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Academic Emergency Medicine : Official... Jan 2023Adjunct therapy with anticholinergic agents has been proposed to reduce the incidence of extrapyramidal side effects such as akathisia following treatment with... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
Adjunct therapy with anticholinergic agents has been proposed to reduce the incidence of extrapyramidal side effects such as akathisia following treatment with neuroleptics or metoclopramide. This systematic review assessed the effectiveness of anticholinergic agents to prevent neuroleptic or metoclopramide-induced akathisia in patients presenting to the emergency department (ED) with benign headache.
METHODS
Eight electronic databases and the gray literature were searched to identify randomized controlled trials involving adult patients presenting to the ED with primary headache treated with neuroleptic or metoclopramide. Study selection, data extraction, and quality assessment were completed by two independent reviewers. Individual or pooled meta-analysis of dichotomous outcomes were calculated as relative risks (RRs) with 95% confidence intervals (CIs) using a random-effects model. Heterogeneity was assessed using the I statistic.
RESULTS
A total of 1032 studies were screened, of which two studies were included in the review. Both studies provided patients with diphenhydramine following treatment with neuroleptics or metoclopramide. Treatment with diphenhydramine did not reduce the incidence of akathisia compared to treatment with placebo (RR 0.83, 95% CI 0.43-1.61, I = 0%). The impact of diphenhydramine on pain relief, need for rescue medications, and relief of other extrapyramidal side effects was reported in one of the two studies, with no significant differences noted in any outcomes compared to patients treated with placebo.
CONCLUSION
This review found insufficient evidence to recommend the use of diphenhydramine as an adjunct therapy to prevent akathisia in ED patients treated with neuroleptics or metoclopramide for primary headache. This finding relies on the results of two small randomized controlled trials with incomplete outcome reporting. Additional high-quality studies are needed to better understand the clinical efficacy of agents with anticholinergic properties in the ED management of patients with primary headaches.
Topics: Adult; Humans; Antipsychotic Agents; Cholinergic Antagonists; Diphenhydramine; Emergency Service, Hospital; Headache; Metoclopramide; Psychomotor Agitation; Randomized Controlled Trials as Topic
PubMed: 35962748
DOI: 10.1111/acem.14581 -
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 -
International Journal of Environmental... Apr 2022Delirium and psychomotor agitation are relevant clinical conditions that may develop during COVID-19 infection, especially in intensive care unit (ICU) settings. The... (Review)
Review
Delirium and psychomotor agitation are relevant clinical conditions that may develop during COVID-19 infection, especially in intensive care unit (ICU) settings. The psychopharmacological management of these conditions is receiving increasing interest in psychiatry, considering hyperkinetic delirium as one of the most common neuropsychiatries acute consequences in COVID-19 recovery patients. However, there are no actual internationally validated guidelines about this topic, due to the relatively newly introduced clinical condition; in addition, a standardized psychopharmacologic treatment of these cases is a complex goal to achieve due to the risk of both drug-drug interactions and the vulnerable conditions of those patients. The aim of this systematic review and case series is to evaluate and gather the scientific evidence on pharmacologic handling during delirium in COVID-19 patients to provide practical recommendations on the optimal management of psychotropic medication in these kinds of patients. The electronic databases PubMed, Embase and Web of Science were reviewed to identify studies, in accordance with the PRISMA guidelines. At the end of the selection process, a total of 21 studies ( = 2063) were included. We also collected a case series of acute psychomotor agitation in COVID-19 patients hospitalized in ICU. Our results showed how the symptom-based choice of the psychotropic medication is crucial, and even most of the psychotropic drug classes showed good safety, one must not underestimate the possible drug interactions and also the possible decrease in vital functions which need to be strictly monitored especially during treatment with some kinds of molecules. We believe that the evidence-based recommendations highlighted in the present research will enhance the current knowledge and could provide better management of these patients.
Topics: Delirium; Humans; Intensive Care Units; Psychomotor Agitation; Psychotropic Drugs; SARS-CoV-2; COVID-19 Drug Treatment
PubMed: 35564372
DOI: 10.3390/ijerph19094978 -
Academic Emergency Medicine : Official... Dec 2022Agitation in children in acute care settings poses significant patient and staff safety concerns. While behavioral approaches are central to reducing agitation and oral... (Review)
Review
OBJECTIVE
Agitation in children in acute care settings poses significant patient and staff safety concerns. While behavioral approaches are central to reducing agitation and oral medications are preferred, parenteral medications are used when necessary to promote safety. The goal of this systematic review was to evaluate the effectiveness and safety of an ultra-short-acting parenteral medication, droperidol, for the management of acute, severe agitation in children in acute care settings.
METHODS
A systematic review of randomized controlled trials, observational studies, and case series/reports examined the effectiveness and safety of parenteral droperidol for management of acute agitation in patients ≤21 years old in acute care settings. Effectiveness outcomes included time to sedation and need for a subsequent dose of medication. Safety outcomes were adverse effects such as QTc prolongation, hypotension, respiratory depression, and dystonic reactions.
RESULTS
A total of 431 unique articles were identified. Six articles met inclusion criteria: two in the prehospital setting, one in the emergency department, and three in the inpatient hospital setting. The articles included a prospective observational study, three retrospective observational studies, and two case reports. The largest study reported a median time to sedation of 14 min (interquartile range 10-20 min); other studies reported a time to sedation of 15 min or less. Across studies, 8%-22% of patients required a second dose of medication for ongoing agitation. The most frequent adverse effects were dystonic reactions and transient hypotension. One patient had QTc prolongation and another developed respiratory depression, but both had significant comorbidities that may have contributed. The risk of bias in included studies ranged from moderate to critical.
CONCLUSIONS
Existing data on droperidol for management of acute agitation in children suggest that droperidol is both effective and safe for acute, severe agitation in children. Data are limited by study designs that may introduce bias.
Topics: Humans; Child; Young Adult; Adult; Droperidol; Retrospective Studies; Emergency Service, Hospital; Prospective Studies; Respiratory Insufficiency; Psychomotor Agitation; Observational Studies as Topic
PubMed: 35490341
DOI: 10.1111/acem.14515 -
Critical Care (London, England) Mar 2022Delirium is the most common cerebral dysfunction in the intensive care unit (ICU) and can be subdivided into a hypoactive, hyperactive, or mixed motor subtype based on...
BACKGROUND
Delirium is the most common cerebral dysfunction in the intensive care unit (ICU) and can be subdivided into a hypoactive, hyperactive, or mixed motor subtype based on the clinical manifestation. The aim of this review was to describe the distribution, pharmacological interventions, and outcomes of delirium motor subtypes in ICU patients.
METHODS
This systematic scoping review was performed according to the PRISMA-ScR and Cochrane guidelines. We performed a systematic search in six major databases to identify relevant studies. A meta-regression analysis was performed where pooled estimates with 95% confidence intervals were computed by a random effect model.
RESULTS
We included 131 studies comprising 13,902 delirious patients. There was a large between-study heterogeneity among studies, including differences in study design, setting, population, and outcome reporting. Hypoactive delirium was the most prevalent delirium motor subtype (50.3% [95% CI 46.0-54.7]), followed by mixed delirium (27.7% [95% CI 24.1-31.3]) and hyperactive delirium (22.7% [95% CI 19.0-26.5]). When comparing the delirium motor subtypes, patients with mixed delirium experienced the longest delirium duration, ICU and hospital length of stay, the highest ICU and hospital mortality, and more frequently received administration of specific agents (antipsychotics, α2-agonists, benzodiazepines, and propofol) during ICU stay. In studies with high average age for delirious patients (> 65 years), patients were more likely to experience hypoactive delirium.
CONCLUSIONS
Hypoactive delirium was the most prevalent motor subtype in critically ill patients. Mixed delirium had the worst outcomes in terms of delirium duration, length of stay, and mortality, and received more pharmacological interventions compared to other delirium motor subtypes. Few studies contributed to secondary outcomes; hence, these results should be interpreted with care. The large between-study heterogeneity suggests that a more standardized methodology in delirium research is warranted.
Topics: Aged; Critical Care; Critical Illness; Delirium; Humans; Intensive Care Units; Psychomotor Agitation
PubMed: 35241132
DOI: 10.1186/s13054-022-03931-3 -
Annals of Palliative Medicine Jan 2022The incidence of hyperactive brain syndrome in patients in the intensive care unit (ICU) is very high. Compared with other sedative drugs, existing research shows that... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The incidence of hyperactive brain syndrome in patients in the intensive care unit (ICU) is very high. Compared with other sedative drugs, existing research shows that dexmedetomidine can significantly reduce the incidence of hyperactive brain syndrome. This study systematically analyzed the clinical efficacy of a dexmedetomidine intravenous injection in ICU patients with hyperactive brain syndrome.
METHODS
The databases PubMed, Web of Science, Embase, and the Cochrane Library were searched from January 2000 to December 2020 to identify papers that studied the clinical efficacy of dexmedetomidine intravenous injection in ICU patients with hyperactive brain syndrome. The basic information and evaluation indexes in the literature were screened and extracted. Revman5.3 software was used for quality assessment and meta-analysis of the included studies, and forest maps were drawn.
RESULTS
A total of 255 patients were included in 5 studies. The results of the meta-analysis showed that intravenous infusion of dexmedetomidine could reduce the incidence of restless delirium in patients [odds ratio (OR) =0.14; 95% confidence interval (CI): 0.07 to 0.29; (Z test) Z=5.39, P<0.00001], total delirium after medication duration [mean difference (MD) =-15.50; 95% CI: -25.70 to -5.29; Z=2.98; P=0.003], and ICU hospitalization time (MD =-1.93; 95% CI: -3.57 to -0.29; Z=2.31; P=0.02). However, there was no significant difference in the incidence of adverse reactions (bradycardia and hypotension) in patients who were given an intravenous infusion of dexmedetomidine (OR =2.85; 95% CI: 0.21 to 38.74; Z=0.79; P=0.43).
DISCUSSION
The incidence of restlessness delirium, the duration of total delirium after medication, and the length of ICU stay in patients treated with a dexmedetomidine intravenous injection were significantly lower than those in patients treated with haloperidol, indicating that a dexmedetomidine intravenous injection had clinical efficacy in ICU patients with hyperactive brain syndrome.
Topics: Brain; Delirium; Dexmedetomidine; Humans; Injections, Intravenous; Intensive Care Units; Psychomotor Agitation; Treatment Outcome
PubMed: 35144421
DOI: 10.21037/apm-21-3762 -
Revista de Neurologia Feb 2022Neuropsychiatric symptoms are common in patients with mild cognitive impairment and dementia. This symptomatology can appear or be exacerbated with changes in routine...
INTRODUCTION
Neuropsychiatric symptoms are common in patients with mild cognitive impairment and dementia. This symptomatology can appear or be exacerbated with changes in routine and in the patient's usual environment. The lockdown situation during the COVID-19 pandemic has meant a drastic and unexpected change in the daily life of the general population, with a particular impact on the most physically and mentally vulnerable groups, including patients with cognitive impairment.
AIM
To know the impact of lockdown measures imposed due to the COVID-19 pandemic on neuropsychiatric symptomatology in people with mild cognitive impairment and dementia.
MATERIALS AND METHODS
Exploratory systematic review, in accordance with the PRISMA guidelines, of Pubmed and Psycinfo databases papers published from January 2020 to April 2021 which related confinement due to COVID-19 with the presentation or worsening of neuropsychiatric symptoms in patients with mild cognitive impairment mild or dementia.
RESULTS
Worsening of neuropsychiatric symptoms was observed in patients with dementia and mild cognitive impairment, especially agitation/aggression, anxiety, depression and apathy. Neuropsychiatric symptoms were more common in patients with dementia than in those with mild cognitive impairment, although their typology varied depending on the severity of dementia.
CONCLUSIONS
During lockdown a worsening in the psychobehavioral area has been observed in people with mild cognitive impairment or dementia. Therefore, considerations arise on the need of promoting social contact in people with mild cognitive impairment and dementia, avoiding situations of isolation and low stimulation.
Topics: Activities of Daily Living; Aggression; Anxiety; Apathy; Argentina; COVID-19; Cognitive Dysfunction; Dementia; Depression; Europe; Humans; Mental Disorders; Mood Disorders; Neuropsychological Tests; Pandemics; Psychomotor Agitation; Quarantine; Retrospective Studies; SARS-CoV-2; Sleep Initiation and Maintenance Disorders; Social Isolation; United States
PubMed: 35084733
DOI: 10.33588/rn.7403.2021356 -
The American Journal of Emergency... Jan 2022Safe and effective tranquilization of the acutely agitated patient is challenging, and head-to-head comparisons of medications are limited. We aimed to identify the most... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Safe and effective tranquilization of the acutely agitated patient is challenging, and head-to-head comparisons of medications are limited. We aimed to identify the most optimal agent(s) for rapid tranquilization of the severely agitated patient in the emergency department (ED).
METHODS
The protocol for systematic review was registered (PROSPERO; CRD42020212534). We searched MEDLINE, Embase, PsycINFO, and Cochrane Database/CENTRAL from inception to June 2, 2021. We limited studies to randomized controlled trials that enrolled adult ED patients with severe agitation and compared drugs for rapid tranquilization. Predetermined outcomes were: 1) Adequate sedation within 30 min (effectiveness), 2) Immediate, serious adverse event - cardiac arrest, ventricular tachydysrhythmia, endotracheal intubation, laryngospasm, hypoxemia, hypotension (safety), and 3) Time to adequate sedation (effect onset). We extracted data according to PRISMA-NMA and appraised trials using Cochrane RoB 2 tool. We performed Bayesian network meta-analysis (NMA) using a Markov Chain Monte Carlo method with random-effects model and vague prior distribution to calculate odds ratios with 95% credible intervals for dichotomous outcomes and frequentist NMA to calculate mean differences with 95% confidence intervals for continuous outcomes. We assessed confidence in results using CINeMA. We used surface under the cumulative ranking (SUCRA) curves to rank agent(s) for each outcome.
RESULTS
Eleven studies provided data for effectiveness (1142 patients) and safety (1147 patients). Data was insufficient for effect onset. The NMA found that ketamine (SUCRA = 93.0%) is most likely to have superior effectiveness; droperidol-midazolam (SUCRA = 78.8%) is most likely to be safest. There are concerns with study quality and imprecision. Quality of the point estimates varied for effectiveness but mostly rated "very low" for safety.
CONCLUSIONS
Available evidence suggests that ketamine and droperidol have intermediate effectiveness for rapid tranquilization of the severely agitated patient in the ED. There is insufficient evidence to definitively determine which agent(s) may be safest or fastest-acting. Further, direct-comparison study of ketamine and droperidol is recommended.
Topics: Adult; Droperidol; Emergence Delirium; Emergency Service, Hospital; Humans; Ketamine; Network Meta-Analysis; Psychomotor Agitation; Randomized Controlled Trials as Topic; Severity of Illness Index; Treatment Outcome
PubMed: 34823192
DOI: 10.1016/j.ajem.2021.11.011 -
Trends in Psychiatry and Psychotherapy Jun 2022Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by persistent deficits in social communication and social interaction, associated with the... (Review)
Review
INTRODUCTION
Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by persistent deficits in social communication and social interaction, associated with the presence of restricted and repetitive patterns of behavior, interests, or activities. Cannabis has been used to alleviate symptoms associated with ASD.
METHOD
We carried out a systematic review of studies that investigated the clinical effects of cannabis and cannabinoid use on ASD, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA checklist). The search was carried out in four databases: MEDLINE/PubMed, Scientific Electronic Library Online (SciELO), Scopus, and Web of Science. No limits were established for language during the selection process. Nine studies were selected and analyzed.
RESULTS
Some studies showed that cannabis products reduced the number and/or intensity of different symptoms, including hyperactivity, attacks of self-mutilation and anger, sleep problems, anxiety, restlessness, psychomotor agitation, irritability, aggressiveness perseverance, and depression. Moreover, they found an improvement in cognition, sensory sensitivity, attention, social interaction, and language. The most common adverse effects were sleep disorders, restlessness, nervousness and change in appetite.
CONCLUSION
Cannabis and cannabinoids may have promising effects in the treatment of symptoms related to ASD, and can be used as a therapeutic alternative in the relief of those symptoms. However, randomized, blind, placebo-controlled clinical trials are necessary to clarify findings on the effects of cannabis and its cannabinoids in individuals with ASD.
SYSTEMATIC REVIEW REGISTRATION
International Prospective Register of Systematic Reviews (PROSPERO), code 164161.
Topics: Anxiety; Anxiety Disorders; Autism Spectrum Disorder; Cannabinoids; Cannabis; Humans; Psychomotor Agitation
PubMed: 34043900
DOI: 10.47626/2237-6089-2020-0149 -
Frontiers in Psychiatry 2021In recent years, an increase in the frequency of hospitalizations of patients taking newer and newer psychoactive substances has been observed around the world. Each...
In recent years, an increase in the frequency of hospitalizations of patients taking newer and newer psychoactive substances has been observed around the world. Each year, authors publish case reports of patients who consumed previously unknown NPS. Most publications of this type concern the period between 2014 and 2016. However, no publication systematically reviews the pharmacotherapy used in these cases. This study aims to review the case reports of patients taking NPS published between 2010 and 2019, as well as analyzing the pharmacotherapy used. We searched the Thomson (Web of Knowledge), PubMed/Medline, Science Direct, Scopus and Google Scholar databases. The search was performed using all possible combinations of the term "case report" describing the use of NPS, also referred to as designer medications, internet medications, research chemicals and herbal highs. We analyzed 51 case reports on the intake of various types of NPS. Most of them ( < 0.001) concerned the use of synthetic cannabinoids (41.2%) and cathinones (31.4%). The pharmacotherapy applied primarily ( < 0.001) consisted of administering benzodiazepines to patients (62.7%), most of whom took only this group of medications (25.5%), followed by groups receiving benzodiazepines combined with neuroleptics (15.7%) and muscle relaxants (11.8%). Opioids were administered primarily to patients taking synthetic opioids ( < 0.001). Of the 5 cases of deaths from NPS reported in the literature, three relate specifically to the synthetic opioid MT-45. The later the time period, the more medications patients were administered ( = 0.02). In the pharmacotherapy for NPS poisoning, one should focus primarily on combating psychomotor agitation.
PubMed: 33967865
DOI: 10.3389/fpsyt.2021.669921