DRUG TREATMENT OF ACUTE BEHAVIOURAL DISTURBANCE

DRUG TREATMENT OF ACUTE BEHAVIOURAL DISTURBANCE IN GENERAL ADULT (18 65YRS) PSYCHIATRIC IN-PATIENTS This algorithm is a good practice guideline developed by multidisciplinary staff in NHS Lothian. You are strongly encouraged to adhere to it, circumstances permitting. This algorithm does not cover the treatment of patients over the age of 65. For these patients please refer to the individual management plan or discuss with the responsible/duty consultant. Preventative skilled management (e.g. de-escalation techniques) is obviously preferable to the use of medication. Medication prescribed in an emergency should be reviewed at least daily to prevent subsequent inappropriate escalation of dose. Continued use of medication after the acute disturbance may require review of Mental Health Act or Consent to Treatment status (T2/T3). Rationale for Choice of Regimens for Algorithm Haloperidol and lorazepam/midazolam is the treatment choice in acute behavioural disturbance and must be considered first line for all patients. This combination of haloperidol and a benzodiazepine is desirable to avoid very high antipsychotic doses when the immediate aim is sedation. Olanzapine is the second treatment choice and may only be considered for: - patients who have had severe dystonic reactions to haloperidol previously - patients with less extreme agitation who are refusing oral therapy but who are showing escalating levels of hostility IM Olanzapine must not be administered with a benzodiazepine. Potential Risks associated with Rapid Tranquillisation Acute hypotension; seizures (caution with antipsychotics in alcohol withdrawal as they lower seizure threshold); cardiovascular complications; respiratory complications; extrapyramidal symptoms, especially acute dystonia; CNS depression; Neuroleptic Malignant Syndrome - a medical emergency - stop antipsychotics and seek advice from Consultant or Specialist Registrar. Flumazenil reverses respiratory depression and sedation caused by benzodiazepines. Treating clinicians should note that as flumazenil has a short half-life as compared to the benzodiazepines, over-sedation and consequent respiratory depression can re-emerge. The SPC for haloperidol recommends a baseline ECG prior to treatment in all patients, especially with a positive personal or family history of cardiac disease or abnormal findings on cardiac clinical examination. It is recognised this may not always be practical in the context of rapid tranquilisation. However each prescriber must make his/her own decisions based on the risk-benefit when prescribing haloperidol. NOTES Resuscitation facilities must be available as per local guidelines. Use the minimum effective doses to achieve tranquillisation. Question aetiology if no response to repeated doses. Consider referring to other guidelines, e.g. Alcohol Detoxification. If patient loses consciousness because of administration of benzodiazepines, monitor as for a full anaesthetic procedure. Give flumazenil if respiratory rate drops below 10 per minute. Flumazenil should be given by IV injection, 200 micrograms over 15 seconds, then 100 micrograms at 60 second intervals if required; usual dose range 300-600 micrograms; maximum total dose 1mg. Procyclidine can be given for acute dystonia by IM injection, 5-10mg repeated if necessary after 20 minutes; maximum 20mg daily; by IV injection, 5mg usually effective after 5 minutes; occasionally 10mg may be needed. PRN oral and IM doses of the same medication should be written separately on the prescription sheet as bioavailability of oral versus IM routes can vary widely. Repeated prn doses may increase total antipsychotic daily dose above BNF maximum. Consider need for monitoring according to High Dose Antipsychotic Guidelines. The IV route of administration for rapid tranquilisation is no longer recommended in inpatient psychiatric setting. There is no evidence of additional benefit from increasing doses of medication. Seek further advice. Consider further non-pharmacological interventions. Consider increasing security. Acute Behavioural Disturbance 2011

GENERAL ADULT (18 65YRS) PSYCHIATRIC IN-PATIENTS ALGORITHM FOR DRUG TREATMENT OF ACUTE BEHAVIOURAL DISTURBANCE NB TO BE USED IN CONJUNCTION WITH THE NOTES OVERLEAF Assess situation fully including collateral history, review of past notes, etc. Try to make a diagnosis; consider concurrent medication, drug misuse, etc. Consider non-drug measures: talking down, distraction and change of environment. Having taken age, weight, cardiac status and previous exposure to antipsychotics into account a decision is made on which treatment route to use following guidance from Consultant and MDT. Try ORAL therapy: FIRST CHOICE OR SECOND CHOICE (Ensure patient meets criteria listed over) HALOPERIDOL 5mg oral AND LORAZEPAM 2mg oral OLANZAPINE 5-10mg oral AFTER 30mins or PATIENT REFUSES (consider medico-legal issues) HALOPERIDOL 5mg IM AND LORAZEPAM 2mg IM OR MIDAZOLAM 2mg IM Do not mix in same syringe Dilute lorazepam with equal volume of water for injection or 0.9% sodium chloride. OLANZAPINE 10mg IM Do not administer with benzodiazepine. 5mg recommended in renal/hepatic impairment. 2.5-5mg recommended in patients over 60 years of age Monitor physical observations every 5-10 minutes as clinical condition warrants Remember maximum doses in 24 hours: Haloperidol 30mg oral OR Haloperidol 18mg IM TOTAL BENZODIAZEPINE 8mg oral/im (ie total Lorazepam + Midazolam 8mg) (maximum 4mg for elderly) AFTER 30mins Repeat the above and wait 30 minutes. May repeat again using IM route 3 times up to maximum doses (if no oral benzodiazepines given within 24 hours). Remember to account for ORAL DOSES. Remember maximum dose in 24 hours: Olanzapine 20mg oral/im AFTER 2 hours Repeat with olanzapine 5-10mg and wait 2 hours. May repeat again using IM route up to maximum of 3 injections in 24 hours. Maximum duration of IM treatment is 3 days. Remember to account for ORAL DOSES. Seek further advice from Consultant or Specialist Registrar. Seek further advice from Consultant or Specialist Registrar. Give ZUCLOPENTHIXOL ACETATE (CLOPIXOL ACUPHASE ), but only to patients with previous exposure to antipsychotics. This should only be used if the patient is likely to refuse to take oral medication and should not be considered as the first option. Dose = 50 150mg by deep IM injection (maximum 100mg for elderly) Sedative effects not apparent for at least 2 hrs. Peak effect at 24 36 hrs, effective for 72 hrs; repeat if necessary after 2 3 days one additional dose may be needed after 24 hours. Acuphase is NOT intended for long term use. Duration of treatment, e.g. a course, should not be greater than 2 weeks. Maximum cumulative dose in this 2-week period is 400mg. However, maximum of 4 injections allowed in 2-week period. Produced: June 2011 Review date: February 2012 Acute Behavioural Disturbance 2011

i Chapter 8 ACUTE DETERIORATION IN THE ELDERLY DELIRIUM Delirium is a medical emergency and needs prompt assessment and treatment. Delirium ( acute confusional state ) is an acute deterioration in cognition, often with altered arousal (drowsiness, stupor, or hyperactivity) and psychotic features (eg. paranoia). The main cognitive deficit in delirium is inattention, eg. the patient is distractable, cannot consistently follow commands, and loses the thread during a conversation. Delirium is different from dementia, where there is a much slower decline in cognition and inattention is much less prominent, but the two conditions commonly co-exist. Delirium affects 1 in 5 of older patients in hospital. It is important because it frequently indicates serious illness NB confusion in the CURB-65 score. The outcome is frequently poor. CAUSES OF DELIRIUM Three main groups: 1. physical and psychological stress: any acute illness, trauma, surgery, etc. 2. drugs: drugs with anticholinergic activity (eg. amitriptyline, oxybutinin), opiates, benzodiazepines, steroids; also drug withdrawal (eg. benzodiazepines, alcohol) 3. metabolic, eg. hyponatraemia, hypercalcaemia, hypoglycaemia Note that a higher number predisposing factors (old age, baseline cognitive impairment, multiple comorbidities) mean that an apparently minor insult, eg. a UTI or a change of drugs, can precipitate delirium. INITIAL ASSESSMENT Delirium should be suspected in any patient with (a) cognitive impairment and/or altered arousal and (b) evidence that the altered mental status is of recent onset (hours, days, weeks). Therefore, to screen for delirium you need to assess cognition and arousal, and seek a third party history regarding the patient s baseline state. Assessment of cognition can be done formally using the Abbreviated Mental Test, and through clinical observation (eg. inability to converse normally, distractibility, inability to follow commands, etc.) Note other features, such as irritability, paranoia, lability of mood, apathy, etc. Agitation is not necessary to make the diagnosis: more than 50% of patients will not show this. Once you have made the diagnosis you need to consider the predisposing and precipitating factors. In older patients delirium may be the presenting feature of acute illness, for example pneumonia, UTI, cholecystitis, etc. Often patients will lack other obvious features of the illness. Thus, initial examination is directed at looking for an acute cause. Do not neglect examination of the nervous system (stroke can cause delirium), joints, and skin. ABBREVIATED MENTAL TEST SCORE (AMT) SCORE OUT OF 10 COMMENTS 1. What is your present age (± 1 year)? 2. What is the time just now (± 1 hour)? 3. What year is it? 4. What is the name of this place? Please memorise this address - 42 West St 5. When is your birthday (date and month)? 6. When did the First World War begin? 7. What is the Queen s name? 8. Can you recognise 2 people? 9. Count backwards from 20 to 1? 10. Can you remember the address I just gave you? INVESTIGATIONS Exclude hypoglycaemia and hypoxia at the bedside. U&Es, Ca LFTs FBC ESR & CRP Troponin Glucose Blood cultures if any evidence of infection ABGs if tachypnoeic, low 0 2 sats (<96%), possibility of C0 2 retention or metabolic acidosis 232 adult medical emergencies handbook NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION 2009/11 adult medical emergencies handbook NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION 2009/11 233

Urinalysis +/- MSU CXR ECG Abdo USS if LFTs deranged eg. to investigate possible cholecystitis Consider CT brain +/- LP if delirium persists without known precipitant. Further investigations should be under the supervision of a specialist. MANAGEMENT Because delirium is usually due an interaction between multiple predisposing factors and precipitating factors, management should be aimed at not just finding and treating the assumed cause, but also optimising all aspects of care: 1. optimise physiology: correct hypoxia and hypoglycemia, treat anaemia, dehydration, hyponatraemia, malnourishment, etc. 2. treat any possible precipitants 3. stop or reduce deliriumogenic drugs (amitriptyline, etc.) consult pharmacist if unsure 4. minimise mental stress provide repeated re-orientation, involve family/carers, and provide care in as quiet and stable an environment as possible (eg. side room) 5. avoid prolonged bedrest: mobilisation can help recovery Management is best carried out on specialist units: transfer to Acute Medicine of the Elderly ward early. Appropriate nursing care can often avoid sedation (quiet, well lit environment). If agitation causes severe distress or immediate danger of injury consider using drug treatment. The first line drug is haloperidol 0.5mg oral or im, at intervals of 20 min 1 hr until agitation is reduced to acceptable levels. If in any doubt contact a senior colleague for advice or seek specialist help. See below for further details ADDITIONAL POINTS Benzodiazepines prolong delirium and may worsen outcome. Do not use unless under specialist supervision, alcohol withdrawal is suspected, or the patient has Parkinson s disease or dementia with Lewy Bodies. Delirium is very common in dying patients treat cause(s) if possible and consider antipsychotics Differentiation between depression, dementia and delirium can be difficult, and where the delirium persists seek specialist advice. ACUTE AGITATED CONFUSION IN AN OLDER PATIENT PRESCRIBING GUIDELINE Look for possible precipitants Metabolic problems - sodium, Is your patient in pain? calcium, hypoxia, hypoglycaemia? Is there infection in chest, urine, Is alcohol withdrawal skin, joints, or meninges? a possibility? Is benzodiazepine withdrawal Is urinary retention a possibility? a possibility? Drugs - be suspicious of all prescribed drugs and check that none have been suddenly stopped. Can you modify the environment? One to one nursing - discuss extra Try to find a quiet, well lit, staff with the directorate manager. side room. Can family stay with the patient for Provide an understanding nurse. some of the time? Is your patient too hot, too cold, or hungry? Drug Treatment N.B. Only use drugs if your patient is at risk of causing harm to themselves or others. If alcohol or benzodiazepine withdrawal is a possibility refer to the alcohol withdrawal guideline. In other cases use: 1. Haloperidol 0.5-1mg orally if possible Wait 20 mins at least 2. If no response 0.5-2mg orally or IM Wait 20 mins at least repeat Haloperidol 3. If no response discuss with a senior member of your team 4. If agitation remains an acute problem discuss with on-call psychiatric staff. (Out of hours contact via REH switchboard on Ext.7600) An alternative to haloperidol in patients in whom this is unsuitable (eg. Parkinson s disease, dementia with Lewy Bodies) is lorazepam 0.5mg orally or im, using same regime as for haloperidol. Use as little as possible: benzodiazepines prolong delirium and may be associated with a worse outcome. REMEMBER This is a general guideline - your patients have individual problems Seek and treat participants Try to modify the environment Give drugs time to work 234 adult medical emergencies handbook NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION 2009/11 adult medical emergencies handbook NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION 2009/11 235

LUHD Medicine of the elderly ACUTE CONFUSIONAL STATE MANAGEMENT See also guideline on delirium at http://www.bgs.org.uk/publications/clinical%20guidelines/clinical_1-2_fulldelirium.htm Look for possible precipitants: Metabolic problems - Na / Ca / hypoxia / hypoglycaemia Infection chest / urine / skin / joints / meninges / other Alcohol or benzodiazepine withdrawal Urinary retention Drugs has anything been started or suddenly withdrawn? Is the patient in pain? If so, why? Can you modify the environment? One to one nursing discuss additional member of staff with nurse manager Can family help by staying with the patient? A quiet, well lit side room may help Is your patient too hot, cold or hungry? Drug treatment: Only use drugs if your patient is at risk of causing harm to herself or others. If alcohol withdrawal is a possibility refer to the alcohol withdrawal protocol If drug treatment essential use Haloperidol 0.5 2mg orally if possible, if not IM WAIT 20 MINS AT LEAST If no response, repeat this treatment WAIT 20 MINS AT LEAST If no response, consider lorazepam 0.5mg orally and discuss with senior If agitation remains a problem discuss with on-call psychiatric staff Out of hours contact Royal Edinburgh switchboard 7600 If patient settles but precipitants remain consider regular maintenance treatment with haloperidol 0.5 2mg orally 8 12 hourly, maximum 5mg in 24 hours. Consider trazodone 50-100mg at night if nocturnal symptoms predominate. This is a general guideline your patients have individual problems Seek and treat precipitants Try to modify the environment Give drugs time to work