ICL 8.9: Psychopharmacology of Agitation & Behavioral Emergencies Flashcards
what is considered a psychiatric emergency?
- risk of violence to self
- risk of violence to others
- new onset psychosis
- catatonia
what is considered a medical emergency?
- intoxication
- overdose
- agitation
- serotonin syndrome
- neuroleptic malignant syndrome (NMS)
- delirium
what is agitation?
an extreme form of arousal that is associated with increased verbal and motor activity
wig gets agitated?
- those with and without mental illnesses
- those with and without substance use disorders
- those on and off psychotropic medications
- those with and without medical comorbidities
what is the most important part of the assessment of agitation from most to least important?
- medical illnesses**
- medication/substance use related**
- psychotic disorders
- mood disorders
- anxiety disorders
- personality disorders
- other psychiatric illnesses
- situational problems
what should you ask about during an HPI for someone with agitation?
- baseline behaviors
- baseline mental status
- medication adherence
- past and current substance use
- past and current physical health
- recent changes: illness, fever, trauma, medication, changes, drug use, symptoms with a focus on neurological and psychiatric symptoms
- verify prescriptions
the HPI has a sensitivity of 94% in detecting medical illness in psychiatric patients
what is the progression of the symptoms of alcohol withdrawal?
MINOR SYMPTOMS
- anxiety
- insomnia
- GI upset
- headache
- palpitations
- anorexia
there can also be alcoholic hallucinosis, withdrawal seizures, or delirium tremens
minor symptoms –> alcoholic halllucinosis(1 day) –> withdrawal seizures (2 days)–> delirium tremens (3 days)
what is delirium tremens?
a condition caused by severe alcohol withdrawal
- agitation
- hallucinations
- disorientation
- tachycardia
- HTP
- fever
- diaphoresis
what is serotonin syndrome?
- akathisia
- tremors
- altered mental status
- clonus
- muscular hypertonicity
- hyperthermia
any SSRI or SNRI increases your risk for serotonin syndrome; also antipsychotics can cause this
what is a serious side effect of lithium?
renal failure
parathyroid dysfunction
what are some of the side effects of clozapine?
- confusion
- muscarinic side effects
- hypotension
what happens if you stop venlafaxine?
it’s an SNRI antidepressant that has THE shortest half life!
so if you stop it you’re going to have horrible withdrawal symptoms and you’re going to feel agitated, anxious, panic attacks, emotional lability
you can get all this from missing just one more dose!
what is the clinic presentation of someone with PCP intoxication?**
- aggression
- vertical nystagmus
- elevated BP
- hallucinations
what is the clinic presentation of someone with cocaine intoxication?**
- euphoria
- paranoia
- cardiac side effects
what is the clinic presentation of someone with hallucinogens intoxication?**
- pupillary dilation
2. perceptual distortions
what is the clinic presentation of someone with methanol intoxication?**
- visual disturbances
- ataxia
- confusion
how do you treat BZD, opioid, TCA, B blocker, and anticholinergic substance overdose?
- benzodiazepine –> flumazenil is the antidote
- opioids –> naloxone
- TCA –> sodiumbicarbonate
- B blocker –> glucagon
- anticholinergics –> atropine
what are the side effects of paroxetine?
paroxetine is THE most anticholinergic of the antidepressants
the threshold for having anticholinergic toxicity symptoms decreases as you get older
venlafaxine is the shortest 1/2 life
what are anticholinergic drug toxicities?
blind as a bat = dry eyes, difficulty adjusting visual focus/lens accommodation, sensitivity to bright light due to dilated pupils
mad as a hatter = hallucinations, tremulousness, memory impairment
red as a beet = flushing
hot as a hare = decreased sweating
dry as a bone = dry mouth, difficulty swallowing
the bowel and bladder lose their tone = constipation, urinary retention
the heart runs alone = tachycardia
which drugs can cause anticholinergic toxicity?
- muscarinic antagonists = atropine, scopolamine, hyoscine, benztropine, many plants
- muscarinic antagonists with other mixed effects = antihistamines, TCAs, antipsychotics
- decrease ACh release = carbamazepine, opiates, cannabinoids, ethanol, clonidine
- decreased ACh synthesis = thiamine deficiency
what is the antidote and MOA of the antidote for anticholinergic medication overdose?**
physostigmine
acetylcholinesterase inhibitor
what is the antidote and MOA of the antidote for benzodiazepine overdose?**
flumazenil
GABA(A) receptor antagonists
so it’s an antidote through competitive inhibition
what is the antidote and MOA of the antidote for opiod overdose?**
naloxone
antagonists at the mu opioid receptor
what is the antidote and MOA of the antidote for TCA overdose?**
sodium bicarbonate
TCAs cause sodium channel blockade that results in QRS prolongation
sodium bicarbonate causes serum alkalinisation
what is the antidote and MOA of the antidote for B-blocker overdose?**
glucagon
acts by directly activating adenyl cyclase by a mechanism separate from catecholamines so it bypasses beta blockade
it also increases hepatic gluconeogenesis which counteracts the hypoglycemia caused by B 2 blockade
what is delirium?
disruption in the neurobiological circuitry of attention in non-dominant parietal and frontal lobes
neurotransmitter (acetylcholine, serotonin, NE, GABA, endorphins) mechanisms
pro-inflammatory cytokines
30% of older medical pts experience delirium at some point during hospitalization
surgical patients & risk of delirium: 10-70% and higher with frail pts (hip fracture, cardiac surgery)
how do you manage delirium?
- continuity of care (nurses, techs, physicians)
- avoid room changes
- adhere to routines
- private or semi private room
- remove unnecessary equipment or clutter
- visible clock
- home management
- coping skills
- long term planning
- dry erase board
- call patient by preferred name
- glasses, dentures, hearing aids
- limit unnecessary awakenings
- turn lights & TV off at 10pm, and on during the day
- blinds open/sunlight in, during the day
what do you do some someone has agitation with delirium?
- recognize delirium (hypoactive versus hyperactive)
- assess its cause
- treat the cause of delirium
- treat l difficulties of agitation from delirium
keep in mind the pharmacokinetic and pharmacodynamics issues, in addition to drug-drug interactions, QTc (450-500?), renal and hepatic functioning when choosing how to manage agitation with medications
which medications can you use to manage delirium?
- depakote/valproate or valproate acid
- haldol
- remeron/mirtazapine (if having trouble sleeping, works on 5HT receptor, can increase appetite)
- buspar/buspirone
- clonidine
- trazodone
do schedule medications then additional medications as needed
adjust bowel care; make sure they’re having normal bowel movements and they’re not in pain
avoid anticholinergics that can induce even more delirium
which drug is useful for literally any kind of agitation?
lorazepam = adavan
what is NMS?
NMS = neuroleptic malignant syndrome
life threatening reaction that can occur in response to neuroleptic/antipsychotic medication
symptoms = high fever, sweating, confusion, rigid muscles, muscle cramps, variable blood pressure, ANS instability, fast heart rate, rhabdomyolysis, high K+, kidney failure, seizures
diagnosis is based on symptoms
can progress within 3 days
differential = heat stroke, malignant hyperthermia, other causes of delirium
risk factors = dehydration, agitation, catatonia, rapid adjusting levodopa
what are the clinical pearls for acute agitation?*
if appropriate, offer oral medication first
after treatment with IM agents: monitor vitals and clinical status at regular intervals
allow adequate time for clinical response between doses
use lower starting and maximum doses in the elderly (QTc!!!) and child and adolescent population
rule-out medical complications as a potential cause of agitation (hyper- or hypoglycemia, electrolyte disturbance, renal or hepatic failure, thyroid or adrenal disorders, Wernicke’s encephalopathy, hypotension, heart failure, neurologic disorders (stroke), meningitis infection (especially in elderly), and dementia)
rule-out substance intoxication or withdrawal
rule-out medication causes of acute agitation (steroids, anticholinergics, barbiturates, amphetamines, antipsychotic-induced akathisia)
what are the really important clinical pearls about agitation?**
- lorazepam is preferred for undifferentiated agitation (provides muscle relaxation, anxiolytic, anticonvulsant effects, and generalized sedation)
- haloperidol has a relatively low propensity for sedation and hypotension compared with other IM agents (such as chlorpromazine); however, it does have a higher incidence of EPS
- the combination of a benzodiazepine and a typical antipsychotic (i.e., haloperidol) has been shown to be superior to monotherapy with either agent and may allow for decreased doses of the antipsychotic medication. The combination can cause excessive sedation
