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Journal of Clinical Nursing Jan 2020To identify key determinants, which lead to the decision to apply physical or chemical restraint on the critical care unit. (Review)
Review
AIMS AND OBJECTIVES
To identify key determinants, which lead to the decision to apply physical or chemical restraint on the critical care unit.
BACKGROUND
Psychomotor agitation and hyperactive delirium are frequently cited as clinical rationale for initiating chemical and physical restraint in critical care. Current restraint guidance is over a decade old, and wide variations in nursing and prescribing practice are evident. It is unclear whether restraint use is grounded in evidence-based practice or custom and culture.
STUDY DESIGN
Integrative review.
METHOD
Seven health sciences databases were searched to identify published and grey literature (1995-2019), with additional hand-searching. The systematic deselection process followed PRISMA guidance. Studies were included if they identified physical or chemical restraint as a method of agitation management in adult critical care units. Quality appraisal was undertaken using Mixed Methods Appraisal Tool. Data were extracted, and thematic analysis undertaken.
RESULTS
A total of 23 studies were included. Four main themes were identified: the lack of standardised practice, patient characteristics associated with restraint use, the struggle in practice and the decision to apply restraint.
CONCLUSIONS
There are wide variations in restraint use despite the presence of international guidance. Nurses are the primary decision-makers in applying restraint and report that caring for delirious patients is physically and psychologically challenging. The decision to restrain can be influenced by the working environment, patient behaviours and clinical acuity. Enhanced clinical support and guidance for nurses caring for delirious patients is indicated.
RELEVANCE TO CLINICAL PRACTICE
Delirium and agitation pose a potential threat to patient safety and the maintenance of life-preserving therapies. Restraint is viewed as one method of preserving patient safety. However, use appears to be influenced by previous adverse experiences and subjective patient descriptors, rather than robust evidence-based knowledge. The need for a precise language to describe restraint and quantify when it becomes necessary is indicated.
Topics: Adult; Critical Care Nursing; Decision Making; Delirium; Humans; Intensive Care Units; Middle Aged; Physician-Nurse Relations; Psychomotor Agitation; Restraint, Physical; Tranquilizing Agents
PubMed: 31495002
DOI: 10.1111/jocn.15052 -
Clinical Therapeutics Apr 2020Valproic acid has been proposed as an alternative agent for treatment of agitation and delirium in the intensive care unit (ICU). Clinical data to support the use of...
PURPOSE
Valproic acid has been proposed as an alternative agent for treatment of agitation and delirium in the intensive care unit (ICU). Clinical data to support the use of valproic acid for this indication are limited. The objective of this analysis was to assess the efficacy and safety associated with the use of valproic acid for the management of agitation and delirium in the ICU.
METHODS
This retrospective descriptive analysis included patients who were prescribed valproic acid for a minimum of 3 days for the treatment of agitation and/or delirium in the cardiac, surgical, or medical ICU from May 31, 2015 to December 31, 2017. The prevalence of agitation and delirium was assessed during valproic acid therapy for up to 7 days. Additional data analyzed included opioid, sedative, and antipsychotic requirements and safety outcomes.
FINDINGS
A total of 47 patients met the inclusion criteria. There was an observed downward trend in the prevalence of agitation (47.8% vs 16.7%) and delirium (84.8% vs. 63.3%) throughout valproic acid therapy. In addition, the proportion of patients who required dexmedetomidine, benzodiazepines, antipsychotics, and opioids decreased while patients were taking valproic acid. No adverse effects attributed to valproic acid occurred in this patient population.
IMPLICATIONS
Valproic acid may be an alternative option to assist in the management of agitation and delirium in the ICU. Additional prospective data are needed to validate the use of this agent for the treatment of agitation and delirium in critically ill patients.
Topics: Aged; Aged, 80 and over; Analgesics, Opioid; Antipsychotic Agents; Benzodiazepines; Critical Care; Critical Illness; Delirium; Dexmedetomidine; Female; Humans; Hypnotics and Sedatives; Intensive Care Units; Male; Middle Aged; Psychomotor Agitation; Retrospective Studies; Valproic Acid
PubMed: 32273047
DOI: 10.1016/j.clinthera.2020.02.007 -
The Medical Letter on Drugs and... Jun 2023
Topics: Humans; Alzheimer Disease; Quinolones; Thiophenes; Psychomotor Agitation; Antipsychotic Agents
PubMed: 37339089
DOI: 10.58347/tml.2023.1679b -
Journal of the American Medical... Jul 2022To test the effect of a personalized music intervention on agitated behaviors and medication use among long-stay nursing home residents with dementia. (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
To test the effect of a personalized music intervention on agitated behaviors and medication use among long-stay nursing home residents with dementia.
DESIGN
Pragmatic, cluster-randomized controlled trial of a personalized music intervention. Staff in intervention facilities identified residents' early music preferences and offered music at early signs of agitation or when disruptive behaviors typically occur. Usual care in control facilities may include ambient or group music.
SETTING AND PARTICIPANTS
The study was conducted between June 2019 and February 2020 at 54 nursing homes (27 intervention and 27 control) in 10 states owned by 4 corporations.
METHODS
Four-month outcomes were measured for each resident. The primary outcome was frequency of agitated behaviors using the Cohen-Mansfield Agitation Inventory. Secondary outcomes included frequency of agitated behaviors reported in the Minimum Data Set and the proportion of residents using antipsychotic, antidepressant, or antianxiety medications.
RESULTS
The study included 976 residents with dementia [483 treatment and 493 control; mean age = 80.3 years (SD 12.3), 69% female, 25% African American]. CMAI scores were not significantly different (treatment: 50.67, SE 1.94; control: 49.34, SE 1.68) [average marginal effect (AME) 1.33, SE 1.38, 95% CI -1.37 to 4.03]. Minimum Data Set-based behavior scores were also not significantly different (treatment: 0.35, SE 0.13; control: 0.46, SE 0.11) (AME -0.11, SE 0.10, 95% CI -0.30 to 0.08). Fewer residents in intervention facilities used antipsychotics in the past week compared with controls (treatment: 26.2, SE 1.4; control: 29.6, SE 1.3) (AME -3.61, SE 1.85, 95% CI -7.22 to 0.00), but neither this nor other measures of psychotropic drug use were statistically significant.
CONCLUSIONS AND IMPLICATIONS
Personalized music was not significantly effective in reducing agitated behaviors or psychotropic drug use among long-stay residents with dementia. Barriers to full implementation included engaging frontline nursing staff and identifying resident's preferred music.
Topics: Aged, 80 and over; Antidepressive Agents; Antipsychotic Agents; Dementia; Female; Humans; Male; Nursing Homes; Psychomotor Agitation
PubMed: 35038407
DOI: 10.1016/j.jamda.2021.12.030 -
BMJ Open Jul 2019The aim of this systematic review was to assess the efficacy and safety of pharmacological agents in the management of agitated behaviours following traumatic brain...
OBJECTIVE
The aim of this systematic review was to assess the efficacy and safety of pharmacological agents in the management of agitated behaviours following traumatic brain injury (TBI).
METHODS
We performed a search strategy in PubMed, OvidMEDLINE, Embase, CINAHL, PsycINFO, Cochrane Library, Google Scholar, Directory of Open Access Journals, LILACS, Web of Science and Prospero (up to 10 December 2018) for published and unpublished evidence on the risks and benefits of 9 prespecified medications classes used to control agitated behaviours following TBI. We included all randomised controlled trials, quasi-experimental and observational studies examining the effects of medications administered to control agitated behaviours in TBI patients. Included studies were classified into three mutually exclusive categories: (1) agitated behaviour was the presenting symptom; (2) agitated behaviour was not the presenting symptom, but was measured as an outcome variable; and (3) safety of pharmacological interventions administered to control agitated behaviours was measured.
RESULTS
Among the 181 articles assessed for eligibility, 21 studies were included. Of the studies suggesting possible benefits, propranolol reduced maximum intensities of agitation per week and physical restraint use, methylphenidate improved anger measures following 6 weeks of treatment, valproic acid reduced weekly agitated behaviour scale ratings and olanzapine reduced irritability, aggressiveness and insomnia between weeks 1 and 3 of treatment. Amantadine showed variable effects and may increase the risk of agitation in the critically ill. In three studies evaluating safety outcomes, antipsychotics were associated with an increased duration of post-traumatic amnesia (PTA) in unadjusted analyses. Small sample sizes, heterogeneity and an unclear risk of bias were limits.
CONCLUSIONS
Propranolol, methylphenidate, valproic acid and olanzapine may offer some benefit; however, they need to be further studied. Antipsychotics may increase the length of PTA. More studies on tailored interventions and continuous evaluation of safety and efficacy throughout acute, rehabilitation and outpatient settings are needed.
PROSPERO REGISTRATION NUMBER
CRD42016033140.
Topics: Antipsychotic Agents; Brain Injuries, Traumatic; Humans; Psychomotor Agitation; Psychoses, Substance-Induced; Randomized Controlled Trials as Topic
PubMed: 31289093
DOI: 10.1136/bmjopen-2019-029604 -
International Psychogeriatrics Apr 2024The International Psychogeriatric Association (IPA) published a provisional consensus definition of agitation in cognitive disorders in 2015. As proposed by the original... (Review)
Review
BACKGROUND
The International Psychogeriatric Association (IPA) published a provisional consensus definition of agitation in cognitive disorders in 2015. As proposed by the original work group, we summarize the use and validation of criteria in order to remove "provisional" from the definition.
METHODS
This report summarizes information from the academic literature, research resources, clinical guidelines, expert surveys, and patient and family advocates on the experience of use of the IPA definition. The information was reviewed by a working group of topic experts to create a finalized definition.
RESULTS
We present a final definition which closely resembles the provisional definition with modifications to address special circumstances. We also summarize the development of tools for diagnosis and assessment of agitation and propose strategies for dissemination and integration into precision diagnosis and agitation interventions.
CONCLUSION
The IPA definition of agitation captures a common and important entity that is recognized by many stakeholders. Dissemination of the definition will permit broader detection and can advance research and best practices for care of patients with agitation.
Topics: Humans; Consensus; Geriatric Psychiatry; Psychomotor Agitation; Cognition Disorders; Cognitive Dysfunction
PubMed: 36880250
DOI: 10.1017/S1041610222001041 -
Annals of Internal Medicine Nov 2019Both pharmacologic and nonpharmacologic interventions are used to treat neuropsychiatric symptoms in persons with dementia. (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
Both pharmacologic and nonpharmacologic interventions are used to treat neuropsychiatric symptoms in persons with dementia.
PURPOSE
To summarize the comparative efficacy of pharmacologic and nonpharmacologic interventions for treating aggression and agitation in adults with dementia.
DATA SOURCES
MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, and PsycINFO between inception and 28 May 2019 without language restrictions; gray literature; and reference lists scanned from selected studies and systematic reviews.
STUDY SELECTION
Randomized controlled trials comparing interventions for treating aggression and agitation in adults with dementia.
DATA EXTRACTION
Pairs of reviewers independently screened studies, abstracted data, and appraised risk of bias.
DATA SYNTHESIS
After screening of 19 684 citations, 163 studies (23 143 patients) were included in network meta-analyses. Analysis of interventions targeting aggression and agitation (148 studies [21 686 patients]) showed that multidisciplinary care (standardized mean difference [SMD], -0.5 [95% credible interval {CrI}, -0.99 to -0.01]), massage and touch therapy (SMD, -0.75 [CrI, -1.12 to -0.38]), and music combined with massage and touch therapy (SMD, -0.91 [CrI, -1.75 to -0.07]) were clinically more efficacious than usual care. Recreation therapy (SMD, -0.29 [CrI, -0.57 to -0.01]) was statistically but not clinically more efficacious than usual care.
LIMITATIONS
Forty-six percent of studies were at high risk of bias because of missing outcome data. Harms and costs of therapies were not evaluated.
CONCLUSION
Nonpharmacologic interventions seemed to be more efficacious than pharmacologic interventions for reducing aggression and agitation in adults with dementia.
PRIMARY FUNDING SOURCE
Alberta Health Services Critical Care Strategic Clinical Network. (PROSPERO: CRD42017050130).
Topics: Aggression; Dementia; Humans; Network Meta-Analysis; Psychomotor Agitation
PubMed: 31610547
DOI: 10.7326/M19-0993 -
Emergency Medicine Clinics of North... Feb 2024The acutely agitated patient should be managed in a step-wise fashion, beginning with non-coercive de-escalation strategies and moving on to pharmacologic interventions... (Review)
Review
The acutely agitated patient should be managed in a step-wise fashion, beginning with non-coercive de-escalation strategies and moving on to pharmacologic interventions and physical restraints as necessary. Face-to-face examination, monitoring, and documentation by the physician are essential. The emergency physician should be familiar with multiple pharmaceutical options, tailored to the individual patient. Use of ketamine, benzodiazepines and antipsychotics should be considered. Patient autonomy, safety, and medical well-being are paramount.
Topics: Humans; Psychomotor Agitation; Ketamine; Antipsychotic Agents; Benzodiazepines; Restraint, Physical; Emergency Service, Hospital
PubMed: 37977745
DOI: 10.1016/j.emc.2023.06.010 -
Emergency Medicine Clinics of North... Feb 2024Hyperactive delirium with severe agitation is a clinical syndrome of altered mental status, psychomotor agitation, and a hyperadrenergic state. The underlying... (Review)
Review
Hyperactive delirium with severe agitation is a clinical syndrome of altered mental status, psychomotor agitation, and a hyperadrenergic state. The underlying pathophysiology is variable and often results from sympathomimetic abuse, psychiatric disease, sedative-hypnotic withdrawal, and metabolic derangement. Patients can go from a combative state to periarrest with little warning. Safety of the patient and of the medical providers is paramount and the emergency department should be prepared to manage these patients with adequate staffing, restraints, and pharmacologic sedatives. Treatment with benzodiazepines, antipsychotics, or ketamine is recommended, followed by airway protection, supportive measures, and cooling of hyperthermia.
Topics: Humans; Psychomotor Agitation; Delirium; Ketamine; Emergency Service, Hospital; Hypnotics and Sedatives
PubMed: 37977752
DOI: 10.1016/j.emc.2023.06.011 -
The Journal of Emergency Medicine Apr 2022Antipsychotic and sedative combinations are commonly used for treating agitation in the emergency department despite limited evidence regarding their comparative safety...
Efficacy of Combination Haloperidol, Lorazepam, and Diphenhydramine vs. Combination Haloperidol and Lorazepam in the Treatment of Acute Agitation: A Multicenter Retrospective Cohort Study.
BACKGROUND
Antipsychotic and sedative combinations are commonly used for treating agitation in the emergency department despite limited evidence regarding their comparative safety and efficacy.
OBJECTIVES
To compare the efficacy and safety of combination haloperidol, lorazepam, and diphenhydramine (B52) to combination haloperidol and lorazepam (52) in treating acute agitation.
METHODS
This multicenter, retrospective cohort study included adult patients ≥ 18 years of age who received either B52 or 52 at a Banner Health facility between August 2017 and September 2020. Patients were excluded if they had a pre-existing movement disorder or were withdrawing from alcohol. The primary outcome was administration of additional agitation medication(s) within 2 h of B52 or 52. Secondary outcomes included incidence of extrapyramidal symptoms, length of stay, and additional safety measures.
RESULTS
There was no difference in administration frequency of additional agitation medication(s) (B52: n = 28 [14%] vs. 52: n = 40 [20%]; p = 0.11). Patients who received 52 were more likely to require an antimuscarinic medication within 2 days (15 vs. 6 patients, p = 0.04). Of the patients who received an antimuscarinic medication, none had documented extrapyramidal symptoms. The 52 group had shorter length of stay (13.8 vs. 17 h; p = 0.03), lower incidence of hypotension (7 vs. 32 patients; p < 0.001), and oxygen desaturation (0 vs. 6 patients; p = 0.01), and fewer physical restraints (53 vs. 86 patients; p = 0.001) compared with the B52 group.
CONCLUSIONS
Both the B52 and 52 combinations infrequently required repeat agitation medication; however, the B52 combination resulted in more oxygen desaturation, hypotension, physical restraint use, and longer length of stay.
Topics: Adult; Antipsychotic Agents; Diphenhydramine; Haloperidol; Humans; Hypotension; Lorazepam; Muscarinic Antagonists; Oxygen; Psychomotor Agitation; Retrospective Studies
PubMed: 35287982
DOI: 10.1016/j.jemermed.2022.01.009