| Agitated Patient | |
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The Problem: Agitation and delirium are related but not identical. Delirium is an etiologically nonspecific disorder of consciousness characterized prominent deficits in attention, cognition, and perception. Sensory perceptual disturbances, including illusions, delusions, and hallucinations, may be seen. There is often disturbance or loss of normal sleep-wake cycles, as well as sleep deprivation. Psychomotor activity may be increased or decreased. It is imoprtant to remember however delirium does not equal psychosis. Agitation is a state of excessive mental and physical activity, usually associated with nonpurposeful movement, which can be hazardous. However, life-threatening agitation may be the most hazardous aspect of the delirious state. Acute agitation is usually a reversible organic syndrome and can be further categorized as hyperactive-hyperalert, hypoactive-hypoalert, and mixed type. Chronic agitation presents excesses of behavior that include some combination of aggression, akathisia (motor restlessness), disinhibition, or emotional lability. An altered level of consciousness, attentional abnormalities, or a disordered sleep-wake cycle may or may not be apparent. This type of agitation is not usually considered reversible and is frequently seen in the patient with dementia or underlying cognitive dysfunction. Chronic agitation can be further categorized into aggressive behavior, physically nonaggressive behavior, and verbally agitated behavior. |
What We Do: Delirium causes include toxic, metabolic, and/or structural disorders of the nervous system, medications, drug withdrawal and systemic illness, such as sepsis or hypotension. Two priorities should be addressed concurrently: 1. swift, definitive treatment of causative factor(s) and 2. supportive measures that protect patients during their delirium, including providing a predictable and orienting environment and, when needed, sedation. Acute mental status changes in any patient are due to hypoxia until proven otherwise. So ensure RBC's. Oxygen therapy may eliminate delirium caused by hypoxemia. Any patient, particularly an elderly one, who develops an unexplained acute delirium should be considered as having a drug intoxication until proved otherwise all drugs not essential for maintenance of life should be withdrawn until it can be determined that they are not contributing to the patient's state. Opiods, benzodiazepines, anticholenergics, NSAIDS and alcohol and sedative withdrawal are most strongly linked to drug-related delerium. Benzodiazepines are the most widely used psychoactive agents, and their use is highest in the elderly. Delerium can endanger a patient's physical safety so judicious use of chemical restraints in in conjunction with the attendance of calming family members or volunteers, may be the wisest course. Haloperidol is probably the most used antipsychotic in the ICU, yet it is one of the most underused sedative agents. Haloperidol (Haldol) a high-potency butyrophenone, is the preferred agent for the treatment of delirium in the critically ill adult. Sanders and Cassem developed a treatment protocol that recommends an initial severity-adjusted bolus of intravenous haloperidol: 0.5-1 mg for mild delirium, 2.0-5 mg for moderate delirium, and 5-10 mg for severe delirium. If agitation continues, the bolus dose should be doubled. The dose may be doubled every 30 to 60 minutes until behavioral calm is established. For clinicians who prefer to titrate continuous infusions, increases in increments of 2-4 mg/hour have been used to achieve therapeutic endpoints. Dosage adjustments ought to be considered for elderly patients. The most prudent advice may be to "start low and go slow," dosing at 30% to 50% of the recommended adult dose.Addition of an intravenous benzodiazepine to a neuroleptic regimen may result in increased behavioral control and decreased incidence and severity of neurologic side effects. Protocols use intravenous lorazepam (1-2 mg Ativan) every 4 hours or midazolam (Versed). Patients with agitation as part of their delirium may be expressing some degree of noradrenergic hyperfunction; the benzodiazepines are superbly suited to diminishing anxiety and decreasing musculoskeletal discomfort, with an additional amnestic benefit. Side effects to be aware of
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| Authorship: Dr Valerie Taylor | Last Revised: 29 May 2002 |