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Cerebrovascular Diseases (Basel,... 2011Mania is a rare consequence of stroke and according to the sparse published information it is difficult to describe its demographic, clinical and prognostic... (Review)
Review
BACKGROUND
Mania is a rare consequence of stroke and according to the sparse published information it is difficult to describe its demographic, clinical and prognostic characteristics.
METHODS
We performed a systematic review of all cases of mania and stroke to describe those characteristics. Studies were identified from comprehensive searches of electronic databases, reference lists of the studies collected and handbooks. Two authors independently assessed abstracts, and collected and extracted data.
RESULTS
From 265 abstracts, 139 were potentially relevant. For the first analysis, which tries to answer the clinical question of the relationship between mania and stroke, 49 studies met the inclusion criteria and described 74 cases. For the second analysis, we looked for an explicit temporal and causal relationship between manic symptoms and stroke, and selected 32 studies describing 49 cases. In both analyses, the typical patient was male, without a personal or family history of psychiatric disorder, with at least one vascular risk factor, but without subcortical atrophy and had suffered a right cerebral infarct. The majority of patients (92%) presented elevated mood as the first symptom. The other frequent symptoms were an increased rate or amount of speech (71%), insomnia (69%) and agitation (63%).
CONCLUSIONS
Post-stroke mania should be considered in any manic patient who presents concomitant neurological focal deficits and is older than expected for the onset of primary mania. The results of a systematic study of mania in acute stroke with subsequent follow-up and data from diffusion MR or perfusion CT in a multicenter study with a central database would be relevant.
Topics: Adult; Aged; Aged, 80 and over; Bipolar Disorder; Cerebral Infarction; Female; Humans; Incidence; Male; Middle Aged; Prognosis; Psychomotor Agitation; Sleep Initiation and Maintenance Disorders; Speech Disorders; Stroke
PubMed: 21576938
DOI: 10.1159/000327032 -
International Journal of Geriatric... Oct 2011Advancing age is associated with high prevalence of both dementia and pain. Dementia is frequently accompanied by distressing behavioral and psychological symptoms,... (Review)
Review
BACKGROUND
Advancing age is associated with high prevalence of both dementia and pain. Dementia is frequently accompanied by distressing behavioral and psychological symptoms, including agitation and aggression, particularly in nursing home patients. The etiology of agitation is multifactorial. It has been suggested that un-diagnosed and untreated pain may contribute to agitation in people with dementia. If this is correct, individual pain treatment could be of benefit in ameliorating agitation and other behavioral changes in people with dementia.
OBJECTIVE
The objective of this paper is to conduct a systematic review of studies of whether pain medication can improve agitation in people with dementia.
METHODS
A systematic search of the PubMed and Cochrane databases for the period 1992-2010 was performed, using dementia, agitation, aggression, depression, behavioral disturbances, behavioral and psychological symptoms (BPSD), pain, pain assessment, pain treatment, pain management, and analgesics as search terms. Inclusion criteria were: prospective studies including patients with dementia, interventions focusing on pain reduction, inclusion of a control condition, and outcome measures including agitation or other related behavioral disturbances.
RESULTS
Only three controlled trials were identified; all were cross-over trials, and two included small sample sizes (<50). Findings were inconsistent, and although some correlations were reported, these did not support the hypothesis that pain management reduced agitation.
CONCLUSION
There is a profound dearth of rigorous studies of the effect of pain treatment in patients with dementia and agitation. The available studies do not support the hypothesis that pain management reduces agitation in nursing-home patients with dementia. Randomized, controlled parallel-group studies are needed.
Topics: Aged; Aged, 80 and over; Analgesics; Dementia; Female; Humans; Male; Pain; Psychomotor Agitation; Randomized Controlled Trials as Topic
PubMed: 21308784
DOI: 10.1002/gps.2649 -
Journal of Clinical Nursing Jul 2016To provide an overview of available sensory stimulation interventions, and their effect on persons with dementia and to present theoretical and methodological... (Review)
Review
AIMS AND OBJECTIVES
To provide an overview of available sensory stimulation interventions, and their effect on persons with dementia and to present theoretical and methodological characteristics of the studies included.
BACKGROUND
Different sensory stimulation interventions are used for persons with dementia to increase alertness, reduce agitation and improve quality of life. However, the effect of these interventions is not clear, neither are their characteristics.
DESIGN
A systematic search and review of the literature with description of the content and an evaluation of theoretical and methodological approaches.
METHODS
Systematic searches in CINAHL, PubMed (Medline), The Cochrane library and PsycINFO. Studies included have been subject to quality assessment by means of Critical Appraisal Skills Programme.
RESULTS
Fifty-five studies were included and thirty of these documented significant effect. The effect of the sensory stimulation interventions mainly reported on negative behaviours, except from five studies assessing quality of life and well-being. The majority of the studies had methodological limitations. The different sensory stimulation interventions were organised into eight categories: music, light therapy, acupressure/reflexology, massage/aromatherapy and doll therapy/pet therapy/toy therapy, the Sonas programme and Snoezelen.
CONCLUSIONS
More studies are needed to clarify appropriate substantial background for the specific interventions. However, most of the studies based their interventions on a theoretical foundation. Furthermore, more research is needed to measure the effect of sensory stimulation on communication as well as quality of life. In addition, studies are to focus on whether the effect depends on the stage of dementia.
RELEVANCE TO CLINICAL PRACTICE
Nurses are to be aware of sensory stimulation as a possible intervention to improve persons' quality of life.
Topics: Animal Assisted Therapy; Aromatherapy; Dementia; Humans; Massage; Music Therapy; Psychomotor Agitation; Quality of Life; Sensory Art Therapies
PubMed: 27030571
DOI: 10.1111/jocn.13169 -
Canadian Journal of Anaesthesia =... Mar 2019Delirium, agitation, and anxiety may hinder weaning from mechanical ventilation and lead to increased morbidity and healthcare costs. The most appropriate clinical... (Meta-Analysis)
Meta-Analysis
A systematic review of interventions to facilitate extubation in patients difficult-to-wean due to delirium, agitation, or anxiety and a meta-analysis of the effect of dexmedetomidine.
BACKGROUND
Delirium, agitation, and anxiety may hinder weaning from mechanical ventilation and lead to increased morbidity and healthcare costs. The most appropriate clinical approach to weaning in these contexts remains unclear and challenging to clinicians. The objective of this systematic review was to identify effective and safe interventions to wean patients that are difficult-to-wean from mechanical ventilation due to delirium, agitation, or anxiety.
METHODS
A systematic review was performed using MEDLINE, EMBASE, and PubMed. Studies evaluating mechanically ventilated patients deemed difficult-to-wean due to delirium, agitation, or anxiety, and comparing the effects of an intervention with a comparator arm were sought. Time-to-extubation was the primary outcome while the secondary outcome was intensive care unit (ICU) length of stay.
RESULTS
From 10,860 studies identified, eight met the inclusion criteria: six studies assessed dexmedetomidine while the remaining two assessed loxapine and biofeedback. Pooled analysis of studies assessing dexmedetomidine showed reduced time-to-extubation (six studies, n = 303) by 10.9 hr compared with controls (95% confidence interval [CI], -15.7 to -6.1; I = 68%) and ICU length of stay (four studies, n = 191) by 2.6 days (95% CI, 1.9 to 3.3; I = 0%). Nevertheless, the evidence was deemed to be of low quality given the small sample sizes and high heterogeneity. Studies assessing other interventions did not identify improvements compared with controls. Safety assessment was globally poorly reported.
CONCLUSIONS
This systematic review and meta-analysis provides low quality evidence to suggest the use of dexmedetomidine in patients deemed difficult-to-wean due to agitation, delirium, or anxiety. Insufficient evidence was found regarding other interventions to provide any recommendation.
TRIAL REGISTRATION
PROSPERO (CRD42016042528); registered 15 July, 2016.
Topics: Airway Extubation; Anxiety; Delirium; Dexmedetomidine; Humans; Hypnotics and Sedatives; Intensive Care Units; Psychomotor Agitation; Time Factors; Ventilator Weaning
PubMed: 30674004
DOI: 10.1007/s12630-018-01289-1 -
European Journal of Anaesthesiology Dec 2015Emergence agitation is a common phenomenon in children recovering from general anaesthesia. An emergence agitation reaction increases the risk of injuring the surgical... (Meta-Analysis)
Meta-Analysis Review
Effects of melatonin premedication to prevent emergence agitation after general anaesthesia in children: A systematic review and meta-analysis with trial sequential analysis.
BACKGROUND
Emergence agitation is a common phenomenon in children recovering from general anaesthesia. An emergence agitation reaction increases the risk of injuring the surgical repair, the patient and the caregivers.
OBJECTIVE
The objective of this study is to examine the efficacy of melatonin premedication in emergence agitation prevention.
DESIGN
A systematic review and meta-analysis of randomised controlled trials (RCTs) with trial sequential analysis (TSA) and meta-regression analysis.
DATA SOURCES
We searched MEDLINE, the Cochrane Central Register of Controlled Trials, Embase, Web of Science, clinicaltrials.gov and UMIN Clinical Trials Registry up to 4 April 2014.
ELIGIBILITY CRITERIA
RCTs reporting effects of melatonin on the incidence of emergence agitation in children who underwent general anaesthesia were included.
RESULTS
Four studies (358 participants) were analysed. A conventional random-effects meta-analysis showed that compared with placebo, melatonin premedication may be effective in emergence agitation prevention [risk ratio 0.31, 95% confidence interval (CI) 0.16 to 0.60; I2 = 0%]. However, TSA corrected the 95% CI to 0.07 to 1.47 and showed that 22.5% of the required information size (RIS) was achieved. The effect of melatonin compared with that of midazolam was not statistically significant (risk ratio 0.48, 95% CI 0.15 to 1.52) with significant heterogeneity (I2 = 36.8%). TSA-adjusted 95% CI could not be calculated because of the small information size (4% of RIS). Meta-regression showed that, compared with midazolam, melatonin dose was significantly correlated with the effect (P = 0.024). The risk ratios (95% CI) of low and high-dose melatonin were 1.02 (0.39 to 2.65) and 0.22 (0.08 to 0.58), respectively. There was no effect of melatonin compared with dexmedetomidine (risk ratio 1.0, 95% CI 0.15 to 6.55). TSA-adjusted 95% CI could not be calculated (0.9% of RIS).
CONCLUSION
Compared with placebo, melatonin premedication may be effective in preventing emergence agitation in children (GRADE: low). This TSA suggests that further studies are required to confirm the results. Compared with midazolam, high-dose melatonin might have a significant effect in preventing emergence agitation (GRADE: very low). The study protocol was registered in the UMIN Clinical Trials Registry (registration number: UMIN000011841).
Topics: Anesthesia Recovery Period; Anesthesia, General; Child; Humans; Melatonin; Premedication; Psychomotor Agitation; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 26225499
DOI: 10.1097/EJA.0000000000000323 -
The Cochrane Database of Systematic... Sep 2017The efficacy of chlorpromazine, a benchmark antipsychotic, has not been fully assessed in direct comparison with different individual antipsychotics. Penfluridol is... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The efficacy of chlorpromazine, a benchmark antipsychotic, has not been fully assessed in direct comparison with different individual antipsychotics. Penfluridol is another old antipsychotic with a long half-life so one oral dose may last up to one week. This could confer advantage.
OBJECTIVES
To assess the clinical effects of chlorpromazine compared with penfluridol for adults with schizophrenia.
SEARCH METHODS
On 31 March 2017, we searched the Cochrane Schizophrenia Group's Study-Based Register of Trials which is based on regular searches of CINAHL, BIOSIS, AMED, Embase, PubMed, MEDLINE, PsycINFO, and registries of clinical trials. There are no language, date, document type, or publication status limitations for inclusion of records in the register.
SELECTION CRITERIA
We included all randomised clinical trials focusing on chlorpromazine versus penfluridol for adults with schizophrenia or related disorders. Outcomes of interest were death, service utilisation, global state, mental state, adverse effects and leaving the study early. We included trials meeting our selection criteria and reporting useable data.
DATA COLLECTION AND ANALYSIS
We extracted data independently. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we planned to estimate the mean difference (MD) between groups and its 95% CI. We employed a fixed-effect model for analyses. We assessed risk of bias for included studies and created a 'Summary of findings' table using GRADE.
MAIN RESULTS
The review includes three studies with a total of 130 participants. Short-term results for hospital admissions showed no clear difference between chlorpromazine and penfluridol (1 RCT, n = 29, RR 0.19, 95% CI 0.01 to 3.60, low-quality evidence). No clear difference in the incidence of akathisia was found at medium term (2 RCTs, n = 85, RR 0.19, 95% CI 0.04 to 1.06, low-quality evidence), and similar numbers of participants - nearly half - from each treatment group left the study early (3 RCTs, n = 130, RR 1.21, 95% CI 0.83 to 1.77, low-quality evidence). The risk of needing additional antiparkinsonian medication was less in the chlorpromazine group (2 RCTs, n = 74, RR 0.70, 95% CI 0.51 to 0.95). No useable data reported clinically important change in global or mental state. No data were reported for relapse. No deaths were reported by the trials.
AUTHORS' CONCLUSIONS
Only three small studies provided data and the quality of reporting and evidence is low. Limited data indicate the efficacy and adverse effects profiles of chlorpromazine and penfluridol are generally similar. Penfluridol, however, may confer advantage by needing to be given only once per week. Firm conclusions are not possible without good-quality trials, and where these treatments are used, such trials are justified.
Topics: Adult; Akathisia, Drug-Induced; Antipsychotic Agents; Chlorpromazine; Humans; Length of Stay; Penfluridol; Randomized Controlled Trials as Topic; Schizophrenia
PubMed: 28940256
DOI: 10.1002/14651858.CD011831.pub2 -
Medicine Aug 2022Montessori based activity are supposed to be an effective nonpharmacological intervention in the treatment of agitation in western countries. However, most studies... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
Montessori based activity are supposed to be an effective nonpharmacological intervention in the treatment of agitation in western countries. However, most studies conducted to evaluate the effectiveness of Montessori based activities on agitation in Asian patients were small sample size, as well as inconsistent outcomes, which may limit the reliability of the conclusions. The present pooled analysis, hence, was conducted to evaluate the effectiveness of the activity on agitation related with dementia in Asian patients with dementia.
DESIGN
Prospective randomized clinical studies were included, of which available data was extracted. Outcomes of physical aggressive behaviors, physical nonaggressive behaviors, and verbal aggressive behaviors were pooled for the analysis by weighted mean differences.
DATA SOURCES
Medline, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), WanFang, and China Science and Technology Journal Database (VIP).
ELIGIBILITY CRITERIA
Prospective, randomized, controlled clinical studies, conducted to evaluate the effectiveness of the activity on agitation related with dementia in Asian patients with dementia.
DATA EXTRACTION AND SYNTHESIS
Available data including baseline characteristics and interested outcomes from the included literature were extracted independently by 2 investigators. Measuring scales including CMAI and NOSIE were adopted for the efficacy comparison between Montessori based activity and standard activity. Weighted mean difference was used for the pooled analysis.
RESULTS
A total of 460 participants were included in the present meta-analysis. The pooled mean difference agitation for Montessori based activity was -3.86 (95% CI: -7.38 to -0.34, P = 0.03) comparing to standard activity. The pooled mean differences for physical aggressive behaviors, physical nonaggressive behaviors, and verbal aggressive behaviors in Montessori based activity group were -0.82 (95% CI: -1.10 to -0.55; P < 0.00001), -0.81 (95% CI: -1.68 to 0.55; P = 0.07), and 0.38 (95% CI: -0.92 to 1.68; P = 0.57).
CONCLUSIONS
Montessori based activities may reduce the frequency of agitation, especially in physical aggressive behaviors comparing to standard activities in Asian patients with dementia. However, the effectiveness of Montessori based activities on reduction of subcategorized agitated behaviors including physical nonaggressive behaviors, and verbal aggressive behaviors may not be reliable as physical aggressive behaviors.
Topics: Aggression; Dementia; Humans; Prospective Studies; Psychomotor Agitation; Reproducibility of Results
PubMed: 35960043
DOI: 10.1097/MD.0000000000029847 -
The Cochrane Database of Systematic... Feb 2014Complementary therapy has received great interest within the field of dementia treatment and the use of aromatherapy and essential oils is increasing. In a growing... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Complementary therapy has received great interest within the field of dementia treatment and the use of aromatherapy and essential oils is increasing. In a growing population where the majority of patients are treated by US Food and Drug Administration (FDA)-approved drugs, the efficacy of treatment is short term and accompanied by negative side effects. Utilisation of complimentary therapies in dementia care settings presents as one of few options that are attractive to practitioners and families as patients often have reduced insight and ability to verbally communicate adverse reactions. Amongst the most distressing features of dementia are the behavioural and psychological symptoms. Addressing this facet has received particular interest in aromatherapy trials, with a shift in focus from reducing cognitive dysfunction to the reduction of behavioural and psychological symptoms in dementia.
OBJECTIVES
To assess the efficacy of aromatherapy as an intervention for people with dementia.
SEARCH METHODS
ALOIS, the Cochrane Dementia and Cognitive Improvement Group Specialized Register, was searched on 26 November 2012 and 20 January 2013 using the terms: aromatherapy, lemon, lavender, rose, aroma, alternative therapies, complementary therapies, essential oils.
SELECTION CRITERIA
All relevant randomised controlled trials were considered. A minimum length of a trial and requirements for follow-up were not included, and participants in included studies had a diagnosis of dementia of any type and severity. The review considered all trials using fragrance from plants defined as aromatherapy as an intervention with people with dementia and all relevant outcomes were considered.
DATA COLLECTION AND ANALYSIS
Titles and abstracts extracted by the searches were screened for their eligibility for potential inclusion in the review. For Burns 2011, continuous outcomes were estimated as the mean difference between groups and its 95% confidence interval using a fixed-effect model. For Ballard 2002, analysis of co-variance was used for all outcomes, with the nursing home being treated as a random effect.
MAIN RESULTS
Seven studies with 428 participants were included in this review; only two of these had published usable results. Individual patient data were obtained from one trial (Ballard 2002) and additional analyses performed. The additional analyses conducted using individual patient data from Ballard 2002 revealed a statistically significant treatment effect in favour of the aromatherapy intervention on measures of agitation (n = 71, MD -11.1, 95% CI -19.9 to -2.2) and behavioural symptoms (n = 71, MD -15.8, 95% CI -24.4 to -7.2). Burns 2011, however, found no difference in agitation (n = 63, MD 0.00, 95% CI -1.36 to 1.36), behavioural symptoms (n = 63, MD 2.80, 95% CI -5.84 to 11.44), activities of daily living (n = 63, MD -0.50, 95% CI -1.79 to 0.79) and quality of life (n = 63, MD 19.00, 95% CI -23.12 to 61.12). Burns 2011 and Fu 2013 found no difference in adverse effects (n = 124, RR 0.97, 95% CI 0.15 to 6.46) when aromatherapy was compared to placebo.
AUTHORS' CONCLUSIONS
The benefits of aromatherapy for people with dementia are equivocal from the seven trials included in this review. It is important to note there were several methodological difficulties with the included studies. More well-designed, large-scale randomised controlled trials are needed before clear conclusions can be drawn regarding the effectiveness of aromatherapy for dementia. Additionally, several issues need to be addressed, such as whether different aromatherapy interventions are comparable and the possibility that outcomes may vary for different types of dementia.
Topics: Aromatherapy; Behavioral Symptoms; Dementia; Humans; Oils, Volatile; Psychomotor Agitation; Randomized Controlled Trials as Topic
PubMed: 24569873
DOI: 10.1002/14651858.CD003150.pub2 -
Pharmacopsychiatry Jul 2017Benzodiazepines are commonly used for the treatment of acute agitation in a psychiatric setting.We searched MEDLINE, EMBASE, PsycINFO, and the Cochrane Central Register... (Review)
Review
Benzodiazepines are commonly used for the treatment of acute agitation in a psychiatric setting.We searched MEDLINE, EMBASE, PsycINFO, and the Cochrane Central Register of Controlled Trials (CENTRAL) for relevant publications. Randomized trials evaluating intramuscular (IM) midazolam or lorazepam given as monotherapy or as add-on treatment, with more than 10 patients aged 18-65 years, conducted in a psychiatric setting, and published between January 1, 1980, and February 3, 2016, were included. 16 studies from a search result of 5 516 studies were included. In total, 577 patients were treated with lorazepam IM 2-4 mg, and 329 patients were treated with midazolam IM 5-15 mg. It is unclear whether lorazepam IM or midazolam IM is as efficacious as an antipsychotic IM. It is a bit more certain that the combination of benzodiazepines IM and a low dose antipsychotic IM is more efficacious than the benzodiazepine and the antipsychotic alone. However, there is no doubt that benzodiazepines are less likely to be associated with treatment emergent side effects, as compared to antipsychotics.
Topics: Anti-Anxiety Agents; Humans; Injections, Intramuscular; Lorazepam; Midazolam; Psychomotor Agitation
PubMed: 28293921
DOI: 10.1055/s-0043-100766 -
BMJ (Clinical Research Ed.) Jan 2016To study serious harms associated with selective serotonin and serotonin-norepinephrine reuptake inhibitors.Design Systematic review and meta-analysis. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To study serious harms associated with selective serotonin and serotonin-norepinephrine reuptake inhibitors.Design Systematic review and meta-analysis.
MAIN OUTCOME MEASURES
Mortality and suicidality. Secondary outcomes were aggressive behaviour and akathisia.
DATA SOURCES
Clinical study reports for duloxetine, fluoxetine, paroxetine, sertraline, and venlafaxine obtained from the European and UK drug regulators, and summary trial reports for duloxetine and fluoxetine from Eli Lilly's website.
ELIGIBILITY CRITERIA FOR STUDY SELECTION
Double blind placebo controlled trials that contained any patient narratives or individual patient listings of harms.
DATA EXTRACTION AND ANALYSIS
Two researchers extracted data independently; the outcomes were meta-analysed by Peto's exact method (fixed effect model).
RESULTS
We included 70 trials (64,381 pages of clinical study reports) with 18,526 patients. These trials had limitations in the study design and discrepancies in reporting, which may have led to serious under-reporting of harms. For example, some outcomes appeared only in individual patient listings in appendices, which we had for only 32 trials, and we did not have case report forms for any of the trials. Differences in mortality (all deaths were in adults, odds ratio 1.28, 95% confidence interval 0.40 to 4.06), suicidality (1.21, 0.84 to 1.74), and akathisia (2.04, 0.93 to 4.48) were not significant, whereas patients taking antidepressants displayed more aggressive behaviour (1.93, 1.26 to 2.95). For adults, the odds ratios were 0.81 (0.51 to 1.28) for suicidality, 1.09 (0.55 to 2.14) for aggression, and 2.00 (0.79 to 5.04) for akathisia. The corresponding values for children and adolescents were 2.39 (1.31 to 4.33), 2.79 (1.62 to 4.81), and 2.15 (0.48 to 9.65). In the summary trial reports on Eli Lilly's website, almost all deaths were noted, but all suicidal ideation events were missing, and the information on the remaining outcomes was incomplete.
CONCLUSIONS
Because of the shortcomings identified and having only partial access to appendices with no access to case report forms, the harms could not be estimated accurately. In adults there was no significant increase in all four outcomes, but in children and adolescents the risk of suicidality and aggression doubled. To elucidate the harms reliably, access to anonymised individual patient data is needed.
Topics: Antidepressive Agents; Depressive Disorder; Double-Blind Method; Humans; Psychomotor Agitation; Selective Serotonin Reuptake Inhibitors; Suicidal Ideation; Suicide; Suicide Prevention
PubMed: 26819231
DOI: 10.1136/bmj.i65