of patient, caregiver and others.

CONCLUSIONS

This transition in perspectives has important implications as it can change health providers' attitudes and responses to agitation and lead to patient-focused and individualized care. Researchers and clinicians are encouraged to avoid labelling agitated behaviour as 'disturbing behaviour'.

Screening for delirium in an adult intensive care unit

Delirium is an acute, reversible disorder of attention and cognition and may be viewed as cerebral dysfunction similar to the failure of any other organ. The development of delirium is associated with increased morbidity and mortality, extended length-of-stay in the intensive care unit and longer time spent sedated and ventilated. Nearly every clinical, pharmacological and environmental factor present and necessary in the ICU setting has the potential to cause delirium. Since all of these factors cannot be removed, it is paramount to increase the awareness amongst health care professionals so as to minimise under-recognition and encourage future research into factors that may improve the long-term outcome for ICU patients. There is a need for user-friendly, validated assessment tools for the intubated and ventilated ICU patient, which can be applied at the time of ICU admission without the need for lengthy psychiatric assessment. Nursing professionals are at the forefront of those who are able to provide holistic care through meaningful conversation and empathetic touch. A 6-month Quality Improvement (QI) project screening patients for signs of delirium provided a foundation for discussion. All patients admitted to ICU for more than 72 h, with a hospital length-of-stay less than 96 h prior to ICU admission were screened. Patients admitted following neurological insults or with pre-existing altered mental state were excluded. The QI project showed the incidence of delirium to be 40% of the total sample (n = 73) in a mixed medical/surgical and elective/emergency patient population.

Case study of hip fracture in an older person

PURPOSE

To discuss proximal femoral (hip) fractures as the leading cause of hospitalization for injuries among older persons, using a case example that illustrates not only the orthopedic injury but also how an older person's chronic problems complicate the acute event.

DATA SOURCES

Extensive review of scientific literature on the conditions discussed, supplemented by the case study.

CONCLUSIONS

Hip fractures in older adults can present multiple challenges to care when complicated by preexisting or coexisting conditions. This case of an older man with a hip fracture emphasizes the resuscitation priorities for the patient found after a "long lie" and the impact of chronic alcoholism and malnutrition, which lead to serious complications.

IMPLICATIONS FOR PRACTICE

Careful physical and psychosocial assessment is important for determining the presenting problem and comorbid conditions. Priorities for postoperative management of hip fracture and its complications guide the nurse practitioner through the successful return of the patient to the community.

Identification and management of delirium in the critically ill patient with cancer

Rather than a specific entity, delirium is at the midpoint on a spectrum of potential mental status changes that ranges from full consciousness to deep coma. The extremes are relatively easy to recognize, but other points along the spectrum may go unrecognized or be misdiagnosed. If recognized and treated expeditiously, delirium may be reversed in some patients. It is imperative that those caring for critically ill patients with cancer have the knowledge and tools necessary to identify and manage delirium appropriately. Although all critically ill patients are at risk for delirium, cancer presents additional assaults to the central nervous system via direct tumor invasion or iatrogenic provocations. This article describes delirium in cancer, and addresses diagnostic and management issues across the course of the disease.

Phenomenology and treatment of psychotic disorders in the psychiatric emergency service

The emergency evaluation of a psychotic patient calls on all of the skills of the psychiatrist. The immediate control of dangerous behavior takes place at the same time that clinicians evaluate patients for delirium. A screening physical examination, a brief mental status examination, and a high index of suspicion for medical diseases are essential tools in the first few minutes of a patient's stay in the psychiatric emergency service. Drugs of abuse are often part of a patient's presentation. Here, too, the first task is to rule out delirium, particularly from sedative or alcohol withdrawal. As soon as a patient's condition is stabilized, the psychiatrist should review all of the available information, develop a working diagnosis, and initiate definitive treatment of the presumed disorder. With fewer emergency patients being hospitalized and with shorter lengths of hospital stay, these initial decisions acquire increasing significance for patient outcome.

Dementia: a complex symptom

The number of perianesthesia patients with dementia increases yearly. Understanding the physiology and functional impairments of these patients will improve the perianesthesia nurse's ability to create a safe environment, communicate effectively, and reduce discomfort.