Faculty Q&A: Agitation in the Hospital
/Objectives
Distinguish the 4 types of agitation
Identify non-pharmacologic interventions for agiatation
Familiarize yourself with the pharmacologic inpatient interventions for agitation
Q&A Session
Questions:
+ What are the QTc prolongation risks with antipsychotics
We get concerned about giving additional QTc prolonging medications when the QTc > 500ms. Ziprasidone has the worst tendency to prolong QTc. Generally, the "-done" medications have more D2 blockage and affec the QTc more (i.e. Ziprasidone, Risperidone), while the "-pine" medications have less D2 activity and therefore less QTc prolongation (Clozapine, Olanzapine, Quetiapine). Aripiprazole is the most atypical and there are some reports of it decreasing QTc!
Click here to read more about Olanzapine, QTc, and whether it can cause Torsades
+ Can you comment on management sundowning in dementia patients? Is there evidence for scheduling medications to help prevent agitation? Does Trazodone work? What is the mortality associated with antipsychotics?
Sundowning is hard to manage. The underlying perspective of "treating" sundowning or agitation is a faulty because all of the medications we've talked about so far do not treat agitation, they mask it with the sedating side effect of the antipsychotic class. From an evidence based perspective, agitation is difficult to study because it is different in every patient - from the underlying pathophysiology to how patients' exhibit it.
Melatonin 3-6 mg qhs and low dose SSRIs have some evidence in preventing sundowning, however these are not medications take time to work.
There are numerous studies detailing the increased risk of mortality in patient's with dementia who recieve antipsychotics long term. A recent two-part meta-analysis in Annals looked at inpatient treatment and prevention of agitation with antipsychotics and did not find any supportive evidence.
- Antipsychotics for Preventing Delirium in Hospitalized Adults
- Antipsychotics for Treating Delirium in Hospitalized Adults
Controlling agitation that is interfering providing care to the patient, or if the patient is a danger to themselves, is possible with the sedating effects of antipsychotics, but to treat and prevent you need to prioritize non-pharmacologic strategies.
+ Can you elaborate on the non-pharmacological interventions that can be attempted before falling back on medications?
The first component of this comes down to diagnosis. The cause of agitation, or hyperactive delirium, can often determined. It has a number of causes: acute illness, dehydration, hypoxia, pain, constipation, urinary retention, medication side effect, lack of sleep, new location, lack of reorientation from familiar surroundings, etc.
When evaluating a patient who is newly delirious take time to categorize their delirium. Then try to see if there are any reversible causes - What are their vitals? Have they had BMs? Good UOP? Is it from a medication we gave them? Is their pain controlled? Are we checking vitals all night? Are their medications q8h (every 8 hours, even at night) instead of TID (breakfast, lunch, dinner)? Is their underlying disease not being treated or getting worse? This is not an exhaustive list but it is a place to start.
+ Can you talk about use of physical restraints for elderly patients not redirectable, old people frequently trying to get out of bed is a common thing I think we see and are often reticent to try meds given age and comorbidities
This speaks to the phenotype of the agitation. If getting out of bed is how they're delirium presents, it is unlikely to respond to medication unless you so thoroughly sedate them that they can barely stay awake. If they are a fall risk, you have evaluated them and tried to identify and treat the underlying cause of the delirium, and attempted non-pharmacologic methods - they may need to be restrained for protection, soft 2-3pt restraints.
+ Could you comment on the use of antipsychotics in delirium in Parkinson’s syndrome.
This is a good question as the antipsychotics are DA antagonists which could worsen Parkinson's symptoms. If you need to use AP in a Parkinsons patient, atypicals would be better as they have less DA activity as compared to the typicals. Be sure to monitor their exam closely.
+ Can you comment on the different side effect profiles of the antipsychotics and why you would choose one over the other? I feel like we always go to seroquel but it can have a lot of side effects
+ If you have someone in the hospital who has required an antipsychotic for agitation fairly regularly, what do you send them out with? when do you stop it or keep it going?
The issue is the over prescription of antipsychotics that do increase mortality in these patients, especially in the first 180 days of starting these medications, so sending them home with them unnecessarily could be dangerous. The first question is whether or not the underlying issue was addressed and is getting better. The second question is if there is a documented response to the antipsychotic. Finally, where are they going? If they are going home, it is worth discussing with the family and PCP, who would be monitoring the medication use. If they are going to a SNF, judicious is key. PRN prescription with a stop date to prevent the medication from becoming chart lore.
