"Unvoluntary" Movement Disorders: Distinguishing between Tics, Akathisia, Restless Legs, and Stereotypies.

Tics, stereotypies, akathisia, and restless legs fall at different places on the spectrum of discrete, unwanted and potentially disabling motor routines. Unlike tremor, chorea, myoclonus, or dystonia, this subgroup of abnormal movements is characterized by the subject's variable ability to inhibit or release undesired motor patterns on demand. Though it may be sometimes clinically challenging, it is crucial to distinguish these "unvoluntary" motor behaviors because secondary causes and management approaches differ substantially. To this end, physicians must consider the degree of repetitiveness of the movements, the existence of volitional control, and the association with sensory symptoms, or cognitive-ideational antecedent. This review aims to summarize the current existing knowledge on phenomenology, diagnosis, and treatment of tics, stereotypies, akathisia, and restless leg syndrome.

Acetaminophen improves tardive akathisia induced by dopamine D2 receptor antagonists.

Tardive akathisia is a movement disorder characterized by internal restlessness with an uncontrollable urge to move, leading to repetitive movements. It is a common side effect of long-term treatment with dopamine D2 receptor antagonists. In the present study, we analyzed the FDA Adverse Event Reporting System and IBM MarketScan Research Database to find a drug that can be used concomitantly with dopamine D2 receptor antagonists and still reduce the risk of akathisia. Acetaminophen was determined to be the most effective akathisia-suppressing drug. In an experimental validation of the hypothesis, chronic treatment of rats with haloperidol caused akathisia symptoms, including increased stereotyped behavior and locomotor activity, and decreased immobility time. Acute treatment with acetaminophen significantly attenuated haloperidol-induced akathisia. In the ventral striata of these rats, acetaminophen prevented haloperidol-induced decrease in the number of c-Fos+ preproenkephalin+ neurons. These results suggest that acetaminophen is effective in suppressing tardive akathisia by activating indirect-pathway medium spiny neurons.

Blood miRNA levels associated with ADHD traits in children across six European birth cohorts.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is a prevalent and highly heritable neurodevelopmental disorder of major societal concern. Diagnosis can be challenging and there are large knowledge gaps regarding its etiology, though studies suggest an interplay of genetic and environmental factors involving epigenetic mechanisms. MicroRNAs (miRNAs) show promise as biomarkers of human pathology and novel therapies, and here we aimed to identify blood miRNAs associated with traits of ADHD as possible biomarker candidates and further explore their biological relevance. METHODS: Our study population consisted of 1126 children (aged 5-12 years, 46% female) from the Human Early Life Exposome study, a study spanning six ongoing population-based European birth cohorts. Expression profiles of miRNAs in whole blood samples were quantified by microarray and tested for association with ADHD-related measures of behavior and neuropsychological functions from questionnaires (Conner's Rating Scale and Child Behavior Checklist) and computer-based tests (the N-back task and Attention Network Test). RESULTS: We identified 29 miRNAs significantly associated (false discovery rate < .05) with the Conner's questionnaire-rated trait hyperactivity, 15 of which have been linked to ADHD in previous studies. Investigation into their biological relevance revealed involvement in several pathways related to neurodevelopment and function, as well as being linked with other neurodevelopmental or psychiatric disorders known to overlap with ADHD both in symptomology, genetic risk, and co-occurrence, such as autism spectrum disorder or schizophrenia. An additional three miRNAs were significantly associated with Conner's-rated inattention. No associations were found with questionnaire-rated total ADHD index or with computer-based tests. CONCLUSIONS: The large overlap of our hyperactivity-associated miRNAs with previous studies on ADHD is intriguing and warrant further investigation. Though this study should be considered explorative and preliminary, these findings contribute towards identifying a set of miRNAs for use as blood-based biomarkers to aid in earlier and easier ADHD diagnosis.

An Exploration of Subgroups of Neuropsychiatric Symptoms in Mild Cognitive Impairment and Their Risks of Conversion to Dementia or Death.

OBJECTIVE: To explore the heterogeneity of neuropsychiatric symptom (NPS) complexes in individuals with mild cognitive impairment (MCI) and assess the relative risks of converting to dementia or dying. DESIGN: Latent class analysis using 7,971 participants with MCI. SETTING: Participants in the Uniform Data Set (UDS) from 39 NIH Alzheimer's Disease Centers. PARTICIPANTS: Persons with a diagnosis of MCI at initial visit from each center and with either a Mini-Mental State Examination (MMSE) score of 22 or greater or an equivalent education-adjusted Montreal Cognitive Assessment (MoCA) score of 16 or greater. MEASUREMENTS: Neuropsychiatric Inventory Questionnaire (NPI-Q) administered at initial visit. RESULTS: In addition to a subgroup with mild or no NPS (relative frequency, 50%), three empirically-based subgroups of NPS were identified: 1) an "affect" or "negative mood" subgroup (27%) with depression, anxiety, apathy, nighttime disturbance, and change in appetite; 2) a "hyperactive" subgroup (14%) with agitation, irritability, and disinhibition; and 3) a "psychotic with additional severe NPS" subgroup (9%) with the highest risk of delusions and hallucinations, as well as highest risk of all other NPS. Each of these three subgroups had significantly higher risk of converting to dementia than the "mild NPS" class, with the "psychotic with additional severe NPS" subgroup possessing a 64% greater risk. The subgroups did not differ in their risks of death without dementia. CONCLUSION: Our findings of three NPS subgroups in MCI characterized by affect, hyperactive, or psychotic features are largely consistent with a previous 3-factor model of NPS found in a demented population. The consistency of these findings across studies and samples, coupled with our results on the associated risks of converting to dementia, suggests that the NPS structure is robust, and warrants further consideration in classification models of MCI.

Neuropsychiatric Symptoms as Predictor of Poor Clinical Outcome in Patients With Vascular Cognitive Impairment.

OBJECTIVE: Examine the association between neuropsychiatric symptoms (NPS) and clinical outcome in memory clinic patients with vascular brain injury. DESIGN/SETTING: TRACE-VCI prospective memory clinic cohort with follow-up (2.1 ± 0.5 years). PARTICIPANTS: Five hundred and seventy-five memory clinic patients with vascular brain injury on MRI (i.e. possible Vascular Cognitive Impairment [VCI]). Severity of cognitive impairment ranged from no objective cognitive impairment to mild cognitive impairment (MCI) and dementia. MEASUREMENTS: We used Neuropsychiatric Inventory (total score and score on hyperactive, psychotic, affective, and apathetic behavior domains) to measure NPS. We assessed the association between NPS and institutionalization, mortality and cognitive deterioration (increase ≥0.5 on Clinical Dementia Rating scale) with Cox proportional hazards models and logistic regression analyses. RESULTS: NPS were present in 89% of all patients, most commonly in the hyperactive and apathetic behavior domain. Across the whole cohort, affective behavior was associated with institutionalization (HR: 1.98 [1.01-3.87]), mainly driven by the dementia subgroup (HR: 2.06 [1.00-4.21]). Apathetic behavior was associated with mortality and cognitive deterioration (HR: 2.07 [1.10-3.90],OR: 1.67 [1.12-2.49], respectively), mainly driven by the MCI subgroup (HR: 4.93 [1.07-22.86],OR: 3.25 [1.46-7.24], respectively). Conversely, hyperactive behavior was related to lower mortality (HR: 0.54 [0.29-0.98]), again particularly driven by the MCI subgroup (HR:0.17 [0.04-0.75]). Psychotic behavior was associated with cognitive deterioration in patients with no objective cognitive impairment (OR: 3.10 [1.09-8.80]) and with institutionalization in MCI (HR: 12.45 [1.28-121.14]). CONCLUSION: NPS are common and have prognostic value in memory clinic patients with possible VCI. This prognostic value depends on the severity of cognitive impairment.

[Neuroleptic malignant syndrome - unexpected complication in a COVID-19 patient].

Neuroleptic malignant syndrome is a life-threatening condition that can be fatal if unrecognized and inadequately treated. This disease is rarely seen in infectious diseases wards. As infectiologists, however, we are confronted with an increasingly broader spectrum of diagnoses and this disease should therefore be considered in any patient taking psychiatric medication who develops the typical symptoms of hyperthermia, rigidity and muscle tremors, autonomic lability and impaired consciousness. A case report is presented of a young man with schizophrenia admitted to the intensive care unit with COVID-19, who was treated with antipsychotics (formerly known as neuroleptics) for restlessness and who developed neuroleptic malignant syndrome. In cooperation with psychiatrists, a targeted therapy was initiated, after which the symptoms subsided and the patient's clinical condition resolved.

Efficacy and Safety of ECT for Behavioral and Psychological Symptoms of Dementia (BPSD): A Retrospective Chart Review.

OBJECTIVE: Much of the functional disturbance in patients with dementia reflects the presence of noncognitive behavioral and psychological symptoms of dementia (BPSD). Agitation is among the most distressing symptoms for patients, clinicians, and caregivers. Currently no pharmacotherapy has clearly been shown to be of value for this condition. This study used a chart review method to examine the safety and efficacy of electroconvulsive therapy (ECT) for patients with dementia receiving ECT for agitation. METHODS: A retrospective chart review was conducted of patients with dementia presenting with symptoms of aggression or agitation and who received ECT treatments. Aggression and agitation were measured by pre- and post-ECT Pittsburg Agitation Scale (PAS) scores. Detailed history of the use of psychotropic medications as well as other clinically relevant variables was analyzed. FINDINGS: Sixty elderly patients (45 women and 15 men, 75% female, mean age 77.5 ± 8.0 years) were included in the analysis. Most patients were treatment resistant to multiple psychotropic medications prior to ECT (mean number 6.1±1.5). The baseline PAS total was 9.3 ± 3.7 and it decreased significantly after three (2.5±2.8) and six (1.5±2.3) ECT treatments. No significant ECT-related medical complications were observed except transient confusion. A decrease in the number of psychotropics prescribed along with an increase in the GAF score was observed after the ECT treatment course. CONCLUSION: ECT was safe in this sample of patients who had co-morbid medical conditions. ECT was associated with the following observations: 1) a reduction in agitation; 2) a reduction in psychotropic polypharmacy; and 3) an improvement in global functioning level. Further research evaluating the effects of ECT in the setting of dementia is warranted.

Neuropsychiatric symptoms and quality of life in Spanish patients with Alzheimer's disease during the COVID-19 lockdown.

BACKGROUND AND PURPOSE: The COVID-19 epidemic is affecting almost all individuals worldwide, and patients with Alzheimer's disease (AD) and amnesic mild cognitive impairment (MCI) are particularly at risk due to their characteristics and age. We analysed the impact of the pandemic on these patients' neuropsychiatric symptoms and their quality of life after 5 weeks of lockdown in Spain. METHODS: A total of 40 patients with a diagnosis of MCI (n = 20) or mild AD (n = 20) from the Cognitive Stimulation Program of the Cognitive Disorders Unit were evaluated. All patients had undergone a previous evaluation during the month before the lockdown, and were re-evaluated after 5 weeks of lockdown. The Neuropsychiatric Inventory (NPI) and EuroQol-5D questionnaire (EQ-5D) were used to assess neuropsychiatric symptoms in patients and the quality of life in patients as well in caregivers. RESULTS: The mean (SD) total baseline NPI score was 33.75 (22.28), compared with 39.05 (27.96) after confinement (P = 0.028). The most frequently affected neuropsychiatric symptoms were apathy [4.15 (3.78) vs. 5.75 (4.02); P = 0.002] and anxiety [3.95 (3.73) vs. 5.30 (4.01); P = 0.006] in patients with MCI, and apathy [2.35 (2.70) vs. 3.75 (3.78); P = 0.036], agitation [0.45 (1.14) vs. 1.50 (2.66); P = 0.029] and aberrant motor behaviour [1.25 (2.86) vs. 2.00 (2.93); P = 0.044] in patients with AD. We did not observe differences in EQ-5D scores during the re-evaluation. The 30% of patients and 40% of caregivers reported a worsening of the patients' health status during confinement. CONCLUSIONS: The results of this study show the worsening of neuropsychiatric symptoms in patients with AD and MCI during 5 weeks of lockdown, with agitation, apathy and aberrant motor activity being the most affected symptoms.

Percutaneous endoscopic gastrostomy: dealing with the issue of dislodgement.

Introduction: Percutaneous Endoscopic Gastrostomy (PEG) is accepted as an efficient method to provide long-term enteral nutrition. PEG accidental dislodgement (device exteriorization confirmed by expert evaluation) rate is high and can lead to major morbidity.Objective: To identify independent risk factors for PEG accidental dislodgement.Methods: Retrospective, single-center study, including consecutive patients submitted to PEG procedure, for 38 consecutive months. Every patient had 12 months minimum follow-up after PEG placement. Univariate analysis selected variables with at least marginal association (p < .15) with the outcome variable, PEG dislodgement, which were included in a logistic regression multivariate model. Discriminative power was assessed using area under curve (AUC) of the receiver operating curve (ROC).Results: We included 164 patients, 67.7% (111) were female, mean age was 81 years. We report 59 (36%) PEG dislodgements, of which 13 (7.9%) corresponded to early dislodgements. The variables with marginal association were hypoalbuminemia (p = .095); living at home (p = .049); living in a nursing home (p = .074); cerebrovascular disease (CVD) (p = .028); weight change of more than 5 kg, either increase or decrease (p = .001); psychomotor agitation (p < .001); distance inner bumper-abdominal wall (p = .034) and irregular appointment follow-up (p = .149). At logistic multivariate regression, the significant variables after model adjustment were CVD OR 4.8 (CI 95% 2.0-11.8), weight change OR 4.7 (CI 95%1.6-13.9) and psychomotor agitation OR 18.5 (CI 95% 5.2-65.6), with excellent discriminative power (AUC ROC 0.797 [CI95% 0.719-0.875]).Conclusion: PEG is a common procedure and accidental dislodgement is a frequent complication. CVD, psychomotor agitation and weight change >5 kg increase the risk of this complication and should be seriously considered when establishing patients' individual care requirements.

Agitation, Oxidative Stress, and Cytokines in Alzheimer Disease: Biomarker Analyses From a Clinical Trial With Nabilone for Agitation.

The endocannabinoid system has been a target of interest for agitation in Alzheimer disease (AD) because of potential behavioral effects and its potential impact on mechanisms implicated in AD such as oxidative stress (OS) and neuroinflammation. We explored whether serum markers of OS and neuroinflammation were associated with response to the cannabinoid nabilone in agitated patients with AD (N = 38). All participants were enrolled in a 14-week, double-blind, cross-over trial comparing nabilone to placebo (6 weeks each) with a 1-week washout between phases. Samples were collected at the start and end of each phase. The cross-sectional relationship agitation (Cohen Mansfield Agitation Inventory) and OS and inflammatory markers were investigated to select markers of interest. Significant markers were then explored for their relationship with response. The OS marker, 4-hydroxynonenal (4-HNE; F1, 35 = 6.41, P = .016), and the proinflammatory cytokine, tumor necrosis factor-α (TNF-α; F1, 29 = 3.97, P = .06), were associated with agitation severity, and TNF-α remained significantly associated (F2, 25 = 3.69, P = .04) after adjustment for cognition. In the placebo phase, lower baseline 4-HNE was associated with decreases in agitation severity only (b = 0.01, P = .01), while lower baseline TNF-α was associated with decreases in agitation severity in the nabilone phase only (b = 1.14, P = .045). Changes in 4-HNE were not associated with changes in agitation severity in either phase. In the nabilone phase, lower baseline TNF-α was associated with decreases in agitation severity (b = 1.14, P = .045), and decreases in TNF-α were associated with decreases in agitation severity (b = 1.12, P = .006). These findings suggest that OS and neuroinflammation may be associated with agitation severity, while nabilone may have anti-inflammatory effects.

A cluster-randomized crossover trial of Montessori activities delivered by family carers to nursing home residents with behavioral and psychological symptoms of dementia.

OBJECTIVES: One-on-one structured Montessori-based activities conducted with people with dementia can improve agitation and enhance engagement. These activities may however not always be implemented by nursing home staff. Family members may present an untapped resource for enabling these activities. This study aimed to evaluate the impact of the Montessori activities implemented by family members on visitation experiences with people who have dementia. DESIGN: Cluster-randomized crossover design. SETTING: General and psychogeriatric nursing homes in the state of Victoria, Australia. PARTICIPANTS: Forty participants (20 residents and 20 carers) were recruited. INTERVENTION: During visits, family members interacted with their relative either through engaging in Montessori-based activities or reading a newspaper (the control condition) for four 30-minute sessions over 2 weeks. MEASUREMENTS: Residents' predominant affect and engagement were rated for each 30-second interval using the Philadelphia Geriatric Center Affect Rating Scale and the Menorah Park Engagement Scale. The Pearlin Mastery Scale was used to rate carers satisfaction with visits. The 15-item Mutuality Scale measured the carers quality of their relationship with the resident. Carers' mood and overall quality of life were measured using the Center for Epidemiological Studies Depression Scale and Carer-QoL questionnaires, respectively. RESULTS: Linear regressions within the generalized estimating equations approach assessed residents' and carers' outcomes. Relative to the control condition, the Montessori condition resulted in more positive engagement (b = 13.0, 95%CI 6.3-19.7, p < 0.001) and affect (b = 0.4, 95%CI 0.2-0.6, p < 0.001) for the residents and higher satisfaction with visits for carers (b = 1.7, 95%CI 0.45-3.00, p = 0.008). No correction was applied to p-values for multiple comparisons. CONCLUSION: This study strengthens the evidence base for the use of the Montessori programs in increasing well-being in nursing home residents. The findings also provide evidence that family members are an additional valuable resource in implementing structured activities such as the Montessori program with residents.

Integrative review: Persistent vocalizations among nursing home residents with dementia.

ABSTRACTBackground:Nursing home (NH) residents with dementia commonly exhibit persistent vocalizations (PVs), otherwise known in the literature as disruptive or problematic vocalizations. Having a better understanding of PVs and the research completed to date on this phenomenon is important to guide further research and clinical practice in NHs. This integrative review examines the current literature on the phenomenon of PVs among NH residents with dementia. METHODS: We conducted a search in the PubMed, Scopus, Ovid Medline, and CINAHL databases for articles published in English. Articles were included if the focus was specifically on research involving vocal behaviors of older adults with dementia residing in NHs. RESULTS: Our literature search revealed eight research articles that met the inclusion criteria. These studies were published in 2011 or earlier and involved small sample sizes. Seven of these studies were descriptive and the eighth was a non-pharmacological intervention study for PVs exhibited by NH residents with dementia. These studies were vastly different in their labeling, definitions, and categorization of the PVs as well as methods of measuring PVs. CONCLUSION: The heterogeneity of the evidence limits the ability to make recommendations for practice. Given the paucity of research on this phenomenon; recommendations for additional research are given.

A systematic review of interventions to facilitate extubation in patients difficult-to-wean due to delirium, agitation, or anxiety and a meta-analysis of the effect of dexmedetomidine.

BACKGROUND: Delirium, agitation, and anxiety may hinder weaning from mechanical ventilation and lead to increased morbidity and healthcare costs. The most appropriate clinical approach to weaning in these contexts remains unclear and challenging to clinicians. The objective of this systematic review was to identify effective and safe interventions to wean patients that are difficult-to-wean from mechanical ventilation due to delirium, agitation, or anxiety. METHODS: A systematic review was performed using MEDLINE, EMBASE, and PubMed. Studies evaluating mechanically ventilated patients deemed difficult-to-wean due to delirium, agitation, or anxiety, and comparing the effects of an intervention with a comparator arm were sought. Time-to-extubation was the primary outcome while the secondary outcome was intensive care unit (ICU) length of stay. RESULTS: From 10,860 studies identified, eight met the inclusion criteria: six studies assessed dexmedetomidine while the remaining two assessed loxapine and biofeedback. Pooled analysis of studies assessing dexmedetomidine showed reduced time-to-extubation (six studies, n = 303) by 10.9 hr compared with controls (95% confidence interval [CI], -15.7 to -6.1; I2 = 68%) and ICU length of stay (four studies, n = 191) by 2.6 days (95% CI, 1.9 to 3.3; I2 = 0%). Nevertheless, the evidence was deemed to be of low quality given the small sample sizes and high heterogeneity. Studies assessing other interventions did not identify improvements compared with controls. Safety assessment was globally poorly reported. CONCLUSIONS: This systematic review and meta-analysis provides low quality evidence to suggest the use of dexmedetomidine in patients deemed difficult-to-wean due to agitation, delirium, or anxiety. Insufficient evidence was found regarding other interventions to provide any recommendation. TRIAL REGISTRATION: PROSPERO (CRD42016042528); registered 15 July, 2016.

RéSUMé: CONTEXTE: Le délirium, l'agitation et l'anxiété peuvent compliquer le sevrage de la ventilation mécanique et aboutir à une augmentation de la morbidité et du coût des soins de santé. L'approche clinique la plus adaptée au sevrage dans ces circonstances n'est pas claire et reste un défi pour les cliniciens. L'objectif de cette étude systématique était d'identifier des interventions efficaces et sécuritaires pour sevrer les patients « difficiles à sevrer ¼ de la ventilation mécanique en raison d'un délirium, d'une agitation ou d'anxiété. MéTHODES: Une revue systématique a été menée en utilisant les bases de données MEDLINE, EMBASE et PubMed. Les études évaluant des patients sous ventilation mécanique jugés difficiles à sevrer en raison d'un délirium, d'une agitation ou d'anxiété, comparant les effets d'une intervention à celle d'un bras comparateur ont été recherchées. Le critère d'évaluation principal a été le délai jusqu'à l'extubation et le critère d'évaluation secondaire a été la durée de séjour en unité de soins intensifs (USI). RéSULTATS: À partir de 10 860 études identifiées, huit satisfaisaient les critères d'inclusion : six études ont évalué la dexmédétomidine tandis que les deux dernières ont évalué la loxapine et le biofeedback. L'analyse groupée des études évaluant la dexmédétomidine a montré une réduction du délai d'extubation (six études, n = 303) de 10,9 heures comparativement aux contrôles (intervalle de confiance [IC] à 95 % : -15,7 à -6,1; I2 = 68 %) et de la durée du séjour en USI (quatre études, n = 191) de 2,6 jours (IC à 95 % : 1,9 à 3,3; I2 = 0 %). Néanmoins, les résultats sont de faible qualité compte tenu de la petite taille des échantillons et d'une grande hétérogénéité. Les études évaluant d'autres interventions n'ont pas identifié d'améliorations par rapport aux contrôles. D'une manière générale, les évaluations de l'innocuité ont été médiocrement décrites. CONCLUSIONS: Cette étude systématique et la méta-analyse procurent une preuve de qualité basse pour suggérer l'utilisation de la dexmédétomidine chez des patients considérés difficiles à sevrer en raison d'un délirium, d'une agitation ou d'anxiété. Les données probantes concernant les autres interventions ont été jugées insuffisantes pour permettre des recommandations quelconques. ENREGISTREMENT DE L'ESSAI CLINIQUE: PROSPERO (CRD42016042528); enregistré le 15 juillet 2016.

Treatment of Behavior Disturbances with Ketamine in a Patient Diagnosed with Major Neurocognitive Disorder.

A 77-year-old woman who had been previously diagnosed with a major neurocognitive disorder became highly agitated and aggressive in a long-term care facility. She did not respond to intramuscular (IM) haloperidol plus lorazepam and had to be transported to the local emergency department (ED). In the ambulance, she remained highly agitated and was given 200 mg IM ketamine. Within minutes of receiving this, she de-escalated dramatically with no apparent adverse effects and remained stable for several days. Although ketamine has been used recently in pre-hospital settings and EDs to reduce agitated behavior, there has been little if any investigation of its potential for reducing behavior disturbances in patients who suffer from major neurocognitive disorders. Ketamine could potentially be a promising treatment option for this population, but more research is needed.

Characterizing the experience of agitation in patients with bipolar disorder and schizophrenia.

BACKGROUND: Agitation is a common manifestation of bipolar disorder and schizophrenia which includes symptoms ranging from inner tension and unease to violence and aggression. Much of the existing literature has focused on agitation in the acute setting, with the patient experience poorly defined. Thus, the aim of this study was to characterize agitation and its management from a patient perspective, with the focus on those who reside in the community. METHODS: Surveys were completed across Germany, Spain and the UK by 583 community dwelling patients with schizophrenia or bipolar disorder who experienced episodes of agitation. Patients were recruited via either their physician or through patient support groups. The survey captured information on demographics, disease characteristics, frequency of agitation episodes and different pre-defined severity levels ranging from mild to severe, symptoms experienced during an episode, awareness of agitation and coping strategies employed by the patient. Statistics were descriptive in nature. RESULTS: The most commonly reported symptoms during an episode of agitation were feeling uneasy (n = 373, 64%), restless (n = 368, 63%) or nervous (n = 368, 63%). Patients experienced an average of 22.4 (SD 57.2) mild, 15.4 (SD 61.2) moderate, 6.8 (SD 63.3) moderate-intense and 2.9 (SD 24.4) severe episodes within the last 12 months; on average 2.7 (SD 6.8) required hospital attendance. Half of patients (n = 313) had attended hospital due to agitation. In total, 71% of patients (n = 412) were aware they were becoming agitated either always or sometimes and 61% of patients (n = 347) were aware of agitation triggers either always or sometimes. The majority of patients reported being able to sometimes control their agitation (56%, n = 329) but 16% (n = 94) stated that there is typically nothing they can do. To cope with episodes 55% (n = 125) of schizophrenia patients and 66% (n = 234) of bipolar disorder patients reported taking prescribed medication. CONCLUSION: Community based patients with schizophrenia and bipolar disorder reported frequently experiencing agitation episodes which they defined most commonly as feeling uneasy, restless or nervous. A range of coping strategies were reported but they were not always successful, highlighting an area of unmet need in this population.

The role of Gabapentin oral solution in decreasing desflurane associated emergence agitation and delirium in children after stabismus surgery, a prospective randomized double-blind study.

BACKGROUND: Short acting inhalational anesthetic (Desflurane) produces emergence agitation (EA) in pediatrics with an incidence up to 80%. The aim of the present study was to examine the role of Gabapentin oral solution in attenuating desflurane associated EA in children after strabismus surgery under general anesthesia. METHODS: Seventy patients, 2-6 years old, scheduled for strabismus surgery were randomly allocated into two groups (35 each); Control group (c): received 5 ml of oral strawberry juice (placebo) and Gabapentin group (G) received 5 mg/Kg gabapentin oral solution in 5 ml strawberry juice, 1 h before anesthesia. Patient separation, cooperation, emergence incidence and emergence severity were assessed. Also time to extubation and time to emergence, duration of PACU stay, PONV and number of patients required meperidine postoperatively were recorded. RESULTS: Duration to extubation and duration to emergence were statistically prolonged in gabapentin group compared to the control group. The incidence of EA and its severity were reduced in gabapentin group with more tendencies to be asleep and less attentive. More patients in the control group required postoperative meperidine to reduce crying and agitation. CONCLUSION: Oral gabapentin 5 mg/kg reduced the incidence and severity scoring of emergence agitation (by 20%) with more tendencies for sleeping with preserved response to stimuli in PACU. TRIAL REGISTRATION: Number: NCT03347916 , date: November 17, 2017, retrospectively.

High-pitch dual-source paranasal sinus CT in agitated patients with maxillofacial trauma: analysis of image quality, motion artifacts, and dose aspects.

Background Image quality benefits from high-pitch scanning in agitated patients by reducing acquisition time. Purpose To compare image quality and exposure parameters in patients with maxillofacial trauma on second- and third-generation dual-source computed tomography (DSCT). Material and Methods Four groups were compared. Group 1 was examined on second-generation DSCT (120 kV/50 mAs, pitch 3.0). The other three groups were examined on third-generation DSCT. Group 2 was scanned with 120 kV/50 mAs, pitch 2.2. Automated exposure control (AEC) was used in group 3 and group 4 with pitch factors of 2.2 and 3.0, respectively. Images of third-generation DSCT were reconstructed with iterative reconstruction (IR), of second-generation DSCT with filtered back-projection. CTDIvol, acquisition time, and image quality were compared. Results Thirty patients were included in each group. Average CTDIvol (2.76 ± 0.00 mGy, 2.66 ± 0.00 mGy, 0.74 ± 0.23 mGy, and 0.75 ± 0.17 mGy) was significantly lower on third-generation DSCT with AEC ( P < 0.001). Subjective image quality was rated worst in group 4 due to strong high-pitch artifacts, while in the remaining three groups it was rated good or very good with good inter-observer agreement (k > 0.64). Average acquisition time was significantly shorter with third-generation DSCT (0.47 s, 0.36 s, 0.38 s, 0.30 s; P < 0.001). Conclusion Third-generation DSCT yields faster acquisition times and substantial dose reduction with AEC. A pitch of 2.2 should be preferred, as it results in fewer artifacts. If AEC is used, latest IR ensures that diagnostic image quality is guaranteed.

[The use and consequences of physical restraint in geriatric care]. / Contention physique en gériatrie, usages et répercussions.

The use of physical restraint with the elderly remains a much-debated topic. Its use remains criticised and is also something of a paradox given its practice in this kind of facilities. All health professionals may use it in their daily practice, in a wide variety of situations.

Co-Occurrence and Predictors of Three Commonly Occurring Behavioral Symptoms in Dementia: Agitation, Aggression, and Rejection of Care.

OBJECTIVE: To investigate co-occurrences of agitation, aggression, and rejection of care in community-dwelling families living with dementia. METHODS: Cross-sectional, secondary analysis from a randomized controlled trial testing a nonpharmacological intervention to reduce behavioral symptoms. We examined frequency of occurrence of presenting behaviors at baseline and their combination. Omnibus tests compared those exhibiting combinations of behaviors on contributory factors. Multinomial logistic regression analyses examined relationships of contributory factors to combinations of behaviors. RESULTS: Of 272 persons with dementia (PwDs), 41 (15%) had agitation alone (Agi), 3 (1%) had aggression alone, 5 (2%) had rejection of care alone. For behavioral combinations, 65 (24%) had agitation and aggression (Agi+Aggr), 35 (13%) had agitation and rejection (Agi+Rej), 1 (0%) had aggression and rejection, and 106 (39%) had all three behaviors (All). Four behavioral subgroups (Agi, Agi+Aggr, Agi+Rej, and All) were examined. Kruskal-Wallis tests showed that there were significant group differences in PwD cognition, functional dependence, and caregiver frustration. PwDs in Agi+Rej and All were more cognitively impaired than those in Agi and Agi+Aggr. Also, caregivers in All were more frustrated than those in Agi. In logistic regression analyses, compared with Agi, greater cognitive impairment was a significant predictor of Agi+Rej and All, but not Agi+Aggr. In contrast, greater caregiver frustration was a significant predictor of Agi+Aggr and All, but not Agi+Rej. CONCLUSIONS: We found that agitation, aggression, and rejection are common but distinct behaviors. Combinations of these behaviors have different relationships with contributory factors, suggesting the need for targeting treatment approaches to clusters.

18F-Fluorodeoxyglucose Positron Emission Tomography Cortical Metabolic Activity Associated with Distinct Agitation Behaviors in Alzheimer Disease.

OBJECTIVE: This study aimed to investigate the neurobiologic correlates of two distinct clusters of agitation symptoms to identify the unique biologic substrates underlying agitated behaviors. METHODS: Eighty-eight outpatients with mild to moderate Alzheimer disease (AD) were recruited from the VA Greater Los Angeles Healthcare System Geropsychiatry Outpatient Program. A cross-sectional investigation was conducted of the relationship between cerebral glucose metabolism measured via 18F-fluorodeoxyglucose positron emission tomography and agitated symptoms from the Neuropsychiatric Inventory (NPI) in patients with AD. Two empirically derived clusters of agitation symptoms were investigated: an Agitation factor comprising agitation/aggression and irritability/lability items of the NPI, and a Behavioral Dyscontrol factor comprising elation/euphoria, disinhibition, aberrant motor behavior, sleep, and appetite items of the NPI. Mean cerebral metabolism for patients who scored positively on each of the two factors was compared with mean cerebral metabolism for those who did not. RESULTS: Patients with AD who scored positively on the Agitation factor showed reduced glucose metabolism of the right temporal, right frontal, and bilateral cingulate cortex. In contrast, the Behavioral Dyscontrol factor did not show specific neurobiologic correlates. CONCLUSION: Symptoms encompassed within the Agitation factor have distinct neurobiologic underpinnings. The precipitants, course, and outcomes related to these symptoms may be unique from other neuropsychiatric symptoms characteristic of AD. Special attention to treatment of agitated behaviors involving anger, aggressiveness, hostility, and irritability/emotional lability is warranted, because they appear to reflect a clinically relevant symptom cluster with unique underlying neurobiologic correlates.