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Agitated Patient
What best describes the situation?
Protest (this is less than agitation)
Agitation
Restlessness
Delirium
Aggression
Violence

What will happen if the situation is not addressed properly?
Harms can increase if situation is not addressed properly.
A correct determination of the situation is essential.
A wrong conclusion can lead to wrong treatment and further harms.

What is agitation?
Agitation can be defined as excessive verbal and/or motor behavior. It can readily escalate to aggression, which can be either verbal (vicious cursing and threats) or physical (toward objects or people). Technically, violence is defined as physical aggression against other people. The key to safety is to intervene early in order to prevent progression of agitation to aggression and violence. Agitation can come on suddenly or over time. It can last for just a few minutes, or for weeks or even months. Pain, stress, and fever can all increase agitation.

What are common causes of agitation?
Agitation due to provocation.
Agitation due to severe stress.
Agitation due to deprivation of rights under the color of law.
Agitation due to harms.
Agitation due to intentional enforced harms.

Common causes of Protest
Protest (this is less than agitation)
Provocation
Severe Stress
Intentional enforced harms

What are various causes of agitation?
There are more than 35 causes of agitation.
Agitation due to harms
Alcohol intoxication or withdrawal
Allergic reaction
Adverse side effects of medication
Asthma
Alcohol withdrawal
Anxiety
Chronic renal failure
Certain forms of heart, lung, liver, or kidney disease
Drug Abuse
Drug withdrawal
Depression
Dementia (such as Alzheimer's disease)
Fatigue
Head injury
Hypoxemia
Hallucinations
Impaired vision or hearing causing the person to misinterpret sight and sounds
Intoxication or withdrawal from drugs of abuse (such as cocaine, marijuana, hallucinogens, PCP, or opiates)
Hospitalization (older adults often have delirium while in the hospital)
Hyperthyroidism (overactive thyroid gland)
Infection (especially in elderly people)
Mania
Nicotine withdrawal
Loss of control over behaviours due to the physical changes in the brain
Physical discomfort such as pain, fever, illness or constipation
Poisoning (for example, carbon monoxide poisoning)
Stress
Sleep deprivation
Schizophrenia
Stroke
Theophylline, amphetamines, steroids, and certain other medicines
Trauma
Vitamin B6 deficiency
What medical history should you seek relevant to this issue?

What is the cause of agitation in this situation?
How many individuals are involved in this situation?
What causes agitation or makes it worse?


Your health care provider will take a medical history and do a physical examination.

To help better understand your agitation, your health care provider may ask the following questions:

Obtain the History

Has the patient’s environment changed?
Is the patient psychotic?

Are you more talkative than usual or do you feel pressure to keep talking?
Do you find yourself doing purposeless activities (e.g., pacing, hand wringing)?
Are you extremely restless?
Are you trembling or twitching?

Time pattern

Was the agitation a short episode?
Does the agitation last?
How long does it last -- for how many day(s)?

Factors that make it worse

Does the agitation seem to be triggered by reminders of a traumatic event?
Did you notice anything else that may have triggered the agitation?
Do you take any medications, especially steroids or thyroid medicine?
How much alcohol do you drink?
How much caffeine do you drink?
Do you use any drugs, such as cocaine, opiates, or amphetamines?
Other
What other symptoms do you have?
Is there confusion, memory loss, hyperactivity, or hostility (these symptoms can play an important role in diagnosis).

Determine the Context of the Disturbed Behavior

Is this a sudden change in behavior or mental status?
Is this an acute exacerbation of a chronic problem?
What is the patient’s baseline level of cognition & behavior?
Are there patterns of or triggers for the problematic behaviors?

Restlessness

What is restlessness?
Restlessness differs from agitation. This behavior often comes after a patient has gone through the agitation stage. This is also considered part of the recovery process. Someone who is restless will have trouble sitting still, will not be able to focus or concentrate, and may be impulsive. The patient may appear nervous and anxious. He may pace or fidget all the time.

What causes restlessness or makes it worse?
Restlessness most often is increased or due to too much stimulation to the brain (like agitation.) But this may also occur if a patient is very confused and not getting enough stimulation.

What can family members do to help?
•Talk to the patient in a calm, quiet voice.
•It is not helpful to yell or argue with the patient. Someone with a brain injury is not able to reason.
•If your loved one becomes aggressive (yelling, striking out) call for help. Ensure your safety first.
•Remove all things that may distract or stimulate the patient. For instance, keep the TV off.
•Limit guests and keep visits short. It is vital for the patient to rest.
•Provide frequent prompts about where your loved one is and their injuries. But be sure not to quiz the patient about what she remembers.
•Tell the hospital staff what helps the patient relax.

Delirium

What is Delirium?
Delirium is an under-recognized, but surprisingly common problem, particularly among older adults who are hospitalized. People who are delirious have trouble thinking clearly, focusing their thoughts and paying attention. Delirium is different than the long-term confusion seen with dementia or Alzheimer’s disease. Delirium can come on within hours, and may come and go throughout the day.

What Causes Delirium?
It can be caused by a number of things – medications, infection, and simply being in an unfamiliar environment like the hospital. Patients at particular risk for delirium are those who have: Memory or thinking problems Severe illness Dehydration Problems seeing or hearing How Is Delirium Treated? Depending on the cause of the delirium, treatment may include medication as well as regular contact from our staff and HELP volunteers. Family members also play an important role in helping a patient with delirium. (See the next page for examples of what you can do to help your loved one).

How is delirium diagnosed?
There are several sub-types of delirium which can be diagnosed in patients who are critically unwell. Hypoactive delirium is the most frequent subtype of delirium in palliative care settings and is associated with lethargy, stupor and varying functioning levels of consciousness.

Can delirium be reversible?
Delirium may be reversible if there is an underlying metabolic, pharmacologic or psychosocial disorder which can be treated, and this is also true with over 50% of delirium episodes reversible in the palliative setting. In some patients delirium can be persistent and associated with longer term cognitive problems much of the evidence about prognosis and treatment of delirium comes from the aged care and critical care literature.

Acute Management of Agitation

An essential step in the management of agitation is the determination of its underlying cause. One approach to evaluating agitation is to carefully characterize the quality of the agitation, the time of day and setting in which it occurs, whether it occurs in a cyclical or a noncyclical pattern, and any possible environmental stimuli.

Treatment of acute agitation in psychotic disorders

Several psychotic disorders, including schizophrenia, may be associated with symptoms of acute agitation and aggression.

Who should be placed in restraints?
What chemical restraints are available?
What is the legality of restraints?

Pharmacologic Management



Most common injection forms of psychotropic drugs
Drug Dosage (mg) Half-time (hrs) Comments
Lorazepam 0,5–2 10–20 Can be used for treatment of alcohol withdrawal syndrome. No antipsychotic efficacy, risk of respiratory depression.
Clonazepam 1–2 20–39 Can be used for treatment of alcohol withdrawal syndrome. No antipsychotic efficacy, risk of respiratory depression.
Diazepam 5–30 50–200 Can be used for treatment of alcohol withdrawal syndrome. Long half-time, slow absorption, active metabolites.
Haloperidol 0,5–10 10–25 Risk of acute dystonia, EPS, akathisia, prolactin elevation, NMS.
Chlorpromazine 25–100 17–30 Risk of acute dystonia, EPS, akathisia, prolactin elevation, NMS.
Levomepromazine 25–50 16–78 Risk of acute dystonia, EPS, akathisia, prolactin elevation, NMS.
Zuclopenthixol 50–150 32 Risk of acute dystonia, EPS, akathisia, prolactin elevation, NMS.
Olanzapine 5–10 2–15 Risk of weight gain in long-term treatment (not in acute treatment). Low risk of EPS, does not induce prolongation of QTc interval.
Ziprasidone 10–20 4–38 Prolongation of QTc interval, low risk of EPS, does not induce weight gain.

Midazolam: Midazolam is the benzodiazepine that has the fastest onset of action and the shortest duration of effect.

Who takes the decision?
Any physician is able to take this decision; it need not be a specialist in either emergency medicine or psychiatry.
What is Abuse?
There are several kinds of abuse and each kind can take many different forms.
Physical
Emotional
Verbal
Sexual
Deprivation of rights under color of law.
Social

Hitting

Slapping

Shoving

Hair Pulling

Put Downs

Guilt Trips

Humiliation

Intimidation

Mind Games

Name Calling

Threats

Yelling

Unwanted Touch of any kind
5 Reasons Why Women Shouldn’t Deprive their Man(spouse) of Sex

 

Sexual Force of any kind

 

What are your basic needs for survival?
Food & Water Needs
Clothing
Water
Walking out
Communication
Healthcare
Housing Needs
Other

Educational Rights
Family Rights(What are Human Rights?)
5 Reasons Why Women Shouldn’t Deprive their Man(spouse) of Sex

 

Discrimination on the basis of race, color, gender, disability, religion, familial status and origin.

Spreading rumors

Controlling contact with friends

 

Isolation from friends or family

Acute Stress Reaction.(Acute Stress Disorder)
Posttraumatic Stress Disorder.
Is there a difference between acute stress reaction and acute stress disorder?
No.
Acute stress reaction or reactions and acute stress disorder mean the same.

Is there a difference between acute stress disorder and posttraumatic stress disorder?
Yes, there is.

What is the difference between acute stress disorder and posttraumatic stress disorder?
ASD refers to symptoms manifested during the period from two days to four weeks post trauma, whereas PTSD can only be diagnosed from four weeks onward.
Here are further guidelines.