Delirium & Agitation
Consulting psychiatrists are often asked to provide effective intervention for patients with behavioral agitation. This group presented an update on strategies for agitation management in 2018, and proposes to return with further review of treatment options for severe and refractory agitated states.
This session will describe approaches to severe agitation and dyscontrol in specific settings and populations. Discussion will include: pharmacologic management of severe and refractory agitation; agitation due to neurologic disease and on the Epilepsy Monitoring Unit; behavioral dyscontrol in Acute Rehabilitation settings; and nonpharmacologic options for refractory agitation such as ECT, restraints and environmental responses. Our group, which includes one senior presenter, one mid-career presenter, and two early career presenters (who are Fellows in 2018-19), will address the epidemiology, evidence base, and practical strategies for management of difficult clinical situations.
A 2 minute introduction will be provided by Lisa J. Rosenthal, MD, FACLP
20 minutes: R. Brett Lloyd, MD will discuss specific populations in the rehabilitation setting, specifically focusing on patients with stroke and hypoxic-ischemic brain injury. The pathology and neurobiology of deficits and agitation resulting from left and right hemispheric stroke as well as hypoxic-ischemic brain injury will be discussed. Behavioral management strategies and pharmacological interventions to reduce agitation and improve engagement in rehabilitation will be reviewed. Additionally, medication side effects and agents that may impede rehabilitation progress will be highlighted.
18 minutes: Gabriel Bendayan Heiber, MD will review the management of refractory agitation with ECT. When second and third line agents fail to treat agitation, consultation liaison psychiatrists need to be familiar with alternatives. Case reports continue to support efficacy of ECT for agitation. This section will focus on the use of ECT for refractory agitation in cases of dementia, encephalitis, TBI, catatonia and delirium.
18 minutes: Brandon Hamm, MD, MSwill present a review of agitated states encountered in the epilepsy monitoring unit, including patients with both epilepsy and functional seizures. Discussion will include influence of the seizure-monitoring context on agitation management, taking into account technology used and clinical objectives of the epileptologist. Psychopharmacology, including anti-epileptic drug interactions and epileptogenicity will be reviewed, as well as consideration of neuroatypicality in agitation management.
30 minutes: JJ Rasimas, MD, PhD, FACLP will review advanced tools – new and old -- in the pharmacologic management of severe and refractory agitation. Noting that the literature is largely limited to case reports, this practical discussion will involve the integration of knowledge and experience from a variety of settings with pharmacologic principles to guide rational interventions in challenging situations. Attention will be given to patient selection, anticipation of complications, and risk reduction. Ketamine, dexmedetomidine, valproic acid and other options will be discussed.