ICL 8.9: Psychopharmacology of Agitation & Behavioral Emergencies

Question 1

what is considered a psychiatric emergency?

Answer 1

1. risk of violence to self
2. risk of violence to others
3. new onset psychosis
4. catatonia

Question 2

what is considered a medical emergency?

Answer 2

1. intoxication
2. overdose
3. agitation
4. serotonin syndrome
5. neuroleptic malignant syndrome (NMS)
6. delirium

Question 3

what is agitation?

Answer 3

an extreme form of arousal that is associated with increased verbal and motor activity

Question 4

wig gets agitated?

Answer 4

1. those with and without mental illnesses
2. those with and without substance use disorders
3. those on and off psychotropic medications
4. those with and without medical comorbidities

Question 5

what is the most important part of the assessment of agitation from most to least important?

Answer 5

1. medical illnesses**
2. medication/substance use related**
3. psychotic disorders
4. mood disorders
5. anxiety disorders
6. personality disorders
7. other psychiatric illnesses
8. situational problems

Question 6

what should you ask about during an HPI for someone with agitation?

Answer 6

1. baseline behaviors
2. baseline mental status
3. medication adherence
4. past and current substance use
5. past and current physical health
6. recent changes: illness, fever, trauma, medication, changes, drug use, symptoms with a focus on neurological and psychiatric symptoms
7. verify prescriptions

the HPI has a sensitivity of 94% in detecting medical illness in psychiatric patients

Question 7

what is the progression of the symptoms of alcohol withdrawal?

Answer 7

MINOR SYMPTOMS

1. anxiety
2. insomnia
3. GI upset
4. headache
5. palpitations
6. anorexia

there can also be alcoholic hallucinosis, withdrawal seizures, or delirium tremens

minor symptoms –> alcoholic halllucinosis(1 day) –> withdrawal seizures (2 days)–> delirium tremens (3 days)

Question 8

what is delirium tremens?

Answer 8

a condition caused by severe alcohol withdrawal

1. agitation
2. hallucinations
3. disorientation
4. tachycardia
5. HTP
6. fever
7. diaphoresis

Question 9

what is serotonin syndrome?

Answer 9

1. akathisia
2. tremors
3. altered mental status
4. clonus
5. muscular hypertonicity
6. hyperthermia

any SSRI or SNRI increases your risk for serotonin syndrome; also antipsychotics can cause this

Question 10

what is a serious side effect of lithium?

Answer 10

renal failure

parathyroid dysfunction

Question 11

what are some of the side effects of clozapine?

Answer 11

1. confusion
2. muscarinic side effects
3. hypotension

Question 12

what happens if you stop venlafaxine?

Answer 12

it’s an SNRI antidepressant that has THE shortest half life!

so if you stop it you’re going to have horrible withdrawal symptoms and you’re going to feel agitated, anxious, panic attacks, emotional lability

you can get all this from missing just one more dose!

Question 13

what is the clinic presentation of someone with PCP intoxication?**

Answer 13

1. aggression
2. vertical nystagmus
3. elevated BP
4. hallucinations

Question 14

what is the clinic presentation of someone with cocaine intoxication?**

Answer 14

1. euphoria
2. paranoia
3. cardiac side effects

Question 15

what is the clinic presentation of someone with hallucinogens intoxication?**

Answer 15

1. pupillary dilation

2. perceptual distortions

Question 16

what is the clinic presentation of someone with methanol intoxication?**

Answer 16

1. visual disturbances
2. ataxia
3. confusion

Question 17

how do you treat BZD, opioid, TCA, B blocker, and anticholinergic substance overdose?

Answer 17

1. benzodiazepine –> flumazenil is the antidote
2. opioids –> naloxone
3. TCA –> sodiumbicarbonate
4. B blocker –> glucagon
5. anticholinergics –> atropine

Question 18

what are the side effects of paroxetine?

Answer 18

paroxetine is THE most anticholinergic of the antidepressants

the threshold for having anticholinergic toxicity symptoms decreases as you get older

venlafaxine is the shortest 1/2 life

Question 19

what are anticholinergic drug toxicities?

Answer 19

blind as a bat = dry eyes, difficulty adjusting visual focus/lens accommodation, sensitivity to bright light due to dilated pupils

mad as a hatter = hallucinations, tremulousness, memory impairment

red as a beet = flushing

hot as a hare = decreased sweating

dry as a bone = dry mouth, difficulty swallowing

the bowel and bladder lose their tone = constipation, urinary retention

the heart runs alone = tachycardia

Question 20

which drugs can cause anticholinergic toxicity?

Answer 20

1. muscarinic antagonists = atropine, scopolamine, hyoscine, benztropine, many plants
2. muscarinic antagonists with other mixed effects = antihistamines, TCAs, antipsychotics
3. decrease ACh release = carbamazepine, opiates, cannabinoids, ethanol, clonidine
4. decreased ACh synthesis = thiamine deficiency

Question 21

what is the antidote and MOA of the antidote for anticholinergic medication overdose?**

Answer 21

physostigmine

acetylcholinesterase inhibitor

Question 22

what is the antidote and MOA of the antidote for benzodiazepine overdose?**

Answer 22

flumazenil

GABA(A) receptor antagonists

so it’s an antidote through competitive inhibition

Question 23

what is the antidote and MOA of the antidote for opiod overdose?**

Answer 23

naloxone

antagonists at the mu opioid receptor

Question 24

what is the antidote and MOA of the antidote for TCA overdose?**

Answer 24

sodium bicarbonate

TCAs cause sodium channel blockade that results in QRS prolongation

sodium bicarbonate causes serum alkalinisation

Question 25

what is the antidote and MOA of the antidote for B-blocker overdose?**

Answer 25

glucagon acts by directly activating adenyl cyclase by a mechanism separate from catecholamines so it bypasses beta blockade it also increases hepatic gluconeogenesis which counteracts the hypoglycemia caused by B 2 blockade

Question 26

what is delirium?

Answer 26

disruption in the neurobiological circuitry of attention in non-dominant parietal and frontal lobes neurotransmitter (acetylcholine, serotonin, NE, GABA, endorphins) mechanisms pro-inflammatory cytokines 30% of older medical pts experience delirium at some point during hospitalization surgical patients & risk of delirium: 10-70% and higher with frail pts (hip fracture, cardiac surgery)

Question 27

how do you manage delirium?

Answer 27

1. continuity of care (nurses, techs, physicians) 2. avoid room changes 3. adhere to routines 4. private or semi private room 5. remove unnecessary equipment or clutter 6. visible clock 7. home management 8. coping skills 9. long term planning 10. dry erase board 11. call patient by preferred name 12. glasses, dentures, hearing aids 13. limit unnecessary awakenings 14. turn lights & TV off at 10pm, and on during the day 15. blinds open/sunlight in, during the day

Question 28

what do you do some someone has agitation with delirium?

Answer 28

1. recognize delirium (hypoactive versus hyperactive) 2. assess its cause 3. treat the cause of delirium 4. treat l difficulties of agitation from delirium keep in mind the pharmacokinetic and pharmacodynamics issues, in addition to drug-drug interactions, QTc (450-500?), renal and hepatic functioning when choosing how to manage agitation with medications

Question 29

which medications can you use to manage delirium?

Answer 29

1. depakote/valproate or valproate acid 2. haldol 3. remeron/mirtazapine (if having trouble sleeping, works on 5HT receptor, can increase appetite) 4. buspar/buspirone 5. clonidine 6. trazodone do schedule medications then additional medications as needed adjust bowel care; make sure they're having normal bowel movements and they're not in pain avoid anticholinergics that can induce even more delirium

Question 30

which drug is useful for literally any kind of agitation?

Answer 30

lorazepam = adavan

Question 31

what is NMS?

Answer 31

NMS = neuroleptic malignant syndrome life threatening reaction that can occur in response to neuroleptic/antipsychotic medication symptoms = high fever, sweating, confusion, rigid muscles, muscle cramps, variable blood pressure, ANS instability, fast heart rate, rhabdomyolysis, high K+, kidney failure, seizures diagnosis is based on symptoms can progress within 3 days differential = heat stroke, malignant hyperthermia, other causes of delirium risk factors = dehydration, agitation, catatonia, rapid adjusting levodopa

Question 32

what are the clinical pearls for acute agitation?*

Answer 32

if appropriate, offer oral medication first after treatment with IM agents: monitor vitals and clinical status at regular intervals allow adequate time for clinical response between doses use lower starting and maximum doses in the elderly (QTc!!!) and child and adolescent population rule-out medical complications as a potential cause of agitation (hyper- or hypoglycemia, electrolyte disturbance, renal or hepatic failure, thyroid or adrenal disorders, Wernicke’s encephalopathy, hypotension, heart failure, neurologic disorders (stroke), meningitis infection (especially in elderly), and dementia) rule-out substance intoxication or withdrawal rule-out medication causes of acute agitation (steroids, anticholinergics, barbiturates, amphetamines, antipsychotic-induced akathisia)

Question 33

what are the really important clinical pearls about agitation?**

Answer 33

1. lorazepam is preferred for undifferentiated agitation (provides muscle relaxation, anxiolytic, anticonvulsant effects, and generalized sedation) 2. haloperidol has a relatively low propensity for sedation and hypotension compared with other IM agents (such as chlorpromazine); however, it does have a higher incidence of EPS 3. the combination of a benzodiazepine and a typical antipsychotic (i.e., haloperidol) has been shown to be superior to monotherapy with either agent and may allow for decreased doses of the antipsychotic medication. The combination can cause excessive sedation