Introduction to Agitation, Delirium, and Psychosis

English-haiti

Introduction to Agitation,

Delirium, and Psychosis

Curriculum for nurses

partiCipant manual

IPartners In Health | partiCipant hanDBOOK

Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses

partners in health (pih) is an independent, non-profit organization founded over twenty years ago in haiti with a mission to provide the very best medical care in places that had none, to accompany patients through their care and treatment and to address the root causes of their illnesses. today, pih works in fourteen countries with a comprehensive approach to breaking the cycle of poverty and disease — through direct health-care delivery as well as community-based interventions in agriculture and nutrition, housing, clean water, and income generation.

pih’s work begins with caring for and treating patients, but it extends far beyond; to the transformation of communities, health systems, and global health policy. pih has built and sustained this integrated approach in the midst of tragedies like the devastating earthquake in haiti. through collaboration with leading medical and academic institutions like harvard medical school and the Brigham & Women’s hospital, pih works to disseminate this model to others. through advocacy efforts aimed at global health funders and policymakers, pih seeks to raise the standard for what is possible in the delivery of health care in the poorest corners of the world.

pih works in haiti, russia, peru, rwanda, sierra leone, liberia, lesotho, malawi, Kazakhstan, mexico and the united states. For more information about pih, please visit www.pih.org.

many pih and Zanmi lasante staff members and external partners contributed to the development of this training. We would like to thank giuseppe raviola, mD, mph; rupinder legha, mD ; père Eddy Eustache, ma; tatiana therosme; Wilder Dubuisson; shin Daimyo, mph; leigh Forbush, mph; Emily Dally, mph; Ketnie aristide, and Jenny lee utech.

this training draws on the following sources: World health Organization, mental Disorders Fact sheet 396, Oct 2014; michelle sherman, support and Family Education: mental health Facts for Families, april 2008, http://www.ouhsc.edu/safeprogram/; World health Organization, mhgap intervention guide (geneva: World health Organization), 2010; american psychiatric association, Diagnostic and statistical manual of mental Disorders (5th ed.) (Washington, DC: american psychiatric association), 2013; Journal of Clinical psychiatry, Consensus development conference on antipsychotic drugs and obesity and diabetes, February 2004; psychiatric times, aims abnormal involuntary movement scale, april 11, 2013, http://www.psychiatrictimes.com/clinical-scales-movement-disorders/clinical-scales-movement-disorders/aims-abnormal-involuntary-movement-scale.

We would like to thank grand Challenges Canada for its financial and technical support of this curriculum and of our broad mental health systems-building in haiti.

© text: partners in health, 2015 photographs: partners in health Design: Katrina noble and partners in health

II Partners In Health | partiCipant hanDBOOK


This manual is dedicated to the thousands of health workers whose tireless efforts

make our mission a reality and who are the backbone of our programs to save lives

and improve livelihoods in poor communities. Every day, they work in health centers,

hospitals and visit community members to offer services, education, and support, and

they teach all of us that pragmatic solidarity is the most potent remedy for pandemic

disease, poverty, and despair.

IIIPartners In Health | partiCipant hanDBOOK


Table of Contents

Introduction to Agitation, Delirium, and Psychosis

introduction ...........................................................................1

Objectives .............................................................................2

Epidemiology, stigma and the treatment gap ........................3

the psychosis system of Care and the Four pillars of Emergency management of agitation, Delirium and psychosis ........................................................................7

safety and management of agitated patients ......................12

medical Evaluation and management of agitation, Delirium, and psychosis .......................................................15

medication management for agitation, Delirium, and psychosis ......................................................................19

Follow-up and Documentation ............................................24

review ...............................................................................26

notes ..................................................................................31

IV Partners In Health | partiCipant hanDBOOK


Annex

psychosis Care pathway ......................................................33

agitation, Delirium and psychosis Checklist ........................34

medical Evaluation protocol for agitation, Delirium, and psychosis ......................................................................35

agitated patient protocol ....................................................37

agitation, Delirium and psychosis Form ..............................38

medication Card for agitation, Delirium and psychosis .......39

Partners In Health | partiCipant hanDBOOK 1


Introduction to Agitation, Delirium, and Psychosis

INTRODUCTION

Psychotic disorders refer to a category of severe mental illness that produces a loss of contact

with reality, including distortions of perception, delusions, and hallucinations. The most

common psychotic disorders are schizophrenia and bipolar disorder, which affect a combined 81

million people. Despite the immense burden of illness from psychotic disorders, about 80% of

people living with a mental disorder in low-income countries do not receive treatment.1 Stigma

and discrimination against people living with severe mental illness often result in a lack of

access to health care and social support. Human rights violations such as being tied up, locked

up, or left in inhumane facilities for years are all common.

Before a psychotic disorder can be diagnosed, however, patients require comprehensive medical

evaluation to ensure that medical problems are not the root cause of the symptoms. The term

‘agitated’ is often misused to describe patients who appear psychotic and are, therefore,

immediately referred to mental health. However, oftentimes these patients are actually

suffering from delirium, a state of mental confusion that can resemble a psychotic disorder but

is actually caused by a potentially severe medical illness. Patients who are delirious are often

injected with high doses of haloperidol to quell their ‘agitation,’ and they frequently do not

receive any medical evaluation or care. Unfortunately, this misdiagnosis and mismanagement

can lead to death.

Fortunately, nurses can learn how to safely manage agitated patients and work with other

providers to properly treat patients’ delirium. Zanmi Lasante nurses work side by side with

psychologists, social workers and community health workers to assist in the management and

diagnosis of agitation, delirium and psychosis. Psychotic disorders are treatable and for some,

completely curable. With the right training and system of coordinated care, people with

psychosis can receive effective treatment and lead rich, productive lives.

In this training, participants will learn how to manage agitated patients safely and effectively.

Participants will also learn how to distinguish between delirium and a psychotic disorder

1. World health Organization. (Oct 2014). mental Disorders Fact sheet 396. retrieved from: http://www.who.int/mediacentre/factsheets/fs396/en/

2 Partners In Health | partiCipant hanDBOOK


caused by mental illness. Ultimately, participants will learn how to provide high-quality

humane medical and mental health care for agitated, delirious, and psychotic patients.

ObjeCTIves

By the end of this training, you will be able to:

a. Describe the epidemiology of psychotic disorders and the corresponding treatment gap.

b. Describe the various ways that psychosis may be viewed by the community and by health providers.

c. Describe the impact of stigma on patient care and outcomes.

d. Identify key clinical information related to the diagnosis of various psychotic disorders.

e. Develop a basic mental health differential diagnosis using the Differential Diagnosis.

f. Information Sheet.

g. Describe the psychosis care pathway and its collaborative care approach.

h. Outline the main roles of physicians, psychologists, social workers, nurses and community health workers in the system of care related to the identification, treatment and management of agitation, delirium and psychosis.

i. Explain the four pillars of emergency management of agitation, delirium and psychosis.

j. Describe how nurses should use the biopsychosocial model when managing a patient with agitation, delirium or psychosis.

k. Describe the identification, triage, referral, and non-pharmacologic management of an agitated patient through the use of the Agitated Patient Protocol and Agitation, Delirium and Psychosis Form.

l. Define medical delirium.

m. Describe the importance of proper medical evaluation for an agitated, delirious or psychotic patient.

n. Explain how to conduct a medical evaluation of an agitated, delirious or psychotic patient.

o. Describe the use and possible side effects of the primary medications for agitation, delirium, and psychosis.

p. Provide comprehensive psychoeducation messages to a patient and their family around medication management.

q. Explain how to provide follow up for people living with psychotic disorders and severe mental illness, including general psychoeducation messaging.

r. Describe the importance of documentation during patient follow-up.



Epidemiology, the Treatment Gap, and Stigma

Severe Mental Illness

Severe mental illnesses are illnesses of longer duration, longer treatment and have a significant impact on activities of daily living. They include psychosis and mood disorders.

What is psychosis?

Psychosis is a syndrome. A syndrome is defined as the association of several clinically recognizable signs and symptoms which may have multiple causes.

Psychosis results in dysfunction in several domains:

• Cognition (disorganized thinking and speech, memory problems)

• Perception (hallucinations)

• Behavior (social withdrawal, catatonia)

• Emotion (decreased emotion)

There are some psychiatric disorders that mimic psychosis, which can include PTSD, acute stress, intellectual development disorder, and autism spectrum disorder.

schizophrenia

Schizophrenia is characterized by profound disruptions in:

• Thinking, affecting language

• Perception

• The sense of self

It often includes psychotic experiences, such as hearing voices, visual hallucinations or delusions. Patients with schizophrenia often first begin to show symptoms of psychosis when they are teenagers. Prior to developing schizophrenia, patients may show subtle non-specific signs such as depression, social withdrawal, and irritability.

Schizophrenia affects more than 21 million people worldwide. The prevalence ranges from 1 – 7 per 1,000 people. People with schizophrenia have a 20% reduction in life expectancy.2




bipolar Disorder

Bipolar disorder is a mood disorder that can include symptoms of depression, mania and/or psychosis. Manic episodes involve elevated or irritable mood swings, over-activity, pressure of speech, inflated self-esteem, and a decreased need for sleep. Some people with bipolar disorder experience mixed episodes that involve both symptoms of mania and depression at the same time or alternating frequently during the same day. Bipolar disorder usually starts during adolescence and early adulthood.

Bipolar disorder affects about 60 million people worldwide. It is the sixth leading cause of disability in the world. People with bipolar disorder have a reduced life expectancy of 9 – 20 years.3




Treatment Gap

Health systems have not yet adequately responded to the burden of mental disorders. As a consequence, there is a wide gap between the need for treatment and its provision all over the world. In low- and middle-income countries, between 76% and 85% of people with mental disorders receive no treatment for their disorder. In high-income countries, between 35% and 50% of people with mental disorders receive no treatment for their disorder.4

stigma

Stigma refers to negative or prejudicial thoughts about someone based on a particular characteristic or condition, in this case someone with a severe mental illness.

As clinicians, it is not acceptable to have stigmatizing thoughts or behaviors toward people with severe mental illnesses. It the clinicians’ responsibility to overcome these feelings to be able to treat patients with dignity and respect.


Statistics taken from World Health Organization Mental Disorders Fact Sheet #396

81 million + People living with severe mental illness

12 –19 million

People living with severe mental illness who receive treatment

Treatment Gap! 62– 69 million

People living with severe mental illness who receive no treatment



The Zanmi Lasante psychosis system of care aims to diminish Haiti’s treatment gap by safely and effectively treating people living with severe mental illness in a community-based system of care. Nurses have the opportunity to close the treatment gap and reduce the stigma related to psychosis by building on the coherent system of care already developed for depression and epilepsy. Nurses have the opportunity to help some of the most vulnerable and marginalized people living in communities — those living with mental illness.

sTIGmA ROle PlAy

sTORy

a patient is brought by his family to the emergency room. he is very talkative and focuses mainly on vodou and religion. the emergency nurse fears that he is violent and does not wish to touch him because he may be contagious. the nurse does not check vital signs or provide any medical care. instead the nurse calls the psychologist and says “a mental health patient is here.” in the meantime, the patient is totally dehydrated, and has a high fever that goes undetected. his sister reports he has never behaved this way before and only became “a crazy person” after a dog bit him. For more than two hours, the patient and his sister wait and no one comes to them for help.

sCRIPT

Family (Participant 2): Brings in the sick patient to the emergency room. “hello, please help us. my brother is sick.”

Patient (Participant 1): arrives at the emergency room with his sister. Begins to talk a lot about vodou and religion.

Nurse (Participant 3): acts scared because he might be violent. Calls the psychologist: “a mental health patient is here for you.”

Patient (Participant 1): is sitting down now. has a fever and is dehydrated. Does not look well. no longer very talkative.

Family (Participant 2): “Excuse me, nurse? i’m looking for help for my brother. he’s never been like this before. he only became like this after a dog bit him.” looks frustrated that no one helps them. “nurse, please help us.”

Nurse (Participant 3): “i have called the psychologist and i will let you know when he is available to see the patient.”



The Psychosis System of Care and the Four Pillars of Emergency Management of Agitation, Delirium, and Psychosis

The Psychosis System of Care

Nurses’ main roles in the Zanmi Lasante system of care are:

a. to ensure safety for the patient and others;

b. to work with the physician and psychologist/social worker to rule out a treatable medical illness and to prevent further harm;

c. to provide follow-up by educating to patient and families and coordinating care with other providers;

d. to perform monitoring and evaluation of patients.

Nurses are just one important element in the collaborative care approach; to provide quality care they need to work closely with other team members that include psychologists, social workers, physicians and community health workers.

Four Pillars of the emergency management of Agitation, Delirium and Psychosis

There are three types of patients that will come looking psychiatric, although not all of them will have a psychiatric illness:

• Patient is agitated

• Patient has a medical illness

• Patient has a psychiatric illness

Any decision around mental health or a treatment plan should include these four elements, in this order:

1. Safety

a. Determine the risk of suicide

b. Understand the exposure to violence

c. Determine the risk of violence

2. Medical Health

a. You cannot diagnose a mental illness without eliminating all medical causes

b. Take vital signs, perform a physical and neurological exam, lab tests (RPR, HIV, hemogram), in some cases consider a scan



3. Mental Health

a. Plan the assessment and ongoing treatment

b. Psychotherapy, pharmacology

c. Create a safety plan

4. Follow-up

a. Next appointment at the clinic

b. Which providers are involved in the patient’s care (CHW, psychologist/social worker, nurse, physician)?

Each pillar will be informed by the nurse’s use of the biopsychosocial model.

biopsychosocial model

Medical providers need to approach the treatment and management of psychotic disorders and severe mental illness from a biopsychosocial approach, because there are biological, psychological and social factors involved in the development of mental disorders.

A biopsychosocial approach to mental health treatment will:

• Assist with understanding the condition

• Assist with structuring assessment and guiding intervention

• Inform multidisciplinary practices

World health Organization: World mental health report, 2001: p. 20

Biological factors

psychological factors

mental and behavioural

disorders

social factors



bIO PsyCHO sOCIAl

• medical comorbidities

• genetic factors, family history

• medications (sensitivity, medication interactions, side-effects)

• Drug or alcohol use

• temperament

• personality

• Weaknesses

• Defense mechanisms (response to stressful situations)

• past trauma and losses

• support from family and friends

• Education and employment

• religious and spiritual beliefs

• socioeconomic stressors

• Exposure to stigmatization

• Explanatory model, system of beliefs

• Different coping strategies

CAse 1

CAse: biopsychosocial Considerations

a 37-year-old man patient is brought by his family to the emergency room. he is very talkative and shouts about vodou and religion as he runs around the emergency room.

the emergency nurses fear that he is violent and do not wish to touch him because he may be contagious. they do not check his vital signs or provide any medical care. instead they call the psychologist and say “a mental health patient is here.” in the meantime, the patient is totally dehydrated and has a high fever that goes undetected.

his family reports he has never behaved this way before and only became ‘a crazy person’ after a dog bit him two weeks ago. since then he has been unable to work and care for his wife and two children. Other family members have to stay with him, thereby losing daily wages.



thE FOur pillars OF EmErgEnCy managEmEnt OF agitatiOn, DElirium, anD psyChOsis

1. sAFeTy

violence:

• is the patient agitated or violent currently? (use the agitated patient protocol)

• What is the history of violence? When did it happen, how severe was it?

• is the patient being exposed to violence/abuse?

suicide:

• is the patient suicidal currently? actively or passively?

• What is the history of suicide? past attempts with medical severity, past suicidal ideation? When did it happen?

management:

• how is safety being managed? is 1:1 present?

• how is risk being decreased?

2. meDICAl

medical evaluation of Psychosis:

• must do a physical and neurological exam, vital signs, weight, laboratory tests (hemogram, hiV and rpr for all patients; renal and hepatic panels if available; CD 4 count for all hiV patients).

• Consider a Ct scan if the patient has a clear neurological deficit.

Consider Delirium:

• Disturbance of consciousness with reduced ability to focus, sustain or shift attention; change in cognition/development of perceptual disturbance not due to dementia; disturbance develops over a short period of time (hours to days) and fluctuates during the day; evidence from the history, physical exam or lab tests that the disturbance is caused by a medical problem.

• treatment is aimed at underlying medical problem and avoiding diazepam.

Consider epilepsy (Post-Ictal Psychosis):

• the family reports the development of psychosis/agitation after seizures.

• treatment is anti-epileptic.

medication management:

• use the medication card to dose and prescribe.

• provide fluids and do an EKg for all hospitalized/emergency room patients receiving haloperidol.

• Check for medication side-effects; do aims.

• Check vital signs and weight for all patients



3. meNTAl HeAlTH

Diagnosis:

• Work with a psychologist/social worker, use the Differential Diagnosis information sheet.

• reconsider the diagnosis at each visit.

Psychoeducation and support:

• provide education to patients and families regarding psychosis and medication.

medication management:

• use medication Card for agitation, Delirium and psychosis; consider diagnosis.

4. FOllOW-UP

Date of next appointment/visit:

• Follow-up based on acuity; for hospitalized patients, daily or several times a day; for outpatients, can be every 1– 2 days or weekly for more acute patients and every 2 – 4 weeks for stable patients.

• involve community health workers in the care.



Safety and Management of Agitated PatientsSafety is the first pillar when dealing with an agitated, delirious or psychotic patient.

Agitation

Is agitation a disease? Agitation is not a disease, there are many causes:

• Delirium (medical): mental retardation, thyroid abnormalities, dementia, seizures, hypoglycemia, anti-cholinergic intoxication and urinary tract infection, HIV encephalopathy, various states of intoxication and withdrawal

• Psychiatric problems: psychosis, mania, trauma

• Emotional/psychological trauma

Agitation Spectrum

There is a spectrum of agitation and patients can fall anywhere on the spectrum.

Forms to Manage Agitated Patients

The Agitated Patient Protocol will assist clinicians in properly managing different levels of agitation, including reducing the use of physical restraints, and medication.

The Agitation, Delirium, and Psychosis Form assists physicians in recording vital information related to determining if an agitated patient is delirious or psychotic.

When Managing an Agitated Patient: Safety and Talking First!

Often nurses and other health providers are unsure what to do when there is an agitated patient. By talking to the patient, the nurse can evaluate the risk of violence, begin the medical evaluation and calm the patient.

Agitation (mild) Aggression (moderate) violence (severe)

• wringing hands• pacing/moving restlessly• frequent demands• loud, rapid speech• low frustration tolerance

• verbal threats• yelling, cursing• does not respond to

verbal redirection• does not respond to

increased staff presence

• destroying property• making a fist, physically

threatening (e.g. hitting, kicking, biting)

• harming people



How to ensure safety:

• Do not see the patient alone (ask for security). Remain calm. Remember that patients do not suddenly become violent; their behavior occurs along a spectrum.

• Maintain a safe physical distance from the patient. Do not allow the exit to be blocked. Keep large furniture between you and patient.

• Remove all objects that can be used to harm (needles, sharp objects, other small objects). Check whether the patient has a history of violence or substance abuse.

• Talking to the patient is safe and effective. Do not yell. Keep your voice calm, quiet and friendly.

• Make eye contact to show that you care about the patient. Show sympathy and empathy (“I understand that you are scared, but I am here to help. We will not hurt you”).

Intramuscular Medication and Physical Restraint

When should providers give medication intra-muscularly?

From a human rights perspective, you always want the least restrictive approach and should use the fewest interventions necessary. We only give medication intramuscularly to a severely agitated patient who is at risk of imminent self-harm or is harming those around him. We only administer medication intramuscularly when a severely agitated patient refuses oral medication or is unable to comprehend the request to take oral medication. We must remember that administering an intramuscular injection is invasive and can cause physical pain. It can also potentially lead to physical harm towards providers.

In what situations should clinicians use physical restraint?

The goal is to use the least restrictive means necessary. The rights of a person must take priority, in balance with the safety of those around them. Physical restraint can be considered if:

• If calming measures have been tried AND

• The patient has been offered an oral medication and refused AND

• The patient reaches a state of severe agitation where there is a significant worry about harm to self and others AND

• It is felt that all alternatives have been tried



Gathering Information and a Brief Assessment

Physicians should try to obtain as much history about the patient as possible to better inform the management of the patient’s agitation. It is helpful to obtain this information from the patient, if possible, but also from family members or anyone who has accompanied the patient.

• What happened?

• How did this start?

• Has this happened before?

• Has the person suffered from a mental illness in the past?

• Does the person drink a lot of alcohol?

• Has the person been taking medicines lately?

• Has the person had any recent physical illnesses?

Although it would be ideal to obtain information about the agitated patient (whether from the patient or someone else), it is not always possible, depending on the level of agitation.

ROle PlAys

ROle PlAy 1: Agitated Patient

a 55-year-old man is brought to the clinic by concerned neighbors. they report that he has been talking to himself, yelling at people for no reason and making threatening comments. they refer to him as ‘crazy’ and report that he has no friends or family. in the clinic he is disorganized and confused.

ROle PlAy 2: Agitated Patient

a 24-year-old woman is brought to the emergency room by her boyfriend and brother. she is angry, yelling and screaming. her brother has to physically hold her in order to prevent her from lunging at her boyfriend. the brother reports that the patient’s behavior changed several days ago following an argument with her boyfriend in which she accused him of infidelity.

The Risk of Suicide

The identification and triage of patients with suicidal ideation is one of the most important aspects of the clinical history and the evaluation. It is important that each agitated or psychotic-appearing patient with a concern of self-harm is screened for suicidality.

Psychologists/social workers have the responsibility within the system of care to evaluate and properly screen patients for suicidality. The physician, when managing an agitated patient will ask and then record on the Agitated Patient Form if that patient has a history of suicide attempts. If the patient does have a history of suicide attempts, the psychologist/social worker will immediately use the Suicidality Screening Instrument to determine the patient’s level of risk. If a nurse is assessing a patient, and has a concern about a patient’s safety, they should contact the psychologist/social worker immediately so the patient can be properly screened.



Medical Evaluation and the Management of Agitation, Delirium, and PsychosisOnce a clinician has calmed an agitated patient, the physician and psychologist/social worker need to determine if the patient is psychotic or has a medical delirium.

Definition of Agitation, Delirium and Psychosis

Agitation is a symptom to describe behavior. It is not a disease. It is not a mental illness.

Delirium is a medical emergency. It is not a mental illness. It occurs when medical illness results in mental confusion. Delirious patients are confused and off-center and have an increased chance of death. They also have an additional disturbance in cognition (e.g. memory deficit, disorientation, language, visuospatial ability or perception). The disturbance develops over a short period of time (usually hours to a few days) and tends to fluctuate in severity during the course of a day. Delirium is often misdiagnosed as psychosis or other psychiatric illnesses.

There are many causes for delirium including:

• Infections (HIV/AIDS, neurosyphilis, malaria)

• Metabolic disorders (electrolyte disorders, especially hypo/hyperglycemia related to diabetes)

• Drug intoxication/Alcohol withdrawal

• Medications (corticosteriods, cycloserine, phenobarbital, efavirenz, high doses of antihistamines, isoniazid)

• Malnutrition/Vitamin deficiencies

• Brain diseases (dementia, stroke, head injury with bleed)

• Malignancy

• Post-Ictal Psychosis

– Takes place between seizures

– Usually follows a ‘lucid’ interval that lasts from hours to days following a seizure

– Characterized by delusions, hallucinations, and aggressive behavior

– Primary treatment is anti-epileptic medication

• Hypertension



Psychosis is a syndrome. A syndrome is defined as the association of several clinically recognizable signs and symptoms which may have multiple causes. It can be a sign of medical illness or mental illness. It is not always a mental illness! It results in dysfunction in thinking, perception (hallucinations) and behavior (decreased social and professional activity).

Treatment is aimed at a complete medical evaluation and treatment first, then a complete mental health evaluation and treatment, if necessary.

Standard Medical Evaluation for Agitation, Delirium and Psychosis

• History (epilepsy, delirium, substance abuse, medications)

• Vital Signs

• Physical Exam

• Neurological Exam

• Mental Status Exam

• Laboratory Tests (at least CBC, RPR, VIH, CD4 if VIH+)

• Additional Tests (CT Scan, EEG, lumbar puncture)



CAse sTUDy 1

a 45-year-old woman is brought by her family to your health center. she is clearly psychotic, making nonsensical comments about god and other spirits and also yelling. you recognize her as she has been a patient seen in the hiV/aiDs program.

1. After managing her agitation, how would you evaluate her?

you performed a brief assessment and conducted a blood test. you discovered that the patient is hiV positive and the patient’s CD4 count has come back at less than 200.

2. What do you do next?

3. Is this person suffering from medical delirium or a psychotic disorder?



CAse sTUDy 2

a middle-aged man arrives at the health center. his daughter brought him there. he is sweating, disoriented and is anxious. he is mildly agitated and wants to leave the health center. after performing an initial assessment, you find out from his daughter that he drinks alcohol every day (‘a lot’ she reports). the daughter took away all his alcohol and money yesterday because she wants him to stop. you have taken his vital signs, and he has a pulse of 130.

1. What are the signs of alcohol withdrawal you would look for?

2. How would you treat the alcohol withdrawal?

3. Is this person suffering from medical delirium or a psychotic disorder?



Medication Management for Agitation, Delirium, and PsychosisOnce a medical evaluation has been performed, a physician must decide if pharmacological treatment is necessary. Physicians are responsible for prescribing antipsychotics but they must work with psychologists to determine the likely diagnosis. Frequently, the nurse will be assisting the physician administer IM and oral medication.

Prescribing Principles for Agitation, Delirium and Psychosis

The primary tools that can be used to guide prescribing practices are:

• Zanmi Lasante Formulary

• Epilepsy Medication Card

• Agitated Patient Protocol

• Medication Card for Agitation, Delirium, and Psychosis

Haloperidol and risperidone are the primary medications for the management of agitation, delirium, and psychosis. Risperidone has fewer side-effects and should be tried before haloperidol, unless the patient is violent or aggressive and could benefit from the sedation of haloperidol. Begin with a low dose and increase gradually.

Carbamazepine should typically be prescribed before valproate as a long-term mood stabilizer.

Valproate is particularly for patients with long-standing aggression or violence, and should never be prescribed to a pregnant woman (and avoided for women of child-bearing age).

Diazepam is only used in agitated patients and those going through alcohol withdrawal.

Children, the elderly, pregnant and breast-feeding patients are special populations. Please consult with the mental health team before prescribing for them. For suicidal patients, give a small supply of the medication to a family member to prevent possible overdose.



Psychoeducation about Medication

It is incredibly important to speak to patients and their family members in language that they understand, depending on their education level and knowledge. Do not speak to patients and family members in jargon or complex medical language.

Make sure to explain to the patient/family:

• What the medication is for

• How to take the medication properly

• Common side-effects

• Toxic side-effects and when to seek immediate medical care

• How long it takes for medication to work

TIP: To know if the patient/family actually understands the information you are providing about taking the medication, ask the patient/family member to repeat back to you how to take the medication.

Additional information about prescribing principles:

• It is important to take the medication regularly and not miss a dose.

• Do not double up on a dose if a dose is missed.

• It is important to continue to take medication even if symptoms improve.

• Symptoms may worsen if medication is discontinued.

• If any problems of concern develop, contact a member of the treatment team (community health worker, psychologist or physician) by phone, or return to the hospital for evaluation.

Antipsychotics: Side-Effects

Physicians and nurses will need to evaluate and manage antipsychotic medication’s side-effects.

• Akathisia (psychomotor restlessness)

– Tapping of knees

– Difficulty sitting; pacing to alleviate discomfort in knees

– Worsening anxiety or panic

– Difficulty sleeping

• Tardive Dyskinesia (involuntary orofacial movements)

– Unusual facial expressions, such as: lip smacking, puckering or pursing, grimacing, excessive eye blinking



– Rapid, involuntary movements of the lips, torso and fingers

– Cogwheel rigidity of limbs as in Parkinson’s Disease: rigidity in which muscles respond with cogwheel-like jerks when the clinician tries to move the limb

– Rigidity of neck, shoulders and other body parts

• Neuroleptic Malignant Syndrome

– Muscle cramps and rigid muscles (not cogwheel rigidity, but stiffness)

– Tremors

– Fever (hyperpyrexia) to >38 °C (>100.4 °F)

– Autonomic nervous system instability: unstable blood pressure, pulse

– Mental status changes and delirium

– Diaphoresis

Acute dystonia and neuroleptic malignant syndrome are two side-effects that constitute an emergency. Tardive dyskinesia is a possible side-effect of antipsychotic medications, particularly ‘typical’ antipsychotics such as haloperidol. Patients and their families need to know about these side-effects.

lIFe THReATeNING: stop drug immediately and return to health center

COmmON, NOT lIFe -THReATeNING

• Difficulty breathing

• muscle tightness in body

• Difficulty seeing or controlling eyes

• rash

• hot feeling or fever

• Drowsiness

• slowed cognition

• Weight gain

Abnormal Involuntary Movement Scale: Examination and Scoring

The Abnormal Involuntary Movement Scale is a 12-item scale that the clinician administers and scores. The clinician observes the patient and asks questions about involuntary movements due to tardive dyskinesia. If one can catch tardive dyskinesia early, one can intervene.

• Facial and oral

• Extremity

• Truncal

• Patient awareness of movements

The AIMS should be used at the beginning of treatment, and then every six months. It can be done in less than 10 minutes. The clinician tracks the numerical score over time.



meDICATION RevIeW WORksHeeT

Use the Medication Card for Agitation, Delirium, and Psychosis, and the Agitated Patient Protocol.

1. Which three medications on the medication card can Zamni lasante physicians prescribe without consulting the mental Health team?

2. Which two medications on the medication card should NOT be routinely prescribed by Zamni lasante physicians for bipolar disorder or other forms of mental illness?

3. A 63-year-old man arrives in the emergency room. He is violent and out of control, pushing people and running around. He has been brought in by his wife and son, who report he has never behaved this way before. According to the Agitated Patient Protocol Form, which medication should the physician instruct you to give the patient? Give the medication name, dose, and form.



meDICATION RevIeW WORksHeeT (continued)

4. A 25-year-old woman who is six months pregnant is hospitalized for a clot in her leg. she has been psychotic for many years and is currently mildly agitated (she is irritable and does not cooperate with hospital staff, but is not threatening). she refuses to take the anti-coagulant because of her psychosis. Which antipsychotic should the physician prescribe for her?

5. A doctor is working in the emergency room of a local clinic when a father brings his 19-year-old daughter in. she is totally rigid, unable to walk, unable to turn her head, and unable to open her mouth. Her father has to carry her. He reports that she was taken to a psychiatric facility after becoming violent following a breakup with her boyfriend. At the facility, she was given multiple injections. How should you and the physician treat this case? What medication should she be given?



Follow-Up and DocumentationThe Psychosis Care Pathway only works with functional follow-up and documentation.

Patients should be seen for follow-up appointments every one-to-two weeks if their symptoms are acute or if medications are being started, adjusted or stopped. Patients with psychosis whose symptoms are stable can be seen once a month or once every three months.

Once a patient is treated for their agitation or psychosis, the nurse is responsible for educating the patient and family about mental illness and the patient’s next steps in the psychosis care pathway. Because psychoeducation is so important, all Zamni Lasante health providers have a role in delivering psychoeducation.

General Messages to Share with Patients and Families

• A patient’s symptoms can improve with treatment and they can even recover.

• It is important to continue with work, social, and school activities as much as possible.

• The patient has a right to be involved in making decisions about their treatment.

• It is important to exercise, eat healthy, and maintain good personal hygiene.

• Families should not tie up or lock up patients. Instead, bring them to the clinic/hospital or ask the CHW for help/support.

• Prescribing principles:

– It is important to take the medication regularly and not miss a dose.

– Do not double up on a dose if a dose is missed.

– It is important to continue to take medication even if symptoms improve.

– Symptoms may worsen if medication is discontinued.

– If any problems of concern develop, contact a member of the treatment team (community health worker, psychologist or physician) by phone, or return to the hospital for evaluation.



Monitoring Improvement through Coordination with Psychologists

Physicians will need to learn about patient improvement through conversation and interaction with psychologists.

The psychologists will be determining a patient’s improvement through using the Clinical Global Impressions (CGI) Scale and WHODAS 2. The CGI is a tool that psychologists will use to measure symptom severity, treatment response and the efficacy of treatments for a person with a mental disorder. The WHODAS will be used by psychologists to assess a patient’s abilities to perform activities of daily living over the previous 30 days. The WHODAS covers six domains of functioning:

• Cognition – understanding and communicating

• Mobility – moving and getting around

• Self-care – hygiene, dressing, eating and being alone

• Getting along – interacting with other people

• Life activities – domestic responsibilities, leisure, work and school

• Participation – joining in with community activities



CAse sTUDy 1

a 65-year-old woman is brought into the health facility by her two sons. she is barely able to walk and is clearly confused. she is not able to speak easily and she cannot follow simple commands. her sons said that she has been fatigued and feverish for the past few days. the patient is mildly agitated, clearly frustrated with her sons. you are the first to attend to the patient.

1. seeing that the patient is agitated, who would you notify immediately?

2. What would you do to manage the patient’s agitation? What form would you use to guide you?

3. How would you support the physician in evaluating the agitated patient? What forms would you help the physician manage during the medical evaluation?

Review: Case Studies



CAse sTUDy 1 (continued)

you have concluded that the patient probably needs further neurologic testing to determine if the patient has a neurological problem. the patient also has a confirmed fever above 38°C. the two sons said that they are sad that she is now ‘crazy’ and want to know how you can cure her.

4. What would you say to the two sons?



CAse sTUDy 2

a 27-year-old man is brought into the health center by two community health workers. he is yelling that the community health workers are trying to kill him. he lunges at anyone who tries to get close to him, screaming that he will kill everyone.

1. Is this patient agitated? What level of agitation does the patient have?

2. The physician tells you to inject the patient immediately with intramuscular medication. What should you do first before automatically sedating a severely agitated patient?

3. What are some ways you would manage the patient’s behavior and environment? Who would you collaborate with?



CAse sTUDy 2 (continued)

after you speak with the patient, the patient agrees to take some medication and is admitted as an in-patient.

4. How often would you check-in on the patient, and what would you specifically be monitoring?

Once the patient has stabilized, the physician declares the patient able to go home. the patient has been diagnosed by the psychologist/social worker with schizophrenia and has been given medication. the patient will be coming back to the health facility next week to meet with the physician again.

5. Who else should the patient meet with when he comes for his next appointment?



CAse sTUDy 3

During the past year the physician has been seeing a young, 18-year-old woman with who had experienced episodes of psychosis. she was prescribed risperidone. today during her monthly follow up visit, as she waits for her appointment with the psychologist and physician, you notice that she appears restless, frequently wringing her hands.

1. What do you do?

after asking the patient how she is doing and how you can help her, she begins to cry and tells you that things are not going well. she recently broke up with her boyfriend and cannot find a job to support herself.

2. What are some key messages you would give her during this time of stress related to medication and social support?



NOTes

32 Partners In Health | partiCipant hanDBOOK | AnnEx

Annex

33Partners In Health | partiCipant hanDBOOK | AnnEx

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ent,

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ny

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amily

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edia

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psyc

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q

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rm t

o ps

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q

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pat

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s to

do

fo

llow

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ny p

atie

nt t

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patie

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lect

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from

pat

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ily

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ain

at b

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sta

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atie

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car

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sych

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s)

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pat

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ps

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sche

dule

fol

low

-up

with

in o

ne w

eek

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and

supp

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rela

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to m

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d ps

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q

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plet

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OD

as,

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heck

list

FOll

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men

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whe

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, pa

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mpl

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itals

, wei

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are

che

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q

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nt t

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e ph

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ian;

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p ph

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w a

gita

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irium

an

d ps

ycho

sis

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cklis

t

q

plan

fol

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-up

for

1– 2

wee

ks; c

oord

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ith C

hW

q

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psyc

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and

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for

med

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plet

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OD

as,

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gita

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AG

ITA

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PA

TIeN

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ale

rt e

ither

psy

chol

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t/so

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w

orke

r

q

acc

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ny p

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nt t

o em

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ncy

room

q

ref

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o a

gita

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patie

nt

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ocol

q

man

age

envi

ronm

ent

q

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to

patie

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uppo

rt f

amily

q

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ns a

sap

q

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are

oral

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im m

edic

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if ne

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q

arr

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1:1

if n

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sych

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sid

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s, r

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sici

an

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follo

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ly

(at

leas

t ev

ery

15 m

in c

heck

)

q

ass

ist d

octo

r in

med

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eva

luat

ion

and

care

(vi

tal s

igns

, lab

tes

ts,

EKg

, flui

ds)

q

prov

ide

psyc

hoed

ucat

ion

and

supp

ort

to p

atie

nt a

nd f

amily

q

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umen

t al

l wor

k in

nur

sing

fo

rms

INIT

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ON

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lm)

q

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erm

ine

whe

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pat

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may

be

psy

chot

ic

q

acc

ompa

ny p

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nt t

o se

e ps

ycho

logi

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W; s

uppo

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colla

bora

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with

phy

sici

an

q

if p

sych

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is d

iagn

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, pro

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ps

ycho

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n an

d su

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q

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re d

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, ens

ure

the

patie

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as a

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with

ps

ycho

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AG

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ither

psy

chol

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q

Follo

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patie

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term

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and

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q

Con

tinue

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eva

luat

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phy

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exam

, vita

l sig

ns, l

ab t

ests

q

use

med

icat

ion

Car

d to

mon

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antip

sych

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si

de e

ffec

ts (

cons

ider

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g, fl

uids

)

q

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t in

agi

tate

d pa

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m

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ON

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rev

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initi

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valu

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Form

with

psy

chol

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to

diag

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de

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edic

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men

tal d

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Do

com

plet

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, ph

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Ev

alua

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for

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eliri

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and

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if p

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as a

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or d

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Car

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dos

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line

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eryt

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in in

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men

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alua

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q

prov

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med

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ion

to la

st u

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next

app

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q

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psyc

hoed

ucat

ion

abou

t m

edic

atio

n

q

plan

fol

low

-up

with

psy

chol

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t/sW

FOll

OW

-UP

q

rev

iew

the

men

tal h

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Fol

low

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Form

with

ps

ycho

logi

st/s

W t

o se

e if

patie

nt is

impr

ovin

g

q

Do

phys

ical

/neu

ro e

xam

q

Che

ck w

eigh

t/vi

tals

eac

h vi

sit;

lab

test

s an

d a

ims

ever

y 6

mon

ths

q

use

med

icat

ion

Car

d to

che

ck f

or s

ide

effe

cts

and

to a

djus

t do

se a

s ne

eded

q

prov

ide

med

icat

ion

to la

st u

ntil

next

app

t

q

Dis

cuss

dis

cont

inua

tion

of a

ntip

sych

otic

with

m

enta

l hea

lth t

eam

q

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umen

t pr

oper

ly in

men

tal h

ealth

Fo

llow

-up

Form

q

Do

psyc

hoed

ucat

ion

abou

t m

edic

atio

n

q

plan

fol

low

-up

with

psy

chol

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t/sW

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me

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ev

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ls

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el

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m A

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sTeP

1a:

Is P

erso

n A

gita

ted?

Pati

ent

is c

onsi

dere

d ag

itat

ed if

the

y ar

e an

y of

the

follo

win

g:

•V

iole

nt, a

ggre

ssiv

e

•ye

lling

, thr

eate

ning

•m

anic

, del

usio

nal (

has

untr

ue, fi

xed

belie

fs)

•h

allu

cina

ting

•a

cute

ly p

aran

oid

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ringi

ng o

f ha

nds,

pac

ing,

tap

ping

han

d

•r

apid

spe

ech,

rai

sing

voi

ce

•Fr

eque

nt r

eque

sts,

low

fru

stra

tion

tole

ranc

e

sTeP

1b:

Det

erm

ine

leve

l of

Agi

tati

on a

nd m

anag

e•

Ref

er t

o A

gita

ted

Pati

ent

Prot

ocol

to

guid

e ag

itat

ion

man

agem

ent

depe

ndin

g on

sym

ptom

s an

d se

veri

ty

•u

se c

alm

voi

ce

•g

ive

verb

al s

uppo

rt

•D

ecre

ase

stim

uli

•a

sk, “

how

can

i he

lp?”

•a

lert

sta

ff

•K

eep

your

self

safe

•u

se W

hO

mhg

ap

(p.7

4) f

or s

elf-

har

m/s

uici

de a

sses

smen

t

if ne

cess

ary

box

1: s

tand

ard

med

ical

eva

luat

ion

for

Agi

tati

on/D

elir

ium

/Psy

chos

is

•Br

ief

his

tory

–m

edic

al h

isto

ry

–a

lcoh

ol/s

ubst

ance

abu

se

–C

urre

nt m

edic

atio

ns

–h

isto

ry o

f m

enta

l illn

ess

•V

ital s

igns

, phy

sica

l exa

m

•n

euro

logi

cal E

xam

•m

enta

l sta

tus

Exam

–O

rient

atio

n

–a

lert

ness

–C

onfu

sion

box

2: D

elir

ium

1. D

istu

rban

ce o

f co

nsci

ousn

ess;

red

uced

abili

ty t

o fo

cus,

sus

tain

or

shift

att

entio

n.

2. a

cha

nge

in c

ogni

tion

or t

he d

evel

opm

ent

of a

per

cept

ual d

istu

rban

ce (

hallu

cina

tions

)

that

is n

ot d

ue t

o a

pree

xist

ing,

est

ablis

hed

or e

volv

ing

dem

entia

.

3. t

he d

istu

rban

ce d

evel

ops

over

a s

hort

perio

d of

tim

e (u

sual

ly h

ours

to

days

) an

d

fluct

uate

s du

ring

the

day

4. t

here

is e

vide

nce

from

the

his

tory

, phy

sica

l

exam

inat

ion

or la

bora

tory

find

ings

tha

t

the

dist

urba

nce

is c

ause

d by

the

dire

ct

phys

iolo

gica

l con

sequ

ence

s of

a g

ener

al

med

ical

con

diti

on.

NO

THeN

yes

sTeP

2: P

erfo

rm m

edic

al A

sses

smen

t (s

ee b

ox 1

, ReF

eR t

o an

d R

eCO

RD

info

rmat

ion

on A

gita

ted

Pati

ent

Form

, inc

ludi

ng):

•sa

fety

: tal

k fir

st, d

o no

t m

edic

ate

first

•m

edic

al H

ealt

h: t

ake

vita

l sig

ns, p

hysi

cal e

xam

, men

tal s

tatu

s ex

am t

o as

sess

for

del

irium

•m

enta

l Hea

lth:

tak

e hi

stor

y

•Fo

llow

-Up:

con

tact

psy

chol

ogis

t

•C

ontin

ue e

valu

atio

n an

d tr

eatm

ent

of u

nder

lyin

g

med

ical

con

ditio

n.

•C

onsi

der

low

-dos

e an

tipsy

chot

ic f

or d

eliri

um

(see

med

icat

ion

card

)

•C

onsu

lt m

enta

l hea

lth t

eam

/psy

chol

ogis

t

abn

orm

al m

enta

l sta

tus

exam

or

mee

ts c

riter

ia f

or

delir

ium

(se

e b

ox 2

)

see

Page

2 f

or c

onti

nuat

ion

of m

edic

al A

sses

smen

t

yes

NO


2

med

ical

eva

luat

ion

Prot

ocol

s fo

r A

gita

tion

, Del

iriu

m a

nd P

sych

osis

sum

mar

y (c

onti

nued

)

•tr

eat

alco

hol w

ithdr

awal

with

10

mg

iV/i

m

diaz

epam

, rep

eat

afte

r 15

min

s as

nee

ded

until

res

pons

e, t

hen

repe

at in

6 h

ours

.

•m

onito

r re

spira

tory

rat

e to

avo

id o

verd

ose

•m

alar

ia s

mea

r an

d co

nsid

er e

mpi

ric

trea

tmen

t fo

r m

alar

ia

•lu

mba

r pu

nctu

re a

nd c

onsi

der

empi

ric r

x

with

app

ropr

iate

ant

ibio

tic m

edic

atio

n

Con

side

r C

T be

fore

lP

if a

sym

met

ric

pupi

ls o

r

abno

rmal

ext

ra-o

cula

r m

ovem

ent

or g

ait.

•lp

, as

abov

e

•C

onsi

der

empi

ric r

x w

ith a

ppro

pria

te

antib

iotic

med

icat

ion

Con

side

r tr

eatm

ent

for

toxo

plam

osis

or c

ryto

cocc

us.

•C

onsi

der

addi

tiona

l tes

ts: r

enal

pan

el, l

iver

pane

l, ch

est

x-ra

y

•tr

eat

acco

rdin

gly

trea

t fo

r ne

uros

yphi

lis w

ith p

enic

illin

•Fu

rthe

r ne

urol

ogic

al t

estin

g (s

ee b

ox 3

)

•C

onsi

der

Ct,

EEg

, or

lp

•C

onsu

lt w

ith s

peci

alis

ta

bnor

mal

neu

rolo

gic

exam

rec

ent

onse

t an

d

tem

pera

ture

> 3

8 C

hiV

+ w

ith C

D4

coun

t <

200

posi

tive

rpr

abn

l glu

cose

, ele

ctro

lyte

s,

or o

ther

evi

denc

e of

med

ical

illn

ess

(see

box

4)

ris

k fa

ctor

s fo

r dr

ug o

r

alco

hol w

ithdr

awal

or

into

xica

tion?

(se

e b

ox 5

)

Con

side

r a

prim

ary

psyc

hotic

dis

orde

r

Perf

orm

men

tal H

ealt

h A

sses

smen

t

and

Con

sult

men

tal H

ealt

h Te

am

On

med

icat

ion

caus

ing

psyc

hosi

s? (

see

box

6)

Det

erm

ine

whe

ther

his

tory

of

psyc

hosi

s an

d m

edic

atio

n us

e co

inci

de.

Con

side

r di

scon

tinui

ng m

edic

atio

n.

yes yes

yes

yes

yes

yes

yes

yes

THeN

THeN

box

4: C

omm

on s

yste

mic

Con

diti

ons

that

can

Cau

se/C

ontr

ibut

e to

Psy

chos

is

•m

alar

ia

•El

ectr

olyt

e ab

norm

aliti

es (

sodi

um, c

alci

um)

•m

alnu

triti

on, t

hiam

ine

defic

ienc

y

•th

yroi

d di

seas

e

•a

lcoh

ol w

ithdr

awal

•h

ypox

ia

box

6: m

edic

atio

ns t

hat

can

Cau

se/C

ontr

ibut

e

to P

sych

osis

•C

ortic

oste

riods

•C

yclo

serin

e

•is

onia

zid,

Efa

vire

nz

•C

ortic

oste

roid

s

•ph

enob

arbi

tal

•h

igh

dose

s of

ant

i-ch

olin

ergi

c m

edic

atio

n

box

3: N

euro

logi

cal C

ondi

tion

s th

at C

ause

or

Con

trib

ute

to P

sych

osis

•te

rtia

ry s

yphi

lis

•En

ceph

ilitis

•D

emen

tia (

hiV

, alz

heim

ers)

•pa

rkin

sons

•Br

ain

tum

ors

or o

ther

mas

s le

sion

s (t

B,

lym

phom

a, t

oxop

lasm

osis

)

box

5: A

lcoh

ol W

ithd

raw

al

•h

isto

ry o

f he

avy

alco

hol u

se (

last

drin

k

24 –

28

hour

s pr

ior

to s

ympt

oms)

•se

vere

alc

ohol

with

draw

al:

–W

ithin

a f

ew h

ours

: with

draw

al

trem

ors,

nau

sea,

vom

iting

, sw

eatin

g,

anxi

ety

–W

ithin

a f

ew d

ays:

hal

luci

natio

ns,

seiz

ures

, fev

er, d

isor

ient

atio

n,

hype

rten

sion

Con

tinu

atio

n of

med

ical

Ass

essm

ent

NO

NO

NO

NO

NO

NO

NO


AG

ITA

Te

D P

AT

IeN

T P

RO

TO

CO

l

THR

OU

GH

OU

T v

IsIT

: Ass

essm

ent

•R

eFeR

to

Med

ical

eva

luat

ion

Prot

ocol

s

for

Agi

tati

on, D

elir

ium

and

Psy

chos

is

•R

eCO

RD

on

Agi

tati

on, D

elir

ium

and

Psyc

hosi

s Fo

rm

sAFe

Ty F

IRsT

!

•D

o no

t se

e th

e pa

tient

alo

ne

(ask

for

sec

urity

). r

emai

n

calm

. rem

embe

r th

at p

atie

nts

do n

ot s

udde

nly

beco

me

viol

ent;

the

ir be

havi

or o

ccur

s

alon

g a

spec

trum

.

•m

aint

ain

safe

phy

sica

l dis

tanc

e

from

pat

ient

. Do

not

allo

w

exit

to b

e bl

ocke

d. K

eep

larg

e

furn

iture

bet

wee

n yo

u an

d

patie

nt.

•r

emov

e al

l obj

ects

tha

t ca

n

be u

sed

to h

arm

(ne

edle

s,

shar

p ob

ject

s, o

ther

sm

all

obje

cts)

. Che

ck w

heth

er

patie

nt h

as a

his

tory

of

viol

ence

or

subs

tanc

e ab

use.

•ta

lkin

g to

pat

ient

is s

afe

and

effe

ctiv

e. D

o no

t ye

ll. K

eep

your

voi

ce c

alm

, qui

et, a

nd

frie

ndly

.

•m

ake

eye

cont

act

to s

how

you

care

abo

ut t

he p

atie

nt.

show

sym

path

y an

d em

path

y

(“i u

nder

stan

d yo

u ar

e sc

ared

,

but

i am

her

e to

hel

p. i

will

not

hurt

you

.”)

sTeP

1:

Det

erm

ine

leve

l of

agi

tati

on b

y ob

serv

ing

pati

ent

beha

vior

sTeP

2:

man

age

agit

atio

n

Rem

embe

r:

•sa

fety

: tal

k fir

st, d

o no

t m

edic

ate

first

•m

edic

al H

ealt

h: v

ital s

igns

, phy

sica

l exa

m,

men

tal s

tatu

s, e

xam

to

asse

ss f

or d

eliri

um, l

abs

and

stud

ies

•m

enta

l Hea

lth:

tak

e hi

stor

y

•Fo

llow

-Up:

con

tact

psy

chol

ogis

t/so

cial

wor

ker

mIl

D A

gita

tion

q

wrin

ging

/tap

ping

of

hand

s

q

paci

ng, m

ovin

g re

stle

ssly

q

freq

uent

req

uest

s/de

man

ds

q

loud

or

rapi

d sp

eech

q

low

fru

stra

tion

tole

ranc

e

1. m

anag

e b

ehav

ior/

envi

ronm

ent

q

use

cal

m v

oice

, sim

ple

lang

uage

,

soft

voi

ce, s

low

mov

emen

ts

q

ask

“h

ow c

an i

help

?” a

nd

prob

lem

sol

ve w

ith p

atie

nt;

be e

mpa

thic

q

rem

ove

pote

ntia

lly h

arm

ful

obje

cts

from

are

a

q

ask

abo

ut h

unge

r/th

irst

q

Dec

reas

e st

imul

atio

n/ar

rang

e 1:

1

q

Off

er v

erba

l sup

port

and

unde

rsta

ndin

g

q

allo

w t

he p

atie

nt t

o sh

ow

ange

r/fr

ustr

atio

n

q

Cal

m s

taff

q

if a

gita

tion

due

to d

eliri

um,

cons

ider

hal

dol 1

– 2

mg

pO;

not

in e

lder

ly

1. m

anag

e b

ehav

ior/

envi

ronm

ent

2. C

onsi

der

OR

Al

med

icat

ions

q

Off

er p

O m

edic

atio

ns fi

rst

if

(hal

dol 5

mg

+ d

iphe

nhyd

ram

ine

50 m

g O

r D

iaze

pam

10

mg)

q

if p

atie

nt r

efus

es p

O, g

ive

im

med

icat

ions

(h

aldo

l 5 m

g +

diph

enhy

dram

ine

25 m

g O

r

Dia

zepa

m 1

0 m

g)

q

Wai

t 30

min

utes

; if

patie

nt

rem

ains

agi

tate

d, c

an g

ive

½ t

he

orig

inal

dos

e

q

use

med

icat

ion

Car

d to

mon

itor

side

eff

ects

1. m

anag

e b

ehav

ior/

envi

ronm

ent

2. C

onsi

der

OR

Al

med

icat

ions

3. C

onsi

der

INTR

Am

UsC

UlA

R

med

icat

ions

q

hal

dol 5

–10

mg

im +

diph

enhy

dram

ine

25 m

g im

Or

dia

zepa

m 1

0 m

g im

q

Wai

t 30

min

utes

; if

patie

nt

rem

ains

agi

tate

d, c

an r

e-do

se

with

½ t

he o

rigin

al d

ose

q

use

med

icat

ion

Car

d to

mon

itor

side

eff

ects

q

Deb

rief

with

sta

ff

q

Con

sult

men

tal h

ealth

tea

m if

etio

logy

is p

sych

iatr

ic

mO

DeR

ATe

Agi

tati

on q

verb

al t

hrea

ts

q

yelli

ng/c

ursi

ng

q

does

not

res

pond

to

verb

al

redi

rect

ion

q

does

not

res

pond

to

incr

ease

d

staf

f pr

esen

ce

sev

eRe

Agi

tati

on q

dest

royi

ng p

rope

rty

q

phys

ical

agg

ress

ion

(e.g

.,

hitt

ing,

kic

king

, biti

ng)

q

self-

inju

rious

beh

avio

r (e

.g.,

bitin

g ha

nd, h

ead

bang

ing)


AGITATION, Del IR IUm AND PsyCHOsIs FORm

1. sAFeTy (Use AGITATeD PATIeNT PROTOCOl)

Patient is: q not agitated (But appears psychotic) q agitated (mild) q aggressive (moderate) q Violent (severe)

History of violence: q no q yes: Describe violent behavior ________________________________________________________________ When did it take place:__________________________________________________________________

q manage Behavior/Environment Completed Does patient need a 1:1? q no q yes:___________

2. meDICAl HeAlTH (Use meDICAl evAlUATION PROTOCOl)

Vital signs: temp:______ pulse:______ Bp:______ rr:______ O2:______ Weight:______

Physical exam Neurological exam

hEEnt: q normal q abnormal:___________ Cranial nerves: q normal q abnormal:___________

Cardiac: q normal q abnormal:___________ motor strength: q normal q abnormal:___________

pulmonary: q normal q abnormal:___________ sensory: q normal q abnormal:___________

abdominal: q normal q abnormal:___________ reflexes: q normal q abnormal:___________

skin/Extremities: q normal q abnormal:___________ gait/Coordination: q normal q abnormal:___________

mental status exam laboratory Tests Ordered

q alert q sleepy q unable to arouse q hemogram q CD4 q hepatic panel

thought process: q normal q Confused:___________ q rpr q tB q renal panel

Can Follow simple Commands: q no q yes q hiV q urinalysis q malaria

hallucinations: q no q yes:__________ Family History of mental Illness: q no q yes

Orientation: person q no q yes medical History: q hiV/aiDs (CD4:_____) q tB

place q no q yes q htn q head injury (with loss of consciousness)

time/Date q no q yes q Epilepsy q Dementia q Other:___________

Friend/Family member q no q yes Alcohol Use: q no q yes: q Daily?

Current medications (names and doses):___________________________ Drug Use: q no q yes:___________

Delirium

q Disturbance of consciousness with reduced ability to focus, sustain or shift attention.

q a change in cognition or the development of a perceptual disturbance (hallucinations) that is not better accounted for by a preexisting, established or evolving dementia.

q the disturbance develops over a short period of time (usually hours to days) and fluctuates during the day

q there is evidence from the history, physical examination or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition.

q no q yes (Patient must meet all four criteria above to make diagnosis)

3. meNTAl HeAlTH

History of mental illness: q no q yes:___________________________________________________________________________________

Has the patient gone to m&k/beudet/other psych facility? q no q yes:_____________________________

Is this the first episode of agitation? q no q yes:_______________ History of suicide attempt: q no q yes:__________________

Post-Ictal Psychosis: q no q yes (episodes of agitation/psychosis only take place after epileptic seizure)Antipsychotic medication (Use Agitated Patient Protocol; give dose and indicate whether PO/Im):

q risperidone:_______________ q haloperidol:_______________ q Other: Diphenhydramine:_______________

4. FOllOWUP

q psychologist contacted about patient

presumed Etiology of agitation/psychosis: q medical problem/Delirium: _______________ q mental health problem:_______________

has haloperidol been given?: q no q yes q Fluids ordered/given q EKg ordered/done

notes: _________________________________________________________________________________________________________________

Patient Name:________________________ sex:____ Phone:_____________ Provider:_________________ Date: dd/mm/yy


1

me

DIC

AT

ION

CA

RD

FO

R A

GIT

AT

ION

, D

el

IRIU

m,

AN

D P

sy

CH

Os

Is

RIs

PeR

IDO

Ne

HA

lOPe

RID

Ol

DIA

ZePA

mC

AR

bA

mA

ZePI

Ne

vA

lPR

OA

Te

1st

Cho

ice:

“A

typi

cal”

Ant

ipsy

chot

ic/M

ood

stab

ilize

r

Use

for

: Psy

chos

is (

wit

h or

wit

hout

man

ia)

2nd

Cho

ice:

“Ty

pica

l”

Ant

ipsy

chot

ic/M

ood

stab

ilize

r

Use

for

: Agg

ress

ive

or v

iole

nt

psyc

hosi

s (w

ith

or w

itho

ut m

ania

)

Ben

zodi

azep

ine

Use

for

: Alc

ohol

wit

hdra

wal

,

acut

e ag

itat

ion

wit

h or

wit

hout

ant

i-ps

ycho

tic

3rd

Cho

ice:

Moo

d st

abili

zer

Do

not

pres

crib

e w

itho

ut

cons

ulti

ng m

enta

l hea

lth

team

Use

for

: man

ia w

itho

ut

psyc

hosi

s

4th

choi

ce: M

ood

stab

ilize

r

Do

not

pres

crib

e w

itho

ut

cons

ulti

ng m

enta

l hea

lth

team

Use

for

: man

ia w

itho

ut

psyc

hosi

s (l

ongs

tand

ing

aggr

essi

on o

r vi

olen

ce in

mal

es)

DO

NO

T U

se IF

•C

autio

n if

child

/ado

lesc

ent

•pr

ior

hist

ory

of d

ysto

nia

on

antip

sych

otic

med

icat

ion

•C

hild

ren

(18

or y

oung

er)

•pa

tient

is d

eliri

ous

•pr

egna

nt/b

reas

tfee

ding

wom

en

•C

hild

ren

(18

or y

oung

er)

•El

derly

(65

or

olde

r)

•Bl

ood

diso

rder

•Ep

ileps

y: a

bsen

ce s

eizu

res

•C

autio

n if

child

•W

omen

of

child

-bea

ring

age/

preg

nant

wom

en

•li

ver

dise

ase

•C

autio

n if

child

mU

sT C

ON

sUlT

m

eNTA

l H

eAlT

H

TeA

m

•Fo

r ps

ycho

sis

due

to d

emen

tia

(incr

ease

d ris

k of

dea

th)

•C

hild

ren

18 o

r yo

unge

r

•pr

egna

nt w

omen

•Fo

r ps

ycho

sis

due

to d

emen

tia

(incr

ease

d ris

k of

dea

th)

•pr

egna

nt w

omen

•Fo

r tr

eatm

ent

of a

ll m

enta

l

illne

ss (

excl

udin

g ep

ileps

y)

•pr

egna

nt o

r br

east

feed

ing

wom

en

•Fo

r tr

eatm

ent

of a

ll m

enta

l

illne

ss (

excl

udin

g ep

ileps

y)

star

ting

Dos

e (A

dult

)Ta

ke a

t ni

ght

due

to s

edat

ive

effe

cts

•Bi

pola

r/ps

ycho

sis

– 0.

5 – 1

mg

•D

eliri

um –

0.2

5 –

0.5

mg

Take

at

nigh

t du

e to

sed

ativ

e ef

fect

s

•Bi

pola

r/ps

ycho

sis

mod

erat

e sx

s: 0

.5 –

2.5

mg

seve

re s

xs: 2

.5 –

5 m

g

•a

lway

s pr

escr

ibe

diph

enhy

dram

ine

25 –

50

mg

daily

with

hal

oper

idol

•D

eliri

um: 0

.5 –

2.5

mg

at n

ight

(Con

side

r lo

w-d

ose

of

rispe

ridon

e fir

st)

•A

ggre

ssiv

e/v

iole

nt P

atie

nts:

see

Agi

tate

d Pa

tien

t Pr

otoc

ol

see

agi

tate

d pa

tient

pro

toco

l

for

guid

elin

es r

egar

ding

use

.

200

mg

twic

e da

ily20

0 –

250

mg

twic

e da

ily

*pat

ient

s re

ceiv

ing

valp

roic

acid

may

req

uire

a z

idov

udin

e

dosa

ge r

educ

tion

to m

aint

ain

unch

ange

d se

rum

zid

ovud

ine

conc

entr

atio

ns

“ste

p” o

f up

titr

atio

na

ntip

sych

otic

s re

quire

4 –

6 w

eeks

to

reac

h fu

ll ef

fect

. if

ther

e ar

e sa

fety

conc

erns

, phy

sici

ans

can

incr

ease

dose

s m

ore

quic

kly

(eve

ry 3

– 7

day

s)

by 0

.5 m

g in

crem

ents

. Del

irium

:

incr

ease

by

0.25

mg

incr

emen

ts.

ant

ipsy

chot

ics

requ

ire 4

– 6

wee

ks t

o

reac

h fu

ll ef

fect

. if

ther

e ar

e sa

fety

conc

erns

, phy

sici

ans

can

incr

ease

dose

s m

ore

quic

kly

(eve

ry 3

– 7

day

s)

by 2

.5 m

g in

crem

ents

.

see

agi

tate

d pa

tient

pro

toco

l

for

guid

elin

es r

egar

ding

use

.

200

mg

tota

l dai

ly25

0 –

500

mg

tota

l dai

ly

max

imum

Dos

e2

mg

Dos

es a

bove

2 m

g da

ily m

ust

be

revi

ewed

with

the

men

tal h

ealth

tea

m.

10 m

g

Dos

es a

bove

10

mg

daily

mus

t be

revi

ewed

with

the

men

tal h

ealth

team

.

10 m

g

Dos

es a

bove

10

mg

daily

mus

t be

rev

iew

ed w

ith t

he

men

tal h

ealth

tea

m.

800

mg

(for

men

tal i

llnes

s)

Dos

es a

bove

800

mg

mus

t

be r

evie

wed

with

the

men

tal

heal

th t

eam

.

1000

mg

(for

men

tal i

llnes

s)

Dos

es a

bove

100

0 m

g m

ust

be r

evie

wed

with

the

men

tal

heal

th t

eam

.


2

med

icat

ion

Car

d fo

r A

gita

tion

, Del

iriu

m, a

nd P

sych

osis

(co

ntin

ued)

RIs

PeR

IDO

Ne

HA

lOPe

RID

Ol

DIA

ZePA

mC

AR

bA

mA

ZePI

Ne

vA

lPR

OA

Te

Toxi

citi

es*i

f ra

sh, s

top

med

icat

ion

and

retu

rn t

o ho

spita

l

seri

ous

Dys

toni

a (e

spec

ially

of

phar

ynx,

eye

s, n

eck—

tem

pora

ry b

ut p

oten

tially

fat

al),

Tard

ive

Dys

kine

sia

(per

man

ent)

, Aka

this

ia (

rest

less

ness

), D

iabe

tes,

Car

diac

arrh

ythm

ia le

adin

g to

tor

sade

s de

s po

inte

s

Ris

k of

sei

zure

if d

iaze

pam

with

draw

n w

ithou

t ta

per

afte

r re

gula

r us

e at

hig

her

dose

Ras

h, li

ver

failu

re, d

ecre

ased

whi

te b

lood

cou

nt

(Car

bam

azep

ine

can

caus

e hy

pona

trem

ia)

(Val

proa

te c

an c

ause

ser

ious

bir

th d

efec

ts in

pre

gnan

cy)

Com

mon

•se

datio

n

•W

eigh

t g

ain

•la

ctat

ion

•a

men

orrh

ea

•En

ures

is (

for

boys

)

•se

datio

n

•h

eavy

ton

gue

•st

iffne

ss

•a

rrhy

thm

ia (

for

patie

nts

rece

ivin

g

mor

e th

an 1

0 m

g da

ily)

•se

datio

n

•D

epen

denc

e (s

houl

d no

t

be g

iven

for

long

per

iods

of t

ime)

Fatig

ue, d

izzi

ness

, nau

sea/

vom

iting

, inc

oord

inat

ion,

dou

ble

visi

on

(Car

bam

azep

ine

decr

ease

s ef

ficac

y of

ora

l con

trac

eptiv

es;

Valp

roat

e ca

uses

tre

mor

)

mon

itor

ing

•Ba

selin

e: a

ims,

wei

ght,

fas

ting

gluc

ose,

hem

ogra

m, h

epat

ic p

anel

(if a

vaila

ble)

•Ev

ery

visi

t: w

eigh

t, v

ital s

igns

•Ev

ery

6 m

onth

s: a

ims,

fas

ting

gluc

ose,

hep

atic

pan

el, h

emog

ram

•Ba

selin

e: a

ims,

wei

ght,

fas

ting

gluc

ose,

hem

ogra

m, h

epat

ic

pane

l (if

avai

labl

e)

•Ev

ery

visi

t: w

eigh

t, v

ital s

igns

•Ev

ery

6 m

onth

s: a

ims,

fast

ing

gluc

ose,

hep

atic

pan

el,

hem

ogra

m

•m

onito

r fo

r si

gns

of

seda

tion

•m

onito

r fo

r de

pend

ence

(nee

d fo

r in

crea

sed

dose

to a

chie

ve s

ame

effe

ct)

lFts

, CBC

, sod

ium

Wei

ght

gain

, lFt

s, C

BC

hiV

pat

ient

s re

ceiv

ing

valp

roic

acid

may

req

uire

a z

idov

udin

e

dosa

ge r

educ

tin t

o m

aint

ain

unch

ange

d se

rum

zid

ovud

ine

conc

entr

atio

ns.

Tape

ring

/D

isco

ntin

uing

if t

here

is a

life

-

thre

aten

ing/

toxi

c si

de

effe

ct, s

top

imm

edia

tely

.

•C

onsu

lt w

ith

the

men

tal h

ealt

h

team

bef

ore

tape

ring

med

icat

ion.

som

e pa

tien

ts m

ay n

eed

to

cont

inue

ris

peri

done

inde

fini

tely

.

•if

the

pat

ient

has

oth

er s

igni

fican

t

side

eff

ects

, con

side

r de

crea

sing

the

dose

slo

wly

(by

0.2

5 –

0.5

mg

incr

emen

ts)

and

mon

itorin

g cl

osel

y.

Can

als

o co

nsid

er c

hang

ing

to

halo

perid

ol.

•C

onsu

lt w

ith

the

men

tal h

ealt

h

team

bef

ore

tape

ring

med

icat

ion.

som

e pa

tien

ts m

ay n

eed

to

cont

inue

hal

oper

idol

inde

fini

tely

.

•if

the

pat

ient

has

oth

er s

igni

fican

t

side

eff

ects

, con

side

r de

crea

sing

the

dose

slo

wly

(by

2.5

mg

incr

emen

ts)

and

mon

itorin

g

clos

ely.

Can

als

o co

nsid

er

chan

ging

to

rispe

ridon

e.

•O

nly

used

for

the

man

agem

ent

of

agita

ted/

viol

ent

patie

nts

and

alco

hol w

ithdr

awal

.

•it

sho

uld

not

be

cont

inue

d fo

r m

ore

than

seve

ral d

ays.

red

uce

by s

teps

abo

ve e

very

2 –

4 w

eeks

.

red

uce

by s

teps

abo

ve e

very

2 –

4 w

eeks

.

•Fo

r de

liriu

m, s

top

the

med

icat

ion

afte

r m

edic

al il

lnes

s is

tre

ated

.

•Fo

r ch

roni

c ps

ycho

sis

due

to m

enta

l illn

ess:

if t

he p

atie

nt is

sho

win

g

impr

ovem

ent

in s

ympt

oms

and

has

no m

ajor

sid

e ef

fect

s, d

o no

t st

op t

he

med

icat

ion.

•Fo

r ac

ute

psyc

hosi

s du

e to

men

tal i

llnes

s: c

onsi

der

slow

ly t

aper

ing

the

med

icat

ion

afte

r pa

tient

is s

ympt

om-f

ree

for

3 –

6 m

onth

s.

bre

astf

eedi

ngD

o no

t pr

escr

ibe

to p

regn

ant

or

brea

stfe

edin

g pa

tient

s w

ithou

t

cons

ultin

g w

ith t

he m

enta

l hea

lth

team

; giv

e fo

lic a

cid

4 m

g Q

D

thro

ugh

preg

nanc

y.

Do

not

pres

crib

e to

pre

gnan

t or

brea

stfe

edin

g pa

tient

s w

ithou

t

cons

ultin

g w

ith t

he m

enta

l hea

lth

team

; giv

e fo

lic a

cid

4 m

g Q

D

thro

ugh

preg

nanc

y.

Con

trai

ndic

ated

Do

not

pres

crib

e (f

or m

enta

l

illne

ss)

to p

regn

ant

or

brea

stfe

edin

g pa

tient

s w

ithou

t

cons

ultin

g th

e m

enta

l hea

lth

team

; giv

e fo

lic a

cid

4 m

g Q

D

thro

ugh

preg

nanc

y.

Do

not

initi

ate.

if a

lread

y on

,

mak

e su

re t

akin

g 4

mg

folic

acid

QD

.


3

TR

eA

Tm

eN

T F

OR

AN

TIP

sy

CH

OT

IC m

eD

ICA

TIO

N s

IDe

eF

Fe

CT

s

esP

(ex

TRA

PyR

Am

IDA

l sy

mTO

ms)

TAR

DIv

e D

ysk

INes

IAN

eUR

Ole

PTIC

mA

lIG

NA

NT

syN

DR

Om

e (N

ms)

AC

UTe

Dy

sTO

NIA

Ak

ATH

IsIA

man

ifes

tati

onm

uscl

e rig

idity

(po

tent

ially

incl

udin

g:

eye

mus

cles

, thr

oat,

neck

, ton

gue,

bac

k)

EM

ER

GEn

CY

psyc

hom

otor

res

tless

ness

invo

lunt

ary

orof

acia

l mov

emen

ts (

may

be p

erm

anen

t)

Con

fusi

on, d

eliri

um, s

tiffn

ess

(like

a

lead

pip

e), s

wea

ting,

hyp

erpy

rexi

a,

auto

nom

ic in

stab

ility

, dro

olin

g,

elev

ated

WBC

, ele

vate

d C

pK, d

eath

EM

ER

GEn

CY

Trea

tmen

tD

iphe

nhyd

ram

ine

50 –

75

mg

im o

r

pO d

aily

seve

ral l

iters

of

iV o

r pO

flui

ds d

aily

prop

rano

lol 1

0 –

20 m

g ti

D

Can

als

o de

crea

se t

he d

ose

of

med

icat

ion

Dis

cont

inue

neu

role

ptic

or

low

er d

ose

Con

side

r V

itam

in C

(50

0 –

1000

mg/

d)

+ V

itam

in E

(12

00 –

160

0 iu

/d)

1. D

isco

ntin

ue o

ffen

ding

med

icat

ion.

2. m

edic

al e

valu

atio

n an

d su

ppor

t

(con

side

r iV

flui

ds)

3. h

ospi

taliz

e

4. C

onsi

der

dopa

min

e ag

onis

ts o

r

dant

role

ne t

o im

prov

e ou

tcom

e.

Toxi

citi

esse

riou

sa

naph

ylax

is, a

nem

ia, a

rrhy

thm

iaa

rrhy

thm

ia, b

ronc

hosp

asm

, ste

vens

-

John

son

synd

rom

e

Com

mon

Dro

wsi

ness

, diz

zine

ss, h

eada

che,

dry

mou

th, t

achy

card

ia, c

onst

ipat

ion,

blur

red

visi

on

Fatig

ue, d

izzi

ness

, nau

sea,

dep

ress

ion,

inso

mni

a

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Documents

Introduction to Agitation, Delirium, and Psychosis