Prescription Patterns of Intramuscular Medication for Psychomotor Agitation: A Survey of Italian Psychiatrists.

Objective: : Intramuscular medications are widely used to treat psychomotor agitation (PMA) in uncooperative patients. We evaluated knowledge and attitude towards guidelines and the prescribing patterns in a sample of Italian psychiatrists. Methods: : A structured 28-item questionnaire was submitted to psychiatrists of Italian Departments of Mental Health. We considered 8 clinical scenarios of PMA. For comparing two qualitative variables Chi-square tests were performed. Results: : One hundred thirty-four psychiatrists completed the survey. The use of a monotherapy is significatively higher (p ＜ 0.05) over a dual therapy in all clinical scenarios except PMA due to Mood Disorder and Psychotic Disorders, whereas the use of a polytherapy is significatively higher (p ＜ 0.05) in PMA due to Mood Disorders and Psychotic Disorders. The use of second-generation antipsychotic (SGAs) as monotherapy over first-generation antipsychotics (FGAs) is significantly higher (p ＜ 0.05) in PMA due to Central Nervous System (CNS) stimulants. The use of SGAs over FGAs in polytherapy is significantly higher (p ＜ 0.05) in PMA due to CNS stimulants. Knowledge of guidelines results 67.1% and significatively higher (p ＜ 0.05) among those who prefer SGAs as monotherapy rather than FGAs in PMA due to Intellectual Disability, CNS depressants and Delirium. Knowledge of guidelines results significatively higher (p ＜ 0.05) among those who prefer SGAs rather than FGAs in polytherapy in PMA due to Mood disorders. Conclusion: : This survey reports variation in prescribing patterns for medication used to treat PMA. While SGAs are often prescribed as first choice following the more recent guidelines, FGAs and multi-drug solutions seem to be still a popular solution.

[Effect of an Intervention Using Voice Recording of a Family Member on Patients Undergoing Mechanical Ventilator Weaning Process].

PURPOSE: This study aimed to determine the impact of an intervention using voice recording of family members on pain, anxiety, and agitation in patients undergoing weaning from mechanical ventilation. METHODS: A randomized control pre-post experimental design was implemented to 53 participants, with 27 and 26 participants in the experimental and control groups, respectively. A 70-second voice recording of a family member, repeated three times at 10-minute intervals was used as an intervention for the experimental group. Meanwhile, participants in the control group used headset for 30 minutes. Structured instruments were utilized to measure pain, anxiety, agitation, and the weaning process. Wilcoxon Signed Ranks test and the Mann-Whitney U test, or χ² test, were used for data analysis. RESULTS: The experimental group exhibited significant decrease in pain (Z = -3.53, p < .001), anxiety (t = 5.45, p < .001), and agitation (Z = -2.99, p = .003) scores compared with those of the control group. However, there was no significant difference between groups in the weaning process' simplification (χ² = 0.63, p = .727). CONCLUSION: Intervention using family members' voice recording effectively reduces pain, anxiety, and agitation in patients undergoing weaning from mechanical ventilation. This can be actively utilized to provide a more comfortable process for patients.

Behavioral or neuropsychiatric symptoms of Alzheimer's disease: from psychopathology to pharmacological management / Sintomas comportamentais ou neuropsiquiátricos da doença de Alzheimer: psicopatologia e abordagem terapêutica

Abstract Neuropsychiatric or behavioral symptoms of dementia encompass a series of disorders, such as anxiety, depression, apathy, psychosis, and agitation, all commonly present in individuals living with dementia. While they are not required for the diagnosis of Alzheimer's disease (AD), they are ubiquitously present in all stages of the disease, contributing to negative clinical outcomes, including cognitive decline, functional disability, and caregiver burden. Neuropsychiatric symptoms have been conceptualized not only as risk factors but as clinical markers of decline along the AD spectrum. The concept of "mild behavioral impairment", the behavioral correlate of mild cognitive impairment, has been proposed within this framework. The first steps in the management of behavioral symptoms in AD involve defining the target and investigating potential causes and/or aggravating factors. Once these factors are addressed, non-pharmacological approaches are preferred as first-line interventions. Following the optimization of anticholinesterase treatments, specific pharmacological approaches (e.g., antidepressants, antipsychotics) can be considered weighing potential side effects.

Resumo Sintomas neuropsiquiátricos ou comportamentais de demência envolvem uma série de condições, como ansiedade, depressão, apatia, psicose e agitação, frequentemente observadas em indivíduos com demência. Embora esses sintomas não sejam necessários para o diagnóstico da doença de Alzheimer, estão presentes em todas as fases ou estágios da doença, contribuindo negativamente para o declínio cognitivo, comprometimento funcional e sobrecarga do cuidador. Os sintomas neuropsiquiátricos têm sido conceituados não apenas como fatores de risco, mas também como marcadores clínicos de progressão da doença de Alzheimer. O construto "comprometimento comportamental leve", correlato comportamental do comprometimento cognitive leve, tem sido proposto nesse contexto. Os primeiros passos na abordagem dos sintomas comportamentais da doença de Alzheimer envolvem definir os alvos-terapêuticos e investigar potenciais causas ou fatores agravantes. Após intervir nesses fatores, abordagens não farmacológicas constituem a primeira linha de intervenção. Depois da otimização do tratamento anticolinesterásico, terapias farmacológicas específicas (por exemplo, antidepressivos, antipsicóticos) podem ser consideradas, levando-se em conta potencias efeitos colaterais.

Translation, cross-cultural adaptation, and validation of the Behavioral Activity Rating Scale (BARS) for the Brazilian population

Abstract Introduction Few instruments are available in Brazil to evaluate psychomotor activity in psychiatric emergency, clinical, and research settings. This study aimed to perform a cross-cultural adaptation of the Behavioral Activity Rating Scale (BARS) into Brazilian Portuguese and assess the adapted scale's psychometric properties. Method An expert consensus committee conducted a translation and back-translation of the original scale, resulting in the BARS-BR. Four pairs of physicians administered the BARS-BR and the Sedation-Agitation Scale (SAS) to patients in a hospital psychiatry emergency room and patients in the hospital's psychiatric wards. The BARS-BR was compared to the SAS to assess concurrent validity and internal consistency was evaluated with the Bland-Altman technique. Results In the emergency room, the correlation coefficients between the first and second assessments were rho = 0.997 and rho = 1.0, respectively. In the hospital wards, the correlation coefficient between the pair of evaluators was rho = 0.951. There were strong correlations between the BARS-BR score of the first examiner and the SAS score of the second examiner (rho = 0.903) and between the SAS score of the first examiner and the BARS-BR score of the second examiner (rho = 0.893). Conclusion The BARS-BR showed good psychometric properties, and we recommend its use because it constitutes an easy method for assessment of changes in psychomotor activity. Further studies are suggested to evaluate adoption and comprehension of the BARS-BR scale by all classes of healthcare professionals.

Escalas en el control del dolor en pacientes post-ictus con afasia: Un estudio comparativo / Scales in pain control in patients post-ictus with aphasia: A comparative study

La valoración del dolor y su control es un punto clave en los cuidados que reciben los pacientes durante su estancia hospitalaria, siendo la figura de la enfermera esencial y más en aquellos pacientes afectados de ictus a los que les sobreviene un problema de afasia secundaria, que dificulta la verbalización del dolor.El objetivo de este estudio fue averiguar si el uso de una escala específica de control del dolor y la más precisa administración del tratamiento analgésico impactan positivamente en indicadores tales como la estancia media, el grado de dependencia y los episodios de agitación.Mediante un estudio de diseño longitudinal de grupos al azar, realizado durante 2 semanas de seguimiento, se compara la gestión y registro del dolor utilizando una escala de conductas indicadoras de dolor (N=41) y una escala verbal numérica o escala visual analógica (N=39), en pacientes con alteración del lenguaje tras sufrir un ictus y que se encuentren ingresados en la Unidad de Ictus del Servicio de Neurología del Hospital Clínic de Barcelona.Los resultados obtenidos, pese a ir en la línea conjeturada, no son significativos estadísticamente. Sin embargo, algunos modelos estadísticos han mostrado la utilidad de algunos factores (nivel de formación, experiencia enfermera, episodios previos de ictus, entre otros) en la predicción de una mejor evolución, lográndose una capacidad predictiva entre el 20-37%, lo que abre la puerta a nuevos estudios y refuerza el papel de las variables estudiadas en los cuidados de este tipo de pacientes.(AU)

The assessment of pain and its control is a key point in the care received by patients during their hospital stay, with the nurse being an essential figure, especially in stroke patients with secondary aphasia, which makes it difficult to verbalise pain.The aim of this study was to find out whether the use of a specific pain control scale and the more precise administration of analgesic treatment has a positive impact on indicators such as average stay length, dependence degree and agitation episodes.By means of a longitudinal randomised group design study, within a two-week period, we compared the management and recording of pain using a Pain Indicator Behaviour Scale (N=41) and a Verbal Numerical Scale or Visual Analogue Scale (N=39), in patients with language impairment after suffering a stroke who were admitted to the Stroke Unit of the Neurology Department of the Hospital Clínic de Barcelona.The results obtained, despite being in line with what was conjectured, are not statistically significant. However, some statistical models have shown the usefulness of some factors (level of training, nurses experience, previous episodes of stroke, among others) in the prediction of a better evolution, with a predictive capacity between 20-37%, which justifies the necessity of further studies and reinforces the role of the variables studied in the care of this type of patient.(AU)

Delirium, catatonía y síndrome de abstinencia manifestados como agitación psicomotora en COVID-19: una propuesta de manejo farmacológico en el hospital general / Delirium, catatonia and substance withdrawal syndrome manifested as psychomotor agitation in COVID-19: a pharmacological management approach for the general hospital setting

BACKGROUND: Neuropsychiatric symptoms can be part of the clinical spectrum of COVID-19 infections. AIM: To devise an evidence based clinical algorithm as a guide for clinicians, to identify and treat underlying clinical syndromes of psychomotor agitation, such as delirium, catatonia or substance withdrawal in patients who are hospitalized and infected with SARS-CoV-2. MATERIAL AND METHODS: A review of the literature about the pharmacological management of neuropsychiatric manifestations of COVID-19 at the general hospital, to develop a clinical protocol based on a consensus from an interdisciplinary expert panel at a Clinical Hospital. Results: A consensual clinical algorithm for the management of delirium, catatonia, and substance withdrawal, manifested as psychomotor agitation in patients hospitalized with COVID-19, was developed as a clinical proposal for physicians at different levels of complexity in health services. CONCLUSIONS: Cooperation among different clinical units in the general hospital facilitated the implementation of a clinical algorithm for clinicians for the management of psychomotor agitation in COVID-19 patients.

Adolescente con corea de inicio agudo: a propósito de una entidad olvidada / Adolescent with acute-onset chorea: on the subject of a forgotten entity

La corea de Sydenham es como se denomina el cuadro de origen neurológico consistente en agitación y movimientos anormales que ocurre en contexto de una fiebre reumática, secundariamente a la infección por estreptococo del grupo A. Dado que la incidencia de fiebre reumática ha disminuido significativamente en los últimos años, las complicaciones asociadas pueden considerarse actualmente excepcionales. No obstante, dado que presenta un pronóstico excelente si se instaura precozmente el tratamiento, es muy importante saber reconocer el cuadro clínico (AU)

Sydenham’s chorea, with a documented relationship with group A streptococcal infections, is the one of the most common acquired movement disorder of adolescence. However, rheumatic fever´s incidence is significantly lower than years ago. The clinical picture is very characteristic, and its recognition is essential in order to improve the prognostic starting an specific treatment as soon as possible (AU)

Eficacia y seguridad del haloperidol intranasal en una Unidad de Agudos: estudio piloto en pacientes esquizofrénicos con leve-moderada agitación / Efficacy and safety of intranasal haloperidol in an acute Psychiatry Unit: a pilot study on schizophrenic patients with mild-modedate agitation

Objetivo: Estudiar la eficacia y seguridad de la administración de 5 mg de haloperidol intranasal en pacientes conesquizofrenia y trastorno esquizoafectivo, con leve o moderada agitación, ingresados en una unidad de agudos depsiquiatría.Método. Diseño: Estudio piloto de ensayo clínico, fase IV,con evaluador ciego, unicéntrico, aleatorizado y controladode grupos paralelos, comparando la administración intranasalcon la intramuscular. Sujetos: 16 pacientes; 7 administraciónintranasal y 9 administración intramuscular. Medidas de eficacia: Escala de Síntomas Positivas y Negativos-ComponenteExcitación (PANSS-EC); Escala de Impresión Clínica Global(CGI). Medidas de seguridad: Cambios en el ECG registrados5 minutos pretratamiento y 5 minutos postratamiento.Resultados. La administración intranasal mostró mayorrapidez de acción en comparación con la intramuscular enla PANSS-EC (p = 0,042) y la CGI (p = 0,041) a los 10 minutos de la administración, con similar eficacia a los 20, 30 y60 minutos. Sin diferencias significativas en el QTc basal ypostratamiento.Conclusión. El haloperidol intranasal fue una alternativarápida, efectiva y bien tolerada para reducir la agitación leve-moderada en estos pacientes. (AU)

Aim: To study the efficacy and safety of intranasal administration of 5mg haloperidol on mild-moderate agitatedpatients with schizophrenia or schizoaffective disorder in anacute psychiatry unit setting.Method. Design: Pilot study of clinical trial, phase IV,open-label, observer-blind, single-center, randomized a haloperidol-controlled trial comparing intranasal with intramuscular administration. Subjects: 16 patients; 7 intranasaladministration, and 9 intramuscular administration. Efficacymeasurement: Positive and Negative Syndrome Scale-Excited Component (PANSS-EC); Clinical Global Impressions-Improvement Scale (CGI). Safety measurement: Changes inthe ECG registered 5 minutes pre-treatment and 5 minutespost-treatment.Results. Intranasal administration showed more quickaction compared with intramuscular on the PANSS-EC(p=0.042) and CGI (p=0.041) 10 minutes after administration, with similar efficacy up to 20, 30, and 60 minutes. There were no significant differences between QTc baseline andpost-treatment.Conclusion. Intranasal haloperidol was a rapid, effective,and well-tolerated alternative for reducing acute mild-moderate agitation. (AU)

Retirada accidental de sondas enterales en el paciente crítico / Accidental removal of feeding tubes in critical patients

Objetivo: evaluar el impacto de una sesión formativa en las tasas de retirada accidental (RA) [autorretirada y retirada por causa externa al paciente (CEP)] de la sonda enteral (SE) y en los niveles de analgosedación e identificación del delirio, en pacientes de un Servicio de Cuidados Intensivos y Grandes Quemados (UCI-UGQ).Método: estudio observacional prospectivo antes-después, realizado en una UCI-UGQ de 24 camas. Primer periodo: del 15-10-2018 al 15-01-2019, segundo periodo: del 15-07-2019 al 15-01-2020. Entre periodos se comunicaron los resultados y se hizo una sesión formativa (sujeción SE, valoración dolor, sedación y delirio). Incluidos todos los pacientes portadores de SE. Variables: demográficas, gravedad, motivo de retirada, evento adverso como consecuencia de la retirada o reinserción, dolor, sedación/agitación y delirio. Análisis: descriptivo y tasas de incidencia por 1.000 días dispositivo. Aprobado por CEIm.Resultados: ingresos en 2018 vs. 2019: 232 vs. 408 (1.586 vs. 3.149 días estancia); mujeres: 34% vs. 42%. SAPS III, Mediana (RIC): 57 (45-67) vs. 45 (33-54). Insertadas 156 vs. 295 SE. Tasas de RA por 1.000 días de dispositivo: global 56,68 vs. 45,87 (p= 0,42); autorretirada 48,13 vs. 37,72 (p= 0,36), CEP 8,56 vs. 8,15 (p= 0,90). No se registraron eventos adversos. En el momento de la autorretirada presentaban dolor (EVN/ESCID> 0) 26,6% vs. 19% pacientes; agitación (RASS> 0) 66,6% vs. 40,6% pacientes; delirio (CAM-ICU positivo) 33,3% vs. 20,3% pacientes.Conclusiones: tras la sesión formativa se observó una reducción no significativa en las tasas de RA. En las autorretiradas se comprobó un descenso significativo de la agitación y un descenso clínicamente relevante del dolor y presencia de delirio.(AU)

Objective: to assess the impact of a training session on accidental removal (AR) rates of the feeding tube (FT) [self-removal and removal due to a cause external to the patient (CEP] and on the levels of analgesia & sedation and delirium detection, in patients from an Intensive Care and Major Burns Unit (ICU-MBU).Method: an observational, before-and-after, prospective study, conducted in a 24-bed ICU-MBU- First period: October, 15th, 2018 to January, 15th, 2019: second period: July, 15th, 2019 to January, 15th, 2020. Results were reported between periods, and a training session was conducted (FT attachment, pain assessment, sedation, and delirium). All patients with FT were included. Variables: demographics, severity, reason for removal, adverse event as a consequence of removal or reinsertion, pain, sedation/agitation, and delirium. Analysis: descriptive, and incidence rates per 1,000 device days. Approved by the Drug Research Ethics Committee (CEIm).Results: hospitalizations in 2018 vs. 2019: 232 vs. 408 (1,586 vs. 3,149 hospitalization days); women: 34% vs. 42%. SAPS III, Median (IQR): 57 (45-67) vs. 45 (33-54). FTs inserted: 156 vs. 295. AR rates per 1,000 device days: overall 56.68 vs. 45.87 (p= 0.42); self-removal: 48.13 vs. 37.72 (p= 0.36), CEP 8.56 vs. 8.15 (p= 0.90). No adverse events were reported. At the time of self-removal, 26.6% vs. 19% patients presented pain (VAS/ESCID> 0); 66.6% vs. 40.6% patients presented agitation (RASS> 0, and 33.3% vs. 20.3% patients presented delirium (positive CAM-ICU).Conclusions: after the training session, a non-significant reduction in AR rates was observed. In cases of self-removal, a significant reduction in agitation was observed, as well as a clinically relevant reduction in pain and presence of delirium.(AU)

Guía práctica para el manejo de la agitación psicomotora en pediatría / Clinical Guide for the management of psychomotor agitation in pediatrics

La agitación psicomotora es un estado de hiperactividad impulsiva aguda en grados variables, que requiere intervención. Sus manifestaciones abarcan un amplio espectro desde mínima inquietud hasta perturbaciones intensas con grandes movimientos no propositivos o violentos. Datos recientes muestran que aproximadamente 10-20% de los niños, niñas y adolescentes (NNA) presenta una patología de la esfera psiquiátrica y/o abuso de sustancias y, en consecuencia, han aumentado las consultas por estos motivos en servicios de urgencia pediátrica. Hasta 1 de cada 15 NNA requiere contención de algún tipo. Las causas de agitación son múltiples y se deben investigar en cada paciente. El objetivo de este trabajo es concientizar al equipo de salud sobre el problema y contribuir a la estandarización del manejo clínico en pediatría. Se describen intervenciones no farmacológicas, contención farmacológica y física, con sus respectivas indicaciones.

Psychomotor agitation is a state of acute impulsive hyperactivity with varying degrees of magnitude that requires intervention. Its manifestations cover a broad spectrum from minimal unrest to intense disturbances with large non-purposeful or violent movements. Recent data show that approximately 10-20% of children and adolescents have a psychiatric disease and/or substance abuse disorder and, consequently, consultations for these reasons have increased in pediatric emergency services. Up to 1 in 15 children require some form of restraint. Causes of agitation are multiple and must be investigated in each patient. The objectives of this review are to improve awareness of the issue to health work-teams and aims at the standardization of its medical management in pediatrics. Non-pharmacological interventions, chemical and physical restraint methods are described, with their respective indications.

Assessment of delirium in children admitted into the Intensive Care Unit: psCAM-ICU Tool

Abstract Background: Delirium has been identified as a risk factor for the mortality of critically ill patients, generating great social and economic impacts, since patients require more days of mechanical ventilation and a prolonged hospital stay in the intensive care unit (ICU), thus increasing medical costs. Objective: To describe the prevalence and characteristics of delirium episodes in a sample of 6-month to 5-year-old children who are critically ill. Methods: Cohort study at a Pediatric Intensive Care Unit (PICU) in Bogotá (Colombia). Participants were assessed by the Preschool Confusion Assessment Method for the ICU (psCAM-lCU) within the first twenty-four hours of hospitalization. Results: One quarter of the participants (25.8%) presented some type of delirium. Among them, two sub-types of delirium were observed: 62.5% of the cases were hypoactive and 37.5% hyperactive. Moreover, from them, six were male (75%) and 2 female (25%). Primary diagnosis was respiratory tract infection in 62.55% of the patients, while respiratory failure was diagnosed in the remaining 37.5%. Conclusions: The implementation of delirium monitoring tools in critically ill children provides a better understanding of the clinical manifestation of this phenomenon and associated risk factors in order to contribute to the design of efficient intervention strategies.

Resumen Introducción: el delirium se ha identificado como un factor de riesgo para la mortalidad de pacientes en estado crítico, lo que genera un mayor impacto social y económico, teniendo en cuenta que los pacientes requieren más días de ventilación mecánica y una estancia hospitalaria prolongada en la unidad de cuidados intensivos (UCI), lo que incrementa los costos médicos de su estadía. Objetivo: describir la prevalencia y las características de los episodios de delirium en una muestra de niños de seis meses a cinco años en estado crítico. Métodos: estudio de cohorte en una Unidad de Cuidados Intensivos Pediátricos (UCIP) en Bogotá (Colombia). Los participantes fueron evaluados por el método de evaluación de confusión preescolar para la UCI (psCAM-UCI) dentro de las 24 horas iniciales del período de hospitalización. Resultados: una cuarta parte de los participantes (25,8 %) presentó algún tipo de delirium. Entre ellos, se observaron dos subtipos de delirium: el 62,5 % de los casos era hipoactivo y el 37,5 % hiperactivo. Además, el 75% (6) de los participantes delirantes eran hombres y el 25 % (2) mujeres. En 62,5 % de los pacientes el diagnóstico primario fue infección de las vías respiratorias, mientras que la insuficiencia respiratoria fue diagnosticada en el 37,5 % restante. Conclusiones: la implementación de herramientas de monitoreo del delirium con niños en estado crítico proporciona una mejor comprensión de la presentación clínica de este fenómeno y los factores de riesgo asociados, con lo cual es posible contribuir al diseño de estrategias de intervención eficientes.

Resumo Introdução: o delirium foi identificado como um fator de risco para a mortalidade de pacientes graves, o que gera maior impacto social e econômico, visto que os pacientes necessitam de mais dias de ventilação mecânica e internação prolongada na unidade de terapia intensiva (UTI), o que aumenta os custos médicos para a sua estadia. Objetivo: descrever a prevalência e as características dos episódios de delirium em uma amostra de crianças de 6 meses a 5 anos, gravemente doentes. Métodos: estudo de coorte em uma Unidade de Terapia Intensiva Pediátrica (UTIP) em Bogotá (Colômbia). Os participantes foram avaliados pelo método de avaliação de confusão pré-escolar para a UTI (psCAM-UTl) dentro das primeiras 24 horas do período de internação. Resultados: um quarto dos participantes (25,8%) apresentou algum tipo de delirium. Entre eles, dois subtipos de delirium foram observados: 62,5% dos casos eram hipoativos e 37,5% hiperativos. Além disso, 75% (6) dos participantes delirantes eram do sexo masculino e 25% (2) feminino. Em 62,5 % dos pacientes, o diagnóstico primário foi infecção das vias respiratórias, enquanto a insuficiência respiratória foi diagnosticada em 37,5 % restante. Conclusões: a implementação de instrumentos de monitorização do delirium com crianças gravemente doentes permite uma melhor compreensão da apresentação clínica do fenômeno e dos fatores de risco associados, de forma a contribuir para o desenho de estratégias de intervenção eficazes.

Intervenções não farmacológicas de manejo na agitação de idosos com demência em ambiente doméstico / Intervenciones no farmacológicas de manejo de la agitación en ancianos con demencia en ambiente doméstico / Nonpharmacological Interventions for Managing Agitation in Elderlies with Dementia in the Home Setting

Introdução: A agitação é um sintoma neuropsiquiátrico recorrente em idosos com demência. No ambiente doméstico, essa condição impõe aos familiares cuidadores o desafio de intervir adequada e precocemente a fim de minimizar visitas às emergências, internações ou até mesmo institucionalizações de longa permanência. Objetivo: Identificar as intervenções não farmacológicas utilizadas por familiares cuidadores no manejo da agitação em idosos com demência. Métodos: Pesquisa qualitativa realizada com 11 familiares cuidadores de idosos em Minas Gerais, Brasil. Foram realizadas entrevistas com roteiro semiestruturado e, para a análise, foi empregada a técnica de análise de conteúdo. Resultados: As intervenções mais utilizadas foram: a conversa, a escuta, a distração, o uso de brinquedos, a música/canto e a leitura da Bíblia para acessar a espiritualidade/religiosidade. Verificou-se que, diante dos desafios impostos pela demência ao cuidado e dos desgastes físico e emocional experimentados, os familiares esforçaram-se para acolher e oferecer suporte humano ao idoso, além de sentirem-se satisfeitos por terem a oportunidade de retribuir o cuidado que receberam. Conclusão: Não há uma intervenção capaz de responder a todos os comportamentos agitados. A experiência e o vínculo desenvolvido entre familiares cuidadores e idosos ajudaram a guiar a escolha individual de intervenções não farmacológicas mais eficazes, provavelmente, por facultar certa antecipação das respostas dos idosos(AU)

Introducción: La agitación es un síntoma neuropsiquiátrico recurrente en ancianos con demencia. En el cotidiano del ambiente doméstico, esta condición impone a los familiares cuidadores el desafío de encontrar estrategias adecuadas de manejo a fin de evitar las visitas a emergencias, hospitalizaciones o incluso la institucionalización a largo plazo. Objetivo: Identificar las estrategias no farmacológicas utilizadas por los familiares cuidadores en el manejo de la agitación en ancianos con demencia. Métodos: Investigación cualitativa realizada con 11 familiares cuidadores de ancianos en Minas Gerais, Brasil. La recolección de datos fue realizada a través de entrevistas con guión semiestructurado. Para la interpretación de los datos se utilizó la técnica de análisis de contenido. Resultados: Se identificaron como estrategias más utilizadas para el manejo de la agitación: la conversación, la escucha, la distracción, el uso de juguetes, la música/canto y la lectura de la Biblia para acceder a la espiritualidad/religiosidad. Se verificó que, frente a los desafíos impuestos por la demencia al cuidado y el desgaste físico y emocional experimentado, los familiares cuidadores se esforzaron para acoger y brindar apoyo humano al familiar anciano, además de sentirse satisfechos por tener la oportunidad de retribuir el cuidado que recibieron. Conclusiones: No hay una intervención capaz de responder efectivamente a todos los comportamientos agitados. Sin embargo, la experiencia y el vínculo desarrollado entre familiares cuidadores y ancianos guiaron la elección individual de las intervenciones no farmacológicas más efectivas, probablemente al proporcionar cierta anticipación de las respuestas de los ancianos(AU)

Introduction: Agitation is a neuropsychiatric symptom recurrent in elderly people with dementia. In the daily life of the home setting, this condition imposes on the family caregivers the challenge of finding appropriate management strategies for avoiding visits to the emergency room, hospitalizations, or even long-term institutionalization. Objective: To identify the nonpharmacological strategies used by family caregivers in the management of agitation in elderly people with dementia. Methods: Qualitative research carried out with 11 family caregivers of elderly people in Minas Gerais, Brazil. The data collection was carried out through interviews with semi-structured repertory of quotations. The content analysis technique was used to interpret the data. Results: The most commonly used strategies for agitation management were identified. These were conversation, listening, distraction, use of toys, music/singing, and reading the Bible for accessing spirituality or religiosity. It was verified that, in the face of the challenges imposed by dementia onto the care and the physical and emotional outwearing experienced, family caregivers strived to welcome and provide human support to the elderly relative, in addition to feeling satisfied to have the opportunity to give back the care received Conclusions: There is no intervention capable of responding effectively to all agitation-related behaviors. However, the experience and the relationship developed between family caregivers and the elderly guided the individual choice for the most effective nonpharmacological interventions, probably by providing some anticipation to the elderly's responses(AU)

Brazilian guidelines for the management of psychomotor agitation. Part 2. Pharmacological approach

Objective: To present the essential guidelines for pharmacological management of patients with psychomotor agitation in Brazil. Methods: This is a systematic review of articles retrieved from the MEDLINE (PubMed), Cochrane Database of Systematic Reviews, and SciELO databases published from 1997 to 2017. Other relevant articles in the literature were also used to develop these guidelines. The search strategy used structured questions formulated using the PICO model, as recommended by the Guidelines Project of the Brazilian Medical Association. Recommendations were summarized according to their level of evidence, which was determined using the Oxford Centre for Evidence-based Medicine system and critical appraisal tools. Results: Of 5,362 articles retrieved, 1,731 abstracts were selected for further reading. The final sample included 74 articles that met all inclusion criteria. The evidence shows that pharmacologic treatment is indicated only after non-pharmacologic approaches have failed. The cause of the agitation, side effects of the medications, and contraindications must guide the medication choice. The oral route should be preferred for drug administration; IV administration must be avoided. All subjects must be monitored before and after medication administration. Conclusion: If non-pharmacological strategies fail, medications are needed to control agitation and violent behavior. Once medicated, the patient should be monitored until a tranquil state is possible without excessive sedation. Systematic review registry number: CRD42017054440.

Brazilian guidelines for the management of psychomotor agitation. Part 1. Non-pharmacological approach

Objective: To present the essential guidelines for non-pharmacological management of patients with psychomotor agitation in Brazil. Methods: These guidelines were developed based on a systematic review of articles published from 1997 to 2017, retrieved from MEDLINE (PubMed), Cochrane Database of Systematic Review, and SciELO. Other relevant articles identified by searching the reference lists of included studies were also used to develop these guidelines. The search strategy used structured questions formulated using the PICO model, as recommended by the Guidelines Project of the Brazilian Medical Association. Recommendations were summarized according to their level of evidence, which was determined using the Oxford Centre for Evidence-based Medicine system and critical appraisal tools. Results: We initially selected 1,731 abstracts among 5,362 articles. The final sample included 104 articles that fulfilled all the inclusion criteria. The management of agitated patients should always start with the least coercive approach. The initial non-pharmacological measures include a verbal strategy and referral of the patient to the appropriate setting, preferably a facility designed for the care of psychiatric patients with controlled noise, lighting, and safety aspects. Verbal de-escalation techniques have been shown to decrease agitation and reduce the potential for associated violence in the emergency setting. The possibility of underlying medical etiologies must be considered first and foremost. Particular attention should be paid to the patient's appearance and behavior, physical signs, and mental state. If agitation is severe, rapid tranquilization with medications is recommended. Finally, if verbal measures fail to contain the patient, physical restraint should be performed as the ultimate measure for patient protection, and always be accompanied by rapid tranquilization. Healthcare teams must be thoroughly trained to use these techniques and overcome difficulties if the verbal approach fails. It is important that healthcare professionals be trained in non-pharmacological management of patients with psychomotor agitation as part of the requirements for a degree and graduate degree. Conclusion: The non-pharmacological management of agitated patients should follow the hierarchy of less invasive to more invasive and coercive measures, starting with referral of the patient to an appropriate environment, management by a trained team, use of verbal techniques, performance of physical and mental assessment, use of medications, and, if unavoidable, use of the mechanical restraint. Systematic review registry number: CRD42017054440.

Effects of Aromatherapy on Agitation in Patients with Dementia: A Systematic Literature Review and Meta-analysis

PURPOSE: The purpose of this study is to identify the effects of aromatherapy on agitation in patients with dementia using a meta-analysis and systemic literature review. METHODS: The EMBASE, CINAHL, MEDLINE, and other databases were searched up to November 2017. RESULTS: Of 419 publications identified, 12 met inclusion criteria, and 9 studies were used to estimate the effect size of aromatherapy. A total of 837 participants across all studies were included. The commonly applied methods were massage (50%), type of oil lavender (75%), and instrument Cohen-Mansfield Agitation Inventory (75%). A medium effect size of aromatherapy on agitation was identified (d=−0.56, I2=65.0%, p=.001). The massage group has lower effect size than the other group (d=−0.98, I2=0.0%, p=.001). CONCLUSION: Aromatherapy appears to be effective in improving agitation in patients with dementia. However, further studies for home-dwelling patients with dementia and with different types of aroma oil should be conducted in the future. In addition, research with well-designed are needed to assess the effects or aromatherapy on agitation.

A propósito de un caso complejo: agitación psicomotora: ¿TEC y clozapina, sala de aislamiento? / About a complex case: psychomotor agitation: TEC and clozapine, isolation room?

Paciente de 25 años. Ingreso a Servicio de Urgencia. Paciente viene solo, desaseado, relata múltiples ideas bizarras, no sistematizadas. Pensamiento laxo, musita, interferido, a ratos discordante. Diagnóstico: Síndrome esquizomorfo. Antecedentes judiciales: Informe cumplimiento condena en Puerto Montt: Lesiones menos graves y Robo con violencia. Persiste amenazante, exaltado. Paranoide. Durante la tarde amenaza con colgase, cortarse o quemar colchón, cuelga sabana de ventana e intenta ahorcarse. Primera sesión de TEC, Cisordinol accutard. Contención física, Sujeciones. Modecate. Cortes en antebrazo, Amenaza con matar otros pacientes, al apagar las luces se sienta en cama de otro paciente en actitud intimidante, lo agrede con lápiz en ojo derecho. Reinicia TEC, Inicia clozapina 25mg/día. Hostil y desafiante ante funcionarios por el encuadre, Baja en recuento de blancos, inicia litio. Algo hostil y querellante con personal, probablemente relacionado con suspensión de TEC (20 sesiones). Clozapina 450mg/día, Litio 600 mg/día. Traslado de paciente para sala de aislamiento, Se retira chapa de aislamiento ­ Sala de observación, Cuidador especial constante, hombre, Mitones, solicitud a UGC apoyo

Patient of 25 years old. Entrance to Emergency Service. Patient comes alone, untidy, reports multiple bizarre ideas, not systematized. Lax thought, mumble, interfered, discordant at times. Diagnosis: Schizomorphic syndrome. Legal background: Condemning Report in Puerto Montt: Less serious injuries and robbery with violence. He persists threatening, exalted. Paranoid. During the afternoon threatens to hang, cut or burn mattress, hangs a blanket in window and tries to hang himself. First session of TEC, Cisordinol accutard. Physical restraint, Supports. Modecate. Cuts in forearm. Threat to kill other patients, when turning off lights sits in bed of another patient in intimidating attitude, strikes him with pencil in right eye. Restart TEC, Starts clozapine 25mg / day. Hostile and challenging with officials because of setting, White cells: Low counting, initiating lithium. Somehow hostile and prosecuting with staff, probably related to ECT suspension (20 sessions). Clozapine 450mg / day, Lithium 600mg / day. Transfer of patient to isolation room, Removal of insulation sheet - Observation room, Special caregiver constant, male, Mittens, request to UGC support.

Manejo de la excitación psicomotriz en niños y adolescentes / Management of psychomotor excitement in children and adolescents

La agitación o excitación psicomotriz (EPM) es un síndrome que no constituye en sí mismo una enfermedad, sino que se trata de una manifestación de una gran variedad de trastornos psiquiátricos y orgánicos. Se caracteriza por aumento desorganizado de la motricidad acompañado de una activación vegetativa (sudoración, taquicardia, midriasis) y ansiedad severa. Constituye uno de los cuadros de presentación más frecuente en salas de urgencia psiquiátricas y generales. El objetivo del presente artículo es revisar los aspectos clínicos del síndrome, describir las diferentes causas y plantear su manejo en los diferentes ámbitos de la práctica clínica y medidas de seguridad. Se consideran las medidas terapéuticas no farmacológicas (intervenciones verbales, sujeción física) y medicamentosas, mencionando las vías de administración, las opciones de drogas y sus dosis según la presunción diagnóstica. Es una urgencia donde se debe actuar con rapidez para garantizar la seguridad del paciente y del entorno (AU)

Psychomotor agitation or excitation (PMA) is not a disorder in itself but a manifestation of a broad variety of psychiatric and organic disorders. It is characterized by increased disorganization of motor activity associated with vegetative activation (sweating, increased heart rate, mydriasis) and severe anxiety. It is one of the most common disorders presenting in general and psychiatric emergency departments. The aim of this study was to review the clinical aspects of the entity, to describe possible causes, and to evaluate management in different settings of clinical practice as well as safety measures. Non-pharmacological interventions (verbal interventions, physical restraint) and medications are considered, describing routes of administration, options of drugs and drug doses according to the presumed diagnosis. PMA is an urgency in which fast intervention is warranted for the safety of the patient and their environment (AU)

Effect of dexmedetomidine in children undergoing general anesthesia with sevoflurane: a meta-analysis / Efeito da dexmedetomidina em crianças submetidas à anestesia geral com sevoflurano

Abstract Background and objectives: Sevoflurane is often used in pediatric anesthesia and is associated with high incidence of psychomotor agitation. In such cases, dexmedetomidine (DEX) has been used, but its benefit and implications remain uncertain. We assessed the effects of DEX on agitation in children undergoing general anesthesia with sevoflurane. Method: Meta-analysis of randomized clinical and double-blind studies, with children undergoing elective procedures under general anesthesia with sevoflurane, using DEX or placebo. We sought articles in English in PubMed database using the following terms: Dexmedetomidine, sevoflurane (Methyl Ethers/sevoflurante), and agitation (Psychomotor Agitation). Duplicate articles with children who received premedication and used active control were excluded. It was adopted random effects model with DerSimonian-Laird testing and odds ratio (OR) calculation for dichotomous variables, and standardized mean difference for continuous variables, with their respective 95% confidence interval (CI). Results: Of 146 studies identified, 10 were selected totaling 558 patients (282 in DEX group and 276 controls). The use of DEX was considered a protective factor for psychomotor agitation (OR = 0.17; 95% CI 0.13-0.23; p < 0.0001) and nausea and vomiting in PACU (OR = 0.49; 95% CI 0.35-0.68; p < 0.0001). Wake-up time and PACU discharge time were higher in the dexmedetomidine group. There was no difference between groups for extubation time and duration of anesthesia. Conclusion: Dexmedetomidine reduces psychomotor agitation during wake-up time of children undergoing general anesthesia with sevoflurane.

Resumo Justificativa e objetivos: Sevoflurano é frequentemente usado em anestesia pediátrica e está associado à alta incidência de agitação psicomotora ao despertar. Nesses casos a dexmedetomidina (dex) tem sido usada, porém permanecem incertos seus benefícios e suas implicações. Foram avaliados os efeitos da dex sobre a agitação no despertar de crianças submetidas à anestesia geral com sevoflurano. Método: Metanálise de ensaios clínicos randomizados e duplamente encobertos, com crianças submetidas a procedimentos eletivos sob anestesia geral com sevoflurano, que usaram dex ou placebo. Buscaram-se artigos em língua inglesa na base de dados Pubmed com termos como Dexmedetomidine, sevoflurane (Methyl Ethers/sevoflurane) e agitation (Psychomotor Agitation). Artigos duplicados, com crianças que receberam medicação pré-anestésica e que usaram controle ativo foram excluídos. Adotou-se modelo de efeitos aleatórios com testes de DerSimonian-Laird e cálculo de odds ratio (OR) para variáveis dicotômicas e diferença de média padronizada para variáveis contínuas, com seus respectivos intervalos de confiança de 95% (IC). Resultados: Dos 146 estudos identificados, 10 foram selecionados, com 558 pacientes (282 no grupo dex e 276 controles). O uso da dex foi considerado fator de proteção para agitação psicomotora (OR = 0,17; 95% IC 0,13-0,23; p < 0,0001) e para náuseas e vômitos na SRPA (OR = 0,49; 95% IC 0,35-0,68; p < 0,0001). Tempo para despertar e para alta da SRPA foram maiores no grupo dexmedetomidina. Não houve diferença entre os grupos para tempo de extubação e duração da anestesia. Conclusão: A dexmedetomidina reduz a agitação psicomotora no despertar de crianças submetidas à anestesia geral com sevoflurano.

Syndrome of inappropriate antidiuretic hormone secretion induced by the phytotherapy Harpagophytum procumbers: case report / Síndrome da secreção inapropriada do hormônio antidiurético induzida pelo fitoterápico Harpagophytum procumbers: relato de caso

Abstract Introduction: The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is the inability of antidiuretic hormone (ADH) suppression, compromising the mechanisms of water excretion and urinary concentration. It manifests as hyponatremia and its symptoms, especially neurological. There are many causes that trigger such disease, notably: central nervous system disorders, malignant neoplasm, drugs and others. Case Report: A 65 years female hypertensive patient presented clinical and laboratory manifestations of hyponatremia due to SIADH. It happened twice under use of herbal medication for osteoarthritis treatment. Discussion: The drug-related hyponatremia can be triggered by direct effect of the drug or by association with SIADH. The clinical manifestations presented could have been related to psychiatric condition and may have severe outcome if not properly diagnosed. The association of an herbal medicine to SIADH could be confirmed after a new episode of hyponatremia related to Harpagophytum procumbers reintroduction. Our literature review did not find this herbal medicine associated with SIADH, so far. Conclusion: SIADH may be caused by herbal medicine described from now on their association in the literature.

Resumo Introdução: A síndrome da secreção inapropriada do hormônio antidiurético (SIADH) consiste na incapacidade de supressão do hormônio antidiurético (ADH), comprometendo os mecanismos de excreção da água e concentração urinária. Possui como manifestações a hiponatremia e seus sintomas, sobretudo neurológicos. Há variadas causas que desencadeiam tal distúrbio, a se destacarem: distúrbios do sistema nervoso central, neoplasias malignas e drogas, dentre outros. Relato de Caso: Paciente feminina, 65 anos, hipertensa, apresentando manifestações clínicas e laboratoriais correspondentes à hiponatremia. O fato ocorreu em duas ocasiões em vigência de medicação fitoterápica para tratamento de osteoartrite. Discussão: A hiponatremia relacionada às drogas pode ser provocada pelo efeito direto do medicamento ou por desencadear SIADH. As manifestações clínicas apresentadas poderiam ter sido atribuídas a um quadro psiquiátrico, o que poderia ter desfecho grave, caso não diagnosticada corretamente. A associação de um fitoterápico à SIADH pôde ser confirmada após novo episódio de hiponatremia relacionado à reintrodução do Harpagophytum procumbers. Nossa revisão da literatura não encontrou este fitoterápico associado à SIADH, até o momento. Conclusão: SIADH pode ser ocasionada por medicamento fitoterápico doravante descrita sua associação na literatura.

Emergências psiquiátricas: manejo de agitação psicomotora e avaliação de risco suicida / Psychiatric emergencies: psychomotor agitation management and suicide risk assessment

O objetivo deste artigo é a apresentação de diretrizes e protocolos de avaliação de condições frequentemente observadas em contexto de emergências psiquiátricas, a saber; manejo de agitação psicomotora e avaliação de risco suicida. As peculiaridades da interação entre serviços de emergências psiquiá- tricas e rede de saúde mental e do diagnóstico diferencial de primeiro episódio psicótico também são brevemente discutidas. Com base em evidências científicas associadas à experiência clínica dos autores, são apresentadas as habilidades e competências necessárias para o manejo de emergências em psiquiatria, com ênfase em técnicas de entrevista psiquiátrica, abordagem atitudinal/comportamental e intervenções farmacológicas. (AU)

The objective of this article is to present guidelines and assessment protocols of frequently observed conditions in the context of psychiatric emergencies, namely, management of agitation and evaluation of suicide risk. The peculiarities of the interaction between psychiatric emergency and mental health services and the differential diagnosis of first-episode psychosis are briefly presented. Based on scientific evidence associated with our clinical experience, we discuss the skills and competencies needed for the management of emergencies in psychiatry, with emphasis on psychiatric interview techniques, attitudinal/ behavioral approach and pharmacological interventions. (AU)