Introduction to Agitation, Delirium, and Psychosis
Transcript of Introduction to Agitation, Delirium, and Psychosis
English-haiti
Introduction to Agitation,
Delirium, and Psychosis
Curriculum for nurses
partiCipant manual
IPartners In Health | partiCipant hanDBOOK
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
partners in health (pih) is an independent, non-profit organization founded over twenty years ago in haiti with a mission to provide the very best medical care in places that had none, to accompany patients through their care and treatment and to address the root causes of their illnesses. today, pih works in fourteen countries with a comprehensive approach to breaking the cycle of poverty and disease — through direct health-care delivery as well as community-based interventions in agriculture and nutrition, housing, clean water, and income generation.
pih’s work begins with caring for and treating patients, but it extends far beyond; to the transformation of communities, health systems, and global health policy. pih has built and sustained this integrated approach in the midst of tragedies like the devastating earthquake in haiti. through collaboration with leading medical and academic institutions like harvard medical school and the Brigham & Women’s hospital, pih works to disseminate this model to others. through advocacy efforts aimed at global health funders and policymakers, pih seeks to raise the standard for what is possible in the delivery of health care in the poorest corners of the world.
pih works in haiti, russia, peru, rwanda, sierra leone, liberia, lesotho, malawi, Kazakhstan, mexico and the united states. For more information about pih, please visit www.pih.org.
many pih and Zanmi lasante staff members and external partners contributed to the development of this training. We would like to thank giuseppe raviola, mD, mph; rupinder legha, mD ; père Eddy Eustache, ma; tatiana therosme; Wilder Dubuisson; shin Daimyo, mph; leigh Forbush, mph; Emily Dally, mph; Ketnie aristide, and Jenny lee utech.
this training draws on the following sources: World health Organization, mental Disorders Fact sheet 396, Oct 2014; michelle sherman, support and Family Education: mental health Facts for Families, april 2008, http://www.ouhsc.edu/safeprogram/; World health Organization, mhgap intervention guide (geneva: World health Organization), 2010; american psychiatric association, Diagnostic and statistical manual of mental Disorders (5th ed.) (Washington, DC: american psychiatric association), 2013; Journal of Clinical psychiatry, Consensus development conference on antipsychotic drugs and obesity and diabetes, February 2004; psychiatric times, aims abnormal involuntary movement scale, april 11, 2013, http://www.psychiatrictimes.com/clinical-scales-movement-disorders/clinical-scales-movement-disorders/aims-abnormal-involuntary-movement-scale.
We would like to thank grand Challenges Canada for its financial and technical support of this curriculum and of our broad mental health systems-building in haiti.
© text: partners in health, 2015 photographs: partners in health Design: Katrina noble and partners in health
II Partners In Health | partiCipant hanDBOOK
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
This manual is dedicated to the thousands of health workers whose tireless efforts
make our mission a reality and who are the backbone of our programs to save lives
and improve livelihoods in poor communities. Every day, they work in health centers,
hospitals and visit community members to offer services, education, and support, and
they teach all of us that pragmatic solidarity is the most potent remedy for pandemic
disease, poverty, and despair.
IIIPartners In Health | partiCipant hanDBOOK
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
Table of Contents
Introduction to Agitation, Delirium, and Psychosis
introduction ...........................................................................1
Objectives .............................................................................2
Epidemiology, stigma and the treatment gap ........................3
the psychosis system of Care and the Four pillars of Emergency management of agitation, Delirium and psychosis ........................................................................7
safety and management of agitated patients ......................12
medical Evaluation and management of agitation, Delirium, and psychosis .......................................................15
medication management for agitation, Delirium, and psychosis ......................................................................19
Follow-up and Documentation ............................................24
review ...............................................................................26
notes ..................................................................................31
IV Partners In Health | partiCipant hanDBOOK
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
Annex
psychosis Care pathway ......................................................33
agitation, Delirium and psychosis Checklist ........................34
medical Evaluation protocol for agitation, Delirium, and psychosis ......................................................................35
agitated patient protocol ....................................................37
agitation, Delirium and psychosis Form ..............................38
medication Card for agitation, Delirium and psychosis .......39
Partners In Health | partiCipant hanDBOOK 1
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
Introduction to Agitation, Delirium, and Psychosis
INTRODUCTION
Psychotic disorders refer to a category of severe mental illness that produces a loss of contact
with reality, including distortions of perception, delusions, and hallucinations. The most
common psychotic disorders are schizophrenia and bipolar disorder, which affect a combined 81
million people. Despite the immense burden of illness from psychotic disorders, about 80% of
people living with a mental disorder in low-income countries do not receive treatment.1 Stigma
and discrimination against people living with severe mental illness often result in a lack of
access to health care and social support. Human rights violations such as being tied up, locked
up, or left in inhumane facilities for years are all common.
Before a psychotic disorder can be diagnosed, however, patients require comprehensive medical
evaluation to ensure that medical problems are not the root cause of the symptoms. The term
‘agitated’ is often misused to describe patients who appear psychotic and are, therefore,
immediately referred to mental health. However, oftentimes these patients are actually
suffering from delirium, a state of mental confusion that can resemble a psychotic disorder but
is actually caused by a potentially severe medical illness. Patients who are delirious are often
injected with high doses of haloperidol to quell their ‘agitation,’ and they frequently do not
receive any medical evaluation or care. Unfortunately, this misdiagnosis and mismanagement
can lead to death.
Fortunately, nurses can learn how to safely manage agitated patients and work with other
providers to properly treat patients’ delirium. Zanmi Lasante nurses work side by side with
psychologists, social workers and community health workers to assist in the management and
diagnosis of agitation, delirium and psychosis. Psychotic disorders are treatable and for some,
completely curable. With the right training and system of coordinated care, people with
psychosis can receive effective treatment and lead rich, productive lives.
In this training, participants will learn how to manage agitated patients safely and effectively.
Participants will also learn how to distinguish between delirium and a psychotic disorder
1. World health Organization. (Oct 2014). mental Disorders Fact sheet 396. retrieved from: http://www.who.int/mediacentre/factsheets/fs396/en/
2 Partners In Health | partiCipant hanDBOOK
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
caused by mental illness. Ultimately, participants will learn how to provide high-quality
humane medical and mental health care for agitated, delirious, and psychotic patients.
ObjeCTIves
By the end of this training, you will be able to:
a. Describe the epidemiology of psychotic disorders and the corresponding treatment gap.
b. Describe the various ways that psychosis may be viewed by the community and by health providers.
c. Describe the impact of stigma on patient care and outcomes.
d. Identify key clinical information related to the diagnosis of various psychotic disorders.
e. Develop a basic mental health differential diagnosis using the Differential Diagnosis.
f. Information Sheet.
g. Describe the psychosis care pathway and its collaborative care approach.
h. Outline the main roles of physicians, psychologists, social workers, nurses and community health workers in the system of care related to the identification, treatment and management of agitation, delirium and psychosis.
i. Explain the four pillars of emergency management of agitation, delirium and psychosis.
j. Describe how nurses should use the biopsychosocial model when managing a patient with agitation, delirium or psychosis.
k. Describe the identification, triage, referral, and non-pharmacologic management of an agitated patient through the use of the Agitated Patient Protocol and Agitation, Delirium and Psychosis Form.
l. Define medical delirium.
m. Describe the importance of proper medical evaluation for an agitated, delirious or psychotic patient.
n. Explain how to conduct a medical evaluation of an agitated, delirious or psychotic patient.
o. Describe the use and possible side effects of the primary medications for agitation, delirium, and psychosis.
p. Provide comprehensive psychoeducation messages to a patient and their family around medication management.
q. Explain how to provide follow up for people living with psychotic disorders and severe mental illness, including general psychoeducation messaging.
r. Describe the importance of documentation during patient follow-up.
Partners In Health | partiCipant hanDBOOK 3
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
Epidemiology, the Treatment Gap, and Stigma
Severe Mental Illness
Severe mental illnesses are illnesses of longer duration, longer treatment and have a significant impact on activities of daily living. They include psychosis and mood disorders.
What is psychosis?
Psychosis is a syndrome. A syndrome is defined as the association of several clinically recognizable signs and symptoms which may have multiple causes.
Psychosis results in dysfunction in several domains:
• Cognition (disorganized thinking and speech, memory problems)
• Perception (hallucinations)
• Behavior (social withdrawal, catatonia)
• Emotion (decreased emotion)
There are some psychiatric disorders that mimic psychosis, which can include PTSD, acute stress, intellectual development disorder, and autism spectrum disorder.
schizophrenia
Schizophrenia is characterized by profound disruptions in:
• Thinking, affecting language
• Perception
• The sense of self
It often includes psychotic experiences, such as hearing voices, visual hallucinations or delusions. Patients with schizophrenia often first begin to show symptoms of psychosis when they are teenagers. Prior to developing schizophrenia, patients may show subtle non-specific signs such as depression, social withdrawal, and irritability.
Schizophrenia affects more than 21 million people worldwide. The prevalence ranges from 1 – 7 per 1,000 people. People with schizophrenia have a 20% reduction in life expectancy.2
2. World health Organization. (Oct 2014). mental Disorders Fact sheet 396. retrieved from: http://www.who.int/mediacentre/factsheets/fs396/en/
4 Partners In Health | partiCipant hanDBOOK
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
bipolar Disorder
Bipolar disorder is a mood disorder that can include symptoms of depression, mania and/or psychosis. Manic episodes involve elevated or irritable mood swings, over-activity, pressure of speech, inflated self-esteem, and a decreased need for sleep. Some people with bipolar disorder experience mixed episodes that involve both symptoms of mania and depression at the same time or alternating frequently during the same day. Bipolar disorder usually starts during adolescence and early adulthood.
Bipolar disorder affects about 60 million people worldwide. It is the sixth leading cause of disability in the world. People with bipolar disorder have a reduced life expectancy of 9 – 20 years.3
3. World health Organization. (Oct 2014). mental Disorders Fact sheet 396. retrieved from: http://www.who.int/mediacentre/factsheets/fs396/en/
Partners In Health | partiCipant hanDBOOK 5
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
Treatment Gap
Health systems have not yet adequately responded to the burden of mental disorders. As a consequence, there is a wide gap between the need for treatment and its provision all over the world. In low- and middle-income countries, between 76% and 85% of people with mental disorders receive no treatment for their disorder. In high-income countries, between 35% and 50% of people with mental disorders receive no treatment for their disorder.4
stigma
Stigma refers to negative or prejudicial thoughts about someone based on a particular characteristic or condition, in this case someone with a severe mental illness.
As clinicians, it is not acceptable to have stigmatizing thoughts or behaviors toward people with severe mental illnesses. It the clinicians’ responsibility to overcome these feelings to be able to treat patients with dignity and respect.
4. World health Organization. (Oct 2014). mental Disorders Fact sheet 396. retrieved from: http://www.who.int/mediacentre/factsheets/fs396/en/
Statistics taken from World Health Organization Mental Disorders Fact Sheet #396
81 million + People living with severe mental illness
12 –19 million
People living with severe mental illness who receive treatment
Treatment Gap! 62– 69 million
People living with severe mental illness who receive no treatment
6 Partners In Health | partiCipant hanDBOOK
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
The Zanmi Lasante psychosis system of care aims to diminish Haiti’s treatment gap by safely and effectively treating people living with severe mental illness in a community-based system of care. Nurses have the opportunity to close the treatment gap and reduce the stigma related to psychosis by building on the coherent system of care already developed for depression and epilepsy. Nurses have the opportunity to help some of the most vulnerable and marginalized people living in communities — those living with mental illness.
sTIGmA ROle PlAy
sTORy
a patient is brought by his family to the emergency room. he is very talkative and focuses mainly on vodou and religion. the emergency nurse fears that he is violent and does not wish to touch him because he may be contagious. the nurse does not check vital signs or provide any medical care. instead the nurse calls the psychologist and says “a mental health patient is here.” in the meantime, the patient is totally dehydrated, and has a high fever that goes undetected. his sister reports he has never behaved this way before and only became “a crazy person” after a dog bit him. For more than two hours, the patient and his sister wait and no one comes to them for help.
sCRIPT
Family (Participant 2): Brings in the sick patient to the emergency room. “hello, please help us. my brother is sick.”
Patient (Participant 1): arrives at the emergency room with his sister. Begins to talk a lot about vodou and religion.
Nurse (Participant 3): acts scared because he might be violent. Calls the psychologist: “a mental health patient is here for you.”
Patient (Participant 1): is sitting down now. has a fever and is dehydrated. Does not look well. no longer very talkative.
Family (Participant 2): “Excuse me, nurse? i’m looking for help for my brother. he’s never been like this before. he only became like this after a dog bit him.” looks frustrated that no one helps them. “nurse, please help us.”
Nurse (Participant 3): “i have called the psychologist and i will let you know when he is available to see the patient.”
Partners In Health | partiCipant hanDBOOK 7
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
The Psychosis System of Care and the Four Pillars of Emergency Management of Agitation, Delirium, and Psychosis
The Psychosis System of Care
Nurses’ main roles in the Zanmi Lasante system of care are:
a. to ensure safety for the patient and others;
b. to work with the physician and psychologist/social worker to rule out a treatable medical illness and to prevent further harm;
c. to provide follow-up by educating to patient and families and coordinating care with other providers;
d. to perform monitoring and evaluation of patients.
Nurses are just one important element in the collaborative care approach; to provide quality care they need to work closely with other team members that include psychologists, social workers, physicians and community health workers.
Four Pillars of the emergency management of Agitation, Delirium and Psychosis
There are three types of patients that will come looking psychiatric, although not all of them will have a psychiatric illness:
• Patient is agitated
• Patient has a medical illness
• Patient has a psychiatric illness
Any decision around mental health or a treatment plan should include these four elements, in this order:
1. Safety
a. Determine the risk of suicide
b. Understand the exposure to violence
c. Determine the risk of violence
2. Medical Health
a. You cannot diagnose a mental illness without eliminating all medical causes
b. Take vital signs, perform a physical and neurological exam, lab tests (RPR, HIV, hemogram), in some cases consider a scan
8 Partners In Health | partiCipant hanDBOOK
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
3. Mental Health
a. Plan the assessment and ongoing treatment
b. Psychotherapy, pharmacology
c. Create a safety plan
4. Follow-up
a. Next appointment at the clinic
b. Which providers are involved in the patient’s care (CHW, psychologist/social worker, nurse, physician)?
Each pillar will be informed by the nurse’s use of the biopsychosocial model.
biopsychosocial model
Medical providers need to approach the treatment and management of psychotic disorders and severe mental illness from a biopsychosocial approach, because there are biological, psychological and social factors involved in the development of mental disorders.
A biopsychosocial approach to mental health treatment will:
• Assist with understanding the condition
• Assist with structuring assessment and guiding intervention
• Inform multidisciplinary practices
World health Organization: World mental health report, 2001: p. 20
Biological factors
psychological factors
mental and behavioural
disorders
social factors
Partners In Health | partiCipant hanDBOOK 9
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
bIO PsyCHO sOCIAl
• medical comorbidities
• genetic factors, family history
• medications (sensitivity, medication interactions, side-effects)
• Drug or alcohol use
• temperament
• personality
• Weaknesses
• Defense mechanisms (response to stressful situations)
• past trauma and losses
• support from family and friends
• Education and employment
• religious and spiritual beliefs
• socioeconomic stressors
• Exposure to stigmatization
• Explanatory model, system of beliefs
• Different coping strategies
CAse 1
CAse: biopsychosocial Considerations
a 37-year-old man patient is brought by his family to the emergency room. he is very talkative and shouts about vodou and religion as he runs around the emergency room.
the emergency nurses fear that he is violent and do not wish to touch him because he may be contagious. they do not check his vital signs or provide any medical care. instead they call the psychologist and say “a mental health patient is here.” in the meantime, the patient is totally dehydrated and has a high fever that goes undetected.
his family reports he has never behaved this way before and only became ‘a crazy person’ after a dog bit him two weeks ago. since then he has been unable to work and care for his wife and two children. Other family members have to stay with him, thereby losing daily wages.
10 Partners In Health | partiCipant hanDBOOK
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
thE FOur pillars OF EmErgEnCy managEmEnt OF agitatiOn, DElirium, anD psyChOsis
1. sAFeTy
violence:
• is the patient agitated or violent currently? (use the agitated patient protocol)
• What is the history of violence? When did it happen, how severe was it?
• is the patient being exposed to violence/abuse?
suicide:
• is the patient suicidal currently? actively or passively?
• What is the history of suicide? past attempts with medical severity, past suicidal ideation? When did it happen?
management:
• how is safety being managed? is 1:1 present?
• how is risk being decreased?
2. meDICAl
medical evaluation of Psychosis:
• must do a physical and neurological exam, vital signs, weight, laboratory tests (hemogram, hiV and rpr for all patients; renal and hepatic panels if available; CD 4 count for all hiV patients).
• Consider a Ct scan if the patient has a clear neurological deficit.
Consider Delirium:
• Disturbance of consciousness with reduced ability to focus, sustain or shift attention; change in cognition/development of perceptual disturbance not due to dementia; disturbance develops over a short period of time (hours to days) and fluctuates during the day; evidence from the history, physical exam or lab tests that the disturbance is caused by a medical problem.
• treatment is aimed at underlying medical problem and avoiding diazepam.
Consider epilepsy (Post-Ictal Psychosis):
• the family reports the development of psychosis/agitation after seizures.
• treatment is anti-epileptic.
medication management:
• use the medication card to dose and prescribe.
• provide fluids and do an EKg for all hospitalized/emergency room patients receiving haloperidol.
• Check for medication side-effects; do aims.
• Check vital signs and weight for all patients
Partners In Health | partiCipant hanDBOOK 11
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
3. meNTAl HeAlTH
Diagnosis:
• Work with a psychologist/social worker, use the Differential Diagnosis information sheet.
• reconsider the diagnosis at each visit.
Psychoeducation and support:
• provide education to patients and families regarding psychosis and medication.
medication management:
• use medication Card for agitation, Delirium and psychosis; consider diagnosis.
4. FOllOW-UP
Date of next appointment/visit:
• Follow-up based on acuity; for hospitalized patients, daily or several times a day; for outpatients, can be every 1– 2 days or weekly for more acute patients and every 2 – 4 weeks for stable patients.
• involve community health workers in the care.
12 Partners In Health | partiCipant hanDBOOK
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
Safety and Management of Agitated PatientsSafety is the first pillar when dealing with an agitated, delirious or psychotic patient.
Agitation
Is agitation a disease? Agitation is not a disease, there are many causes:
• Delirium (medical): mental retardation, thyroid abnormalities, dementia, seizures, hypoglycemia, anti-cholinergic intoxication and urinary tract infection, HIV encephalopathy, various states of intoxication and withdrawal
• Psychiatric problems: psychosis, mania, trauma
• Emotional/psychological trauma
Agitation Spectrum
There is a spectrum of agitation and patients can fall anywhere on the spectrum.
Forms to Manage Agitated Patients
The Agitated Patient Protocol will assist clinicians in properly managing different levels of agitation, including reducing the use of physical restraints, and medication.
The Agitation, Delirium, and Psychosis Form assists physicians in recording vital information related to determining if an agitated patient is delirious or psychotic.
When Managing an Agitated Patient: Safety and Talking First!
Often nurses and other health providers are unsure what to do when there is an agitated patient. By talking to the patient, the nurse can evaluate the risk of violence, begin the medical evaluation and calm the patient.
Agitation (mild) Aggression (moderate) violence (severe)
• wringing hands• pacing/moving restlessly• frequent demands• loud, rapid speech• low frustration tolerance
• verbal threats• yelling, cursing• does not respond to
verbal redirection• does not respond to
increased staff presence
• destroying property• making a fist, physically
threatening (e.g. hitting, kicking, biting)
• harming people
Partners In Health | partiCipant hanDBOOK 13
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
How to ensure safety:
• Do not see the patient alone (ask for security). Remain calm. Remember that patients do not suddenly become violent; their behavior occurs along a spectrum.
• Maintain a safe physical distance from the patient. Do not allow the exit to be blocked. Keep large furniture between you and patient.
• Remove all objects that can be used to harm (needles, sharp objects, other small objects). Check whether the patient has a history of violence or substance abuse.
• Talking to the patient is safe and effective. Do not yell. Keep your voice calm, quiet and friendly.
• Make eye contact to show that you care about the patient. Show sympathy and empathy (“I understand that you are scared, but I am here to help. We will not hurt you”).
Intramuscular Medication and Physical Restraint
When should providers give medication intra-muscularly?
From a human rights perspective, you always want the least restrictive approach and should use the fewest interventions necessary. We only give medication intramuscularly to a severely agitated patient who is at risk of imminent self-harm or is harming those around him. We only administer medication intramuscularly when a severely agitated patient refuses oral medication or is unable to comprehend the request to take oral medication. We must remember that administering an intramuscular injection is invasive and can cause physical pain. It can also potentially lead to physical harm towards providers.
In what situations should clinicians use physical restraint?
The goal is to use the least restrictive means necessary. The rights of a person must take priority, in balance with the safety of those around them. Physical restraint can be considered if:
• If calming measures have been tried AND
• The patient has been offered an oral medication and refused AND
• The patient reaches a state of severe agitation where there is a significant worry about harm to self and others AND
• It is felt that all alternatives have been tried
14 Partners In Health | partiCipant hanDBOOK
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
Gathering Information and a Brief Assessment
Physicians should try to obtain as much history about the patient as possible to better inform the management of the patient’s agitation. It is helpful to obtain this information from the patient, if possible, but also from family members or anyone who has accompanied the patient.
• What happened?
• How did this start?
• Has this happened before?
• Has the person suffered from a mental illness in the past?
• Does the person drink a lot of alcohol?
• Has the person been taking medicines lately?
• Has the person had any recent physical illnesses?
Although it would be ideal to obtain information about the agitated patient (whether from the patient or someone else), it is not always possible, depending on the level of agitation.
ROle PlAys
ROle PlAy 1: Agitated Patient
a 55-year-old man is brought to the clinic by concerned neighbors. they report that he has been talking to himself, yelling at people for no reason and making threatening comments. they refer to him as ‘crazy’ and report that he has no friends or family. in the clinic he is disorganized and confused.
ROle PlAy 2: Agitated Patient
a 24-year-old woman is brought to the emergency room by her boyfriend and brother. she is angry, yelling and screaming. her brother has to physically hold her in order to prevent her from lunging at her boyfriend. the brother reports that the patient’s behavior changed several days ago following an argument with her boyfriend in which she accused him of infidelity.
The Risk of Suicide
The identification and triage of patients with suicidal ideation is one of the most important aspects of the clinical history and the evaluation. It is important that each agitated or psychotic-appearing patient with a concern of self-harm is screened for suicidality.
Psychologists/social workers have the responsibility within the system of care to evaluate and properly screen patients for suicidality. The physician, when managing an agitated patient will ask and then record on the Agitated Patient Form if that patient has a history of suicide attempts. If the patient does have a history of suicide attempts, the psychologist/social worker will immediately use the Suicidality Screening Instrument to determine the patient’s level of risk. If a nurse is assessing a patient, and has a concern about a patient’s safety, they should contact the psychologist/social worker immediately so the patient can be properly screened.
Partners In Health | partiCipant hanDBOOK 15
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
Medical Evaluation and the Management of Agitation, Delirium, and PsychosisOnce a clinician has calmed an agitated patient, the physician and psychologist/social worker need to determine if the patient is psychotic or has a medical delirium.
Definition of Agitation, Delirium and Psychosis
Agitation is a symptom to describe behavior. It is not a disease. It is not a mental illness.
Delirium is a medical emergency. It is not a mental illness. It occurs when medical illness results in mental confusion. Delirious patients are confused and off-center and have an increased chance of death. They also have an additional disturbance in cognition (e.g. memory deficit, disorientation, language, visuospatial ability or perception). The disturbance develops over a short period of time (usually hours to a few days) and tends to fluctuate in severity during the course of a day. Delirium is often misdiagnosed as psychosis or other psychiatric illnesses.
There are many causes for delirium including:
• Infections (HIV/AIDS, neurosyphilis, malaria)
• Metabolic disorders (electrolyte disorders, especially hypo/hyperglycemia related to diabetes)
• Drug intoxication/Alcohol withdrawal
• Medications (corticosteriods, cycloserine, phenobarbital, efavirenz, high doses of antihistamines, isoniazid)
• Malnutrition/Vitamin deficiencies
• Brain diseases (dementia, stroke, head injury with bleed)
• Malignancy
• Post-Ictal Psychosis
– Takes place between seizures
– Usually follows a ‘lucid’ interval that lasts from hours to days following a seizure
– Characterized by delusions, hallucinations, and aggressive behavior
– Primary treatment is anti-epileptic medication
• Hypertension
16 Partners In Health | partiCipant hanDBOOK
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
Psychosis is a syndrome. A syndrome is defined as the association of several clinically recognizable signs and symptoms which may have multiple causes. It can be a sign of medical illness or mental illness. It is not always a mental illness! It results in dysfunction in thinking, perception (hallucinations) and behavior (decreased social and professional activity).
Treatment is aimed at a complete medical evaluation and treatment first, then a complete mental health evaluation and treatment, if necessary.
Standard Medical Evaluation for Agitation, Delirium and Psychosis
• History (epilepsy, delirium, substance abuse, medications)
• Vital Signs
• Physical Exam
• Neurological Exam
• Mental Status Exam
• Laboratory Tests (at least CBC, RPR, VIH, CD4 if VIH+)
• Additional Tests (CT Scan, EEG, lumbar puncture)
Partners In Health | partiCipant hanDBOOK 17
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
CAse sTUDy 1
a 45-year-old woman is brought by her family to your health center. she is clearly psychotic, making nonsensical comments about god and other spirits and also yelling. you recognize her as she has been a patient seen in the hiV/aiDs program.
1. After managing her agitation, how would you evaluate her?
you performed a brief assessment and conducted a blood test. you discovered that the patient is hiV positive and the patient’s CD4 count has come back at less than 200.
2. What do you do next?
3. Is this person suffering from medical delirium or a psychotic disorder?
18 Partners In Health | partiCipant hanDBOOK
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
CAse sTUDy 2
a middle-aged man arrives at the health center. his daughter brought him there. he is sweating, disoriented and is anxious. he is mildly agitated and wants to leave the health center. after performing an initial assessment, you find out from his daughter that he drinks alcohol every day (‘a lot’ she reports). the daughter took away all his alcohol and money yesterday because she wants him to stop. you have taken his vital signs, and he has a pulse of 130.
1. What are the signs of alcohol withdrawal you would look for?
2. How would you treat the alcohol withdrawal?
3. Is this person suffering from medical delirium or a psychotic disorder?
Partners In Health | partiCipant hanDBOOK 19
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
Medication Management for Agitation, Delirium, and PsychosisOnce a medical evaluation has been performed, a physician must decide if pharmacological treatment is necessary. Physicians are responsible for prescribing antipsychotics but they must work with psychologists to determine the likely diagnosis. Frequently, the nurse will be assisting the physician administer IM and oral medication.
Prescribing Principles for Agitation, Delirium and Psychosis
The primary tools that can be used to guide prescribing practices are:
• Zanmi Lasante Formulary
• Epilepsy Medication Card
• Agitated Patient Protocol
• Medication Card for Agitation, Delirium, and Psychosis
Haloperidol and risperidone are the primary medications for the management of agitation, delirium, and psychosis. Risperidone has fewer side-effects and should be tried before haloperidol, unless the patient is violent or aggressive and could benefit from the sedation of haloperidol. Begin with a low dose and increase gradually.
Carbamazepine should typically be prescribed before valproate as a long-term mood stabilizer.
Valproate is particularly for patients with long-standing aggression or violence, and should never be prescribed to a pregnant woman (and avoided for women of child-bearing age).
Diazepam is only used in agitated patients and those going through alcohol withdrawal.
Children, the elderly, pregnant and breast-feeding patients are special populations. Please consult with the mental health team before prescribing for them. For suicidal patients, give a small supply of the medication to a family member to prevent possible overdose.
20 Partners In Health | partiCipant hanDBOOK
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
Psychoeducation about Medication
It is incredibly important to speak to patients and their family members in language that they understand, depending on their education level and knowledge. Do not speak to patients and family members in jargon or complex medical language.
Make sure to explain to the patient/family:
• What the medication is for
• How to take the medication properly
• Common side-effects
• Toxic side-effects and when to seek immediate medical care
• How long it takes for medication to work
TIP: To know if the patient/family actually understands the information you are providing about taking the medication, ask the patient/family member to repeat back to you how to take the medication.
Additional information about prescribing principles:
• It is important to take the medication regularly and not miss a dose.
• Do not double up on a dose if a dose is missed.
• It is important to continue to take medication even if symptoms improve.
• Symptoms may worsen if medication is discontinued.
• If any problems of concern develop, contact a member of the treatment team (community health worker, psychologist or physician) by phone, or return to the hospital for evaluation.
Antipsychotics: Side-Effects
Physicians and nurses will need to evaluate and manage antipsychotic medication’s side-effects.
• Akathisia (psychomotor restlessness)
– Tapping of knees
– Difficulty sitting; pacing to alleviate discomfort in knees
– Worsening anxiety or panic
– Difficulty sleeping
• Tardive Dyskinesia (involuntary orofacial movements)
– Unusual facial expressions, such as: lip smacking, puckering or pursing, grimacing, excessive eye blinking
Partners In Health | partiCipant hanDBOOK 21
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
– Rapid, involuntary movements of the lips, torso and fingers
– Cogwheel rigidity of limbs as in Parkinson’s Disease: rigidity in which muscles respond with cogwheel-like jerks when the clinician tries to move the limb
– Rigidity of neck, shoulders and other body parts
• Neuroleptic Malignant Syndrome
– Muscle cramps and rigid muscles (not cogwheel rigidity, but stiffness)
– Tremors
– Fever (hyperpyrexia) to >38 °C (>100.4 °F)
– Autonomic nervous system instability: unstable blood pressure, pulse
– Mental status changes and delirium
– Diaphoresis
Acute dystonia and neuroleptic malignant syndrome are two side-effects that constitute an emergency. Tardive dyskinesia is a possible side-effect of antipsychotic medications, particularly ‘typical’ antipsychotics such as haloperidol. Patients and their families need to know about these side-effects.
lIFe THReATeNING: stop drug immediately and return to health center
COmmON, NOT lIFe -THReATeNING
• Difficulty breathing
• muscle tightness in body
• Difficulty seeing or controlling eyes
• rash
• hot feeling or fever
• Drowsiness
• slowed cognition
• Weight gain
Abnormal Involuntary Movement Scale: Examination and Scoring
The Abnormal Involuntary Movement Scale is a 12-item scale that the clinician administers and scores. The clinician observes the patient and asks questions about involuntary movements due to tardive dyskinesia. If one can catch tardive dyskinesia early, one can intervene.
• Facial and oral
• Extremity
• Truncal
• Patient awareness of movements
The AIMS should be used at the beginning of treatment, and then every six months. It can be done in less than 10 minutes. The clinician tracks the numerical score over time.
22 Partners In Health | partiCipant hanDBOOK
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
meDICATION RevIeW WORksHeeT
Use the Medication Card for Agitation, Delirium, and Psychosis, and the Agitated Patient Protocol.
1. Which three medications on the medication card can Zamni lasante physicians prescribe without consulting the mental Health team?
2. Which two medications on the medication card should NOT be routinely prescribed by Zamni lasante physicians for bipolar disorder or other forms of mental illness?
3. A 63-year-old man arrives in the emergency room. He is violent and out of control, pushing people and running around. He has been brought in by his wife and son, who report he has never behaved this way before. According to the Agitated Patient Protocol Form, which medication should the physician instruct you to give the patient? Give the medication name, dose, and form.
Partners In Health | partiCipant hanDBOOK 23
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
meDICATION RevIeW WORksHeeT (continued)
4. A 25-year-old woman who is six months pregnant is hospitalized for a clot in her leg. she has been psychotic for many years and is currently mildly agitated (she is irritable and does not cooperate with hospital staff, but is not threatening). she refuses to take the anti-coagulant because of her psychosis. Which antipsychotic should the physician prescribe for her?
5. A doctor is working in the emergency room of a local clinic when a father brings his 19-year-old daughter in. she is totally rigid, unable to walk, unable to turn her head, and unable to open her mouth. Her father has to carry her. He reports that she was taken to a psychiatric facility after becoming violent following a breakup with her boyfriend. At the facility, she was given multiple injections. How should you and the physician treat this case? What medication should she be given?
24 Partners In Health | partiCipant hanDBOOK
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
Follow-Up and DocumentationThe Psychosis Care Pathway only works with functional follow-up and documentation.
Patients should be seen for follow-up appointments every one-to-two weeks if their symptoms are acute or if medications are being started, adjusted or stopped. Patients with psychosis whose symptoms are stable can be seen once a month or once every three months.
Once a patient is treated for their agitation or psychosis, the nurse is responsible for educating the patient and family about mental illness and the patient’s next steps in the psychosis care pathway. Because psychoeducation is so important, all Zamni Lasante health providers have a role in delivering psychoeducation.
General Messages to Share with Patients and Families
• A patient’s symptoms can improve with treatment and they can even recover.
• It is important to continue with work, social, and school activities as much as possible.
• The patient has a right to be involved in making decisions about their treatment.
• It is important to exercise, eat healthy, and maintain good personal hygiene.
• Families should not tie up or lock up patients. Instead, bring them to the clinic/hospital or ask the CHW for help/support.
• Prescribing principles:
– It is important to take the medication regularly and not miss a dose.
– Do not double up on a dose if a dose is missed.
– It is important to continue to take medication even if symptoms improve.
– Symptoms may worsen if medication is discontinued.
– If any problems of concern develop, contact a member of the treatment team (community health worker, psychologist or physician) by phone, or return to the hospital for evaluation.
Partners In Health | partiCipant hanDBOOK 25
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
Monitoring Improvement through Coordination with Psychologists
Physicians will need to learn about patient improvement through conversation and interaction with psychologists.
The psychologists will be determining a patient’s improvement through using the Clinical Global Impressions (CGI) Scale and WHODAS 2. The CGI is a tool that psychologists will use to measure symptom severity, treatment response and the efficacy of treatments for a person with a mental disorder. The WHODAS will be used by psychologists to assess a patient’s abilities to perform activities of daily living over the previous 30 days. The WHODAS covers six domains of functioning:
• Cognition – understanding and communicating
• Mobility – moving and getting around
• Self-care – hygiene, dressing, eating and being alone
• Getting along – interacting with other people
• Life activities – domestic responsibilities, leisure, work and school
• Participation – joining in with community activities
26 Partners In Health | partiCipant hanDBOOK
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
CAse sTUDy 1
a 65-year-old woman is brought into the health facility by her two sons. she is barely able to walk and is clearly confused. she is not able to speak easily and she cannot follow simple commands. her sons said that she has been fatigued and feverish for the past few days. the patient is mildly agitated, clearly frustrated with her sons. you are the first to attend to the patient.
1. seeing that the patient is agitated, who would you notify immediately?
2. What would you do to manage the patient’s agitation? What form would you use to guide you?
3. How would you support the physician in evaluating the agitated patient? What forms would you help the physician manage during the medical evaluation?
Review: Case Studies
Partners In Health | partiCipant hanDBOOK 27
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
CAse sTUDy 1 (continued)
you have concluded that the patient probably needs further neurologic testing to determine if the patient has a neurological problem. the patient also has a confirmed fever above 38°C. the two sons said that they are sad that she is now ‘crazy’ and want to know how you can cure her.
4. What would you say to the two sons?
28 Partners In Health | partiCipant hanDBOOK
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
CAse sTUDy 2
a 27-year-old man is brought into the health center by two community health workers. he is yelling that the community health workers are trying to kill him. he lunges at anyone who tries to get close to him, screaming that he will kill everyone.
1. Is this patient agitated? What level of agitation does the patient have?
2. The physician tells you to inject the patient immediately with intramuscular medication. What should you do first before automatically sedating a severely agitated patient?
3. What are some ways you would manage the patient’s behavior and environment? Who would you collaborate with?
Partners In Health | partiCipant hanDBOOK 29
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
CAse sTUDy 2 (continued)
after you speak with the patient, the patient agrees to take some medication and is admitted as an in-patient.
4. How often would you check-in on the patient, and what would you specifically be monitoring?
Once the patient has stabilized, the physician declares the patient able to go home. the patient has been diagnosed by the psychologist/social worker with schizophrenia and has been given medication. the patient will be coming back to the health facility next week to meet with the physician again.
5. Who else should the patient meet with when he comes for his next appointment?
30 Partners In Health | partiCipant hanDBOOK
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
CAse sTUDy 3
During the past year the physician has been seeing a young, 18-year-old woman with who had experienced episodes of psychosis. she was prescribed risperidone. today during her monthly follow up visit, as she waits for her appointment with the psychologist and physician, you notice that she appears restless, frequently wringing her hands.
1. What do you do?
after asking the patient how she is doing and how you can help her, she begins to cry and tells you that things are not going well. she recently broke up with her boyfriend and cannot find a job to support herself.
2. What are some key messages you would give her during this time of stress related to medication and social support?
Partners In Health | partiCipant hanDBOOK 31
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
NOTes
33Partners In Health | partiCipant hanDBOOK | AnnEx
Ps
yC
HO
sIs
CA
Re
PA
TH
WA
y
CA
SE I
DEn
TIFIC
ATI
On
A
nD
REFER
RA
LEV
ALU
ATI
On
, D
IAG
nO
SIS
A
nD
TR
EA
TMEn
T
•m
anag
e ag
itate
d pa
tient
•id
entif
y an
d re
fer
•C
oord
inat
e ca
re
•ps
ycho
educ
atio
n
•m
anag
e ag
itate
d pa
tient
•Ev
alua
tion,
dia
gnos
is,
and
trea
tmen
t
•m
edic
atio
n m
anag
emen
t
•C
oord
inat
ed c
are
with
psy
chol
ogis
t/sW
•ps
ycho
educ
atio
n
•id
entif
y, t
riage
, an
d re
fer
•ps
ycho
educ
atio
n
•Fo
llow
-up
•C
omm
unity
act
iviti
es
•m
anag
e ag
itate
d pa
tient
•Ev
alua
tion,
dia
gnos
is,
and
trea
tmen
t
•C
oord
inat
e ca
re w
ith
phys
icia
n an
d C
hW
•ps
ycho
educ
atio
n
•m
EQ/c
heck
list
REFER
FO
LLO
W-U
P
Nur
sePh
ysic
ian
Psy
chol
ogis
t or
so
cial
Wor
ker
CH
W
COLLABORATE
34 Partners In Health | partiCipant hanDBOOK | AnnEx
AG
ITA
TIO
N,
De
lIR
IUm
AN
D P
sy
CH
Os
Is C
He
Ck
lIs
T
Dat
e __
____
____
____
____
____
____
dd
/mm
/yy
CH
WP
SYC
HO
LO
GIS
T/S
OC
IAL
WO
RK
ER
nU
RS
ES
PH
YS
ICIA
n
AG
ITA
TeD
PA
TIeN
T
q
acc
ompa
ny p
atie
nt t
o em
erge
ncy
room
imm
edia
tely
INIT
IAl
evA
lUA
TIO
N (
ON
Ce
CA
lm)
q
if s
uici
dal/
viol
ent,
acc
ompa
ny
patie
nt a
nd f
amily
to
the
clin
ic
imm
edia
tely
q
Dec
reas
e ris
k an
d re
info
rce
safe
ty
if ris
k fo
r su
icid
e or
vio
lenc
e
q
Com
plet
e th
e in
itial
Vis
it Fo
rm
q
use
the
ZlD
si
q
Do
psyc
hoed
ucat
ion
q
giv
e th
e r
efer
ral F
orm
and
initi
al
Vis
it Fo
rm t
o ps
ycho
logi
st/s
W
FOll
OW
-UP
q
if s
uici
dal/
viol
ent,
acc
ompa
ny
patie
nt a
nd f
amily
to
the
clin
ic
imm
edia
tely
q
Dec
reas
e ris
k an
d re
info
rce
safe
ty
if ris
k fo
r su
icid
e or
vio
lenc
e
q
Doc
umen
t w
ith t
he m
enta
l h
ealth
Fol
low
-up
Form
q
use
the
ZlD
si
q
Do
psyc
hoed
ucat
ion
q
giv
e th
e r
efer
ral F
orm
and
initi
al
Vis
it Fo
rm t
o ps
ycho
logi
st/s
W
q
Do
follo
w-u
p of
pat
ient
in
the
com
mun
ity (
chec
k pa
tient
ad
here
nce,
sid
e ef
fect
s,
enco
urag
e pa
tient
s to
do
fo
llow
-ups
)
AG
ITA
TeD
PA
TIeN
T
q
acc
ompa
ny p
atie
nt t
o em
erge
ncy
room
q
ref
er t
o th
e a
gita
ted
patie
nt p
roto
col;
supp
ort
nurs
e an
d ph
ysic
ian
q
Col
lect
info
rmat
ion
from
pat
ient
and
fam
ily
q
arr
ange
1:1
if n
eede
d
q
rem
ain
at b
edsi
de u
ntil
patie
nt is
sta
ble
q
Follo
w p
atie
nt 2
x/da
y, g
ive
phon
e nu
mbe
r to
pat
ient
’s fa
mily
& n
urse
/phy
sici
an
q
usi
ng a
gita
tion,
Del
irium
and
psy
chos
is C
heck
list,
ens
ure
med
icat
ions
giv
en a
nd
med
ical
car
e pr
ovid
ed b
y nu
rse/
mD
q
giv
e pa
tient
/fam
ily p
sych
oedu
catio
n an
d su
ppor
t
q
ass
ess
& m
anag
e so
cioe
cono
mic
bur
den
of il
lnes
s
q
proc
eed
to in
itial
eva
luat
ion
(onc
e ca
lm)
INIT
IAl
evA
lUA
TIO
N (
ON
Ce
CA
lm)
q
Com
plet
e ps
ycho
sis
Che
cklis
t w
ith C
hW
/nur
se
q
Com
plet
e Zl
Dsi
q
Doc
umen
t in
initi
al m
enta
l hea
lth E
valu
atio
n Fo
rm
q
spea
k w
ith p
atie
nt a
nd t
WO
fam
ily m
embe
rs &
rev
iew
phy
sici
an’s
agi
tate
d pa
tient
For
m t
o co
mpl
ete
initi
al m
enta
l hea
lth e
valu
atio
n
q
Ensu
re v
itals
, wei
ght,
and
labs
are
che
cked
q
acc
ompa
ny p
atie
nt t
o se
e ph
ysic
ian
(see
s al
l psy
chot
ic, s
uici
dal,
viol
ent
case
s)
q
hel
p ph
ysic
ian
follo
w c
heck
list
q
mak
e pr
elim
inar
y di
agno
sis
of d
eliri
um/m
edic
al il
lnes
s or
men
tal i
llnes
s w
ith
the
phys
icia
n
q
if p
atie
nt n
eeds
med
ical
car
e, c
oord
inat
e w
ith p
hysi
cian
s, if
pat
ient
has
ps
ycho
tic d
isor
der,
sche
dule
fol
low
-up
with
in o
ne w
eek
q
Do
psyc
hoed
ucat
ion
and
supp
ort
rela
ted
to m
edic
atio
n an
d ps
ycho
sis
q
Com
plet
e C
gi/
Wh
OD
as,
reg
istr
y, C
heck
list
FOll
OW
-UP
q
use
men
tal h
ealth
Fol
low
-up
Form
q
see
whe
ther
pat
ient
is im
prov
ing
(che
ck m
enta
l sta
tus
exam
, fun
ctio
ning
, pa
tient
and
fam
ily r
epor
t)
q
Che
ck m
edic
atio
n co
mpl
ianc
e, s
ide
effe
cts
q
Ensu
re v
itals
, wei
ght,
and
labs
are
che
cked
q
acc
ompa
ny p
atie
nt t
o se
e ph
ysic
ian;
hel
p ph
ysic
ian
follo
w a
gita
tion,
Del
irium
an
d ps
ycho
sis
Che
cklis
t
q
plan
fol
low
-up
for
1– 2
wee
ks; c
oord
inat
e w
ith C
hW
q
Do
psyc
hoed
ucat
ion
and
supp
ort
for
med
icat
ion
and
psyc
hosi
s
q
Com
plet
e C
gi/
Wh
OD
as,
reg
istr
y, a
gita
tion,
Del
irium
and
psy
chos
is C
heck
list
AG
ITA
TeD
PA
TIeN
T
q
ale
rt e
ither
psy
chol
ogis
t/so
cial
w
orke
r
q
acc
ompa
ny p
atie
nt t
o em
erge
ncy
room
q
ref
er t
o a
gita
ted
patie
nt
prot
ocol
q
man
age
envi
ronm
ent
q
talk
to
patie
nt; s
uppo
rt f
amily
q
Do
vita
l sig
ns a
sap
q
prep
are
oral
and
im m
edic
atio
ns
if ne
eded
q
arr
ange
1:1
if n
eede
d
q
mon
itor
antip
sych
otic
sid
e ef
fect
s, r
epor
t to
phy
sici
an
q
Con
tinue
to
follo
w p
atie
nt c
lose
ly
(at
leas
t ev
ery
15 m
in c
heck
)
q
ass
ist d
octo
r in
med
ical
eva
luat
ion
and
care
(vi
tal s
igns
, lab
tes
ts,
EKg
, flui
ds)
q
prov
ide
psyc
hoed
ucat
ion
and
supp
ort
to p
atie
nt a
nd f
amily
q
Doc
umen
t al
l wor
k in
nur
sing
fo
rms
INIT
IAl
evA
lUA
TIO
N (
ON
Ce
CA
lm)
q
Det
erm
ine
whe
ther
pat
ient
may
be
psy
chot
ic
q
acc
ompa
ny p
atie
nt t
o se
e ps
ycho
logi
st/s
W; s
uppo
rt
colla
bora
tion
with
phy
sici
an
q
if p
sych
osis
is d
iagn
osed
, pro
vide
ps
ycho
educ
atio
n an
d su
ppor
t
q
Befo
re d
isch
arge
, ens
ure
the
patie
nt h
as a
fol
low
-up
appt
with
ps
ycho
logi
st/s
W
FOll
OW
-UP
q
Do
vita
l sig
ns, w
eigh
t at
eac
h vi
sit
q
Che
ck la
bs w
hen
nece
ssar
y
q
Doc
umen
t in
men
tal h
ealth
Fo
llow
-up
Form
AG
ITA
TeD
PA
TIeN
T
q
ale
rt e
ither
psy
chol
ogis
t/so
cial
wor
ker
q
Follo
w a
gita
ted
patie
nt p
roto
col t
o de
term
ine
leve
l of
agita
tion
and
to p
resc
ribe
med
icat
ion
if ne
cess
ary
q
Con
tinue
med
ical
eva
luat
ion:
phy
sica
l/ne
uro
exam
, vita
l sig
ns, l
ab t
ests
q
use
med
icat
ion
Car
d to
mon
itor
antip
sych
otic
si
de e
ffec
ts (
cons
ider
EK
g, fl
uids
)
q
Doc
umen
t in
agi
tate
d pa
tient
For
m
INIT
IAl
evA
lUA
TIO
N (
ON
Ce
CA
lm)
q
rev
iew
initi
al m
enta
l hea
lth E
valu
atio
n
Form
with
psy
chol
ogis
t/sW
to
diag
nose
de
liriu
m/m
edic
al il
lnes
s or
men
tal d
isor
der
q
Do
com
plet
e m
edic
al e
valu
atio
n: v
ital s
igns
, ph
ysic
al/n
euro
exa
m, l
ab t
ests
. use
med
ical
Ev
alua
tion
prot
ocol
for
agi
tatio
n, D
eliri
um
and
psyc
hosi
s
q
if p
atie
nt h
as a
psy
chot
ic d
isor
der
or d
eliri
um,
use
med
icat
ion
Car
d to
dos
e
q
Do
base
line
aim
s ex
am
q
Doc
umen
t ev
eryt
hing
in in
itial
men
tal h
ealth
Ev
alua
tion
Form
q
prov
ide
med
icat
ion
to la
st u
ntil
next
app
t
q
Do
psyc
hoed
ucat
ion
abou
t m
edic
atio
n
q
plan
fol
low
-up
with
psy
chol
ogis
t/sW
FOll
OW
-UP
q
rev
iew
the
men
tal h
ealth
Fol
low
-up
Form
with
ps
ycho
logi
st/s
W t
o se
e if
patie
nt is
impr
ovin
g
q
Do
phys
ical
/neu
ro e
xam
q
Che
ck w
eigh
t/vi
tals
eac
h vi
sit;
lab
test
s an
d a
ims
ever
y 6
mon
ths
q
use
med
icat
ion
Car
d to
che
ck f
or s
ide
effe
cts
and
to a
djus
t do
se a
s ne
eded
q
prov
ide
med
icat
ion
to la
st u
ntil
next
app
t
q
Dis
cuss
dis
cont
inua
tion
of a
ntip
sych
otic
with
m
enta
l hea
lth t
eam
q
Doc
umen
t pr
oper
ly in
men
tal h
ealth
Fo
llow
-up
Form
q
Do
psyc
hoed
ucat
ion
abou
t m
edic
atio
n
q
plan
fol
low
-up
with
psy
chol
ogis
t/sW
P
35Partners In Health | partiCipant hanDBOOK | AnnEx
1
me
DIC
Al
ev
Al
UA
TIO
N P
RO
TO
CO
ls
FO
R A
GIT
AT
ION
, D
el
IRIU
m A
ND
Ps
yC
HO
sIs
sU
mm
AR
y
Pr
OT
OC
Ol
iN
A C
liN
iC/H
OS
PiT
Al
Se
TT
iNg
sTeP
1a:
Is P
erso
n A
gita
ted?
Pati
ent
is c
onsi
dere
d ag
itat
ed if
the
y ar
e an
y of
the
follo
win
g:
•V
iole
nt, a
ggre
ssiv
e
•ye
lling
, thr
eate
ning
•m
anic
, del
usio
nal (
has
untr
ue, fi
xed
belie
fs)
•h
allu
cina
ting
•a
cute
ly p
aran
oid
•W
ringi
ng o
f ha
nds,
pac
ing,
tap
ping
han
d
•r
apid
spe
ech,
rai
sing
voi
ce
•Fr
eque
nt r
eque
sts,
low
fru
stra
tion
tole
ranc
e
sTeP
1b:
Det
erm
ine
leve
l of
Agi
tati
on a
nd m
anag
e•
Ref
er t
o A
gita
ted
Pati
ent
Prot
ocol
to
guid
e ag
itat
ion
man
agem
ent
depe
ndin
g on
sym
ptom
s an
d se
veri
ty
•u
se c
alm
voi
ce
•g
ive
verb
al s
uppo
rt
•D
ecre
ase
stim
uli
•a
sk, “
how
can
i he
lp?”
•a
lert
sta
ff
•K
eep
your
self
safe
•u
se W
hO
mhg
ap
(p.7
4) f
or s
elf-
har
m/s
uici
de a
sses
smen
t
if ne
cess
ary
box
1: s
tand
ard
med
ical
eva
luat
ion
for
Agi
tati
on/D
elir
ium
/Psy
chos
is
•Br
ief
his
tory
–m
edic
al h
isto
ry
–a
lcoh
ol/s
ubst
ance
abu
se
–C
urre
nt m
edic
atio
ns
–h
isto
ry o
f m
enta
l illn
ess
•V
ital s
igns
, phy
sica
l exa
m
•n
euro
logi
cal E
xam
•m
enta
l sta
tus
Exam
–O
rient
atio
n
–a
lert
ness
–C
onfu
sion
box
2: D
elir
ium
1. D
istu
rban
ce o
f co
nsci
ousn
ess;
red
uced
abili
ty t
o fo
cus,
sus
tain
or
shift
att
entio
n.
2. a
cha
nge
in c
ogni
tion
or t
he d
evel
opm
ent
of a
per
cept
ual d
istu
rban
ce (
hallu
cina
tions
)
that
is n
ot d
ue t
o a
pree
xist
ing,
est
ablis
hed
or e
volv
ing
dem
entia
.
3. t
he d
istu
rban
ce d
evel
ops
over
a s
hort
perio
d of
tim
e (u
sual
ly h
ours
to
days
) an
d
fluct
uate
s du
ring
the
day
4. t
here
is e
vide
nce
from
the
his
tory
, phy
sica
l
exam
inat
ion
or la
bora
tory
find
ings
tha
t
the
dist
urba
nce
is c
ause
d by
the
dire
ct
phys
iolo
gica
l con
sequ
ence
s of
a g
ener
al
med
ical
con
diti
on.
NO
THeN
yes
sTeP
2: P
erfo
rm m
edic
al A
sses
smen
t (s
ee b
ox 1
, ReF
eR t
o an
d R
eCO
RD
info
rmat
ion
on A
gita
ted
Pati
ent
Form
, inc
ludi
ng):
•sa
fety
: tal
k fir
st, d
o no
t m
edic
ate
first
•m
edic
al H
ealt
h: t
ake
vita
l sig
ns, p
hysi
cal e
xam
, men
tal s
tatu
s ex
am t
o as
sess
for
del
irium
•m
enta
l Hea
lth:
tak
e hi
stor
y
•Fo
llow
-Up:
con
tact
psy
chol
ogis
t
•C
ontin
ue e
valu
atio
n an
d tr
eatm
ent
of u
nder
lyin
g
med
ical
con
ditio
n.
•C
onsi
der
low
-dos
e an
tipsy
chot
ic f
or d
eliri
um
(see
med
icat
ion
card
)
•C
onsu
lt m
enta
l hea
lth t
eam
/psy
chol
ogis
t
abn
orm
al m
enta
l sta
tus
exam
or
mee
ts c
riter
ia f
or
delir
ium
(se
e b
ox 2
)
see
Page
2 f
or c
onti
nuat
ion
of m
edic
al A
sses
smen
t
yes
NO
36 Partners In Health | partiCipant hanDBOOK | AnnEx
2
med
ical
eva
luat
ion
Prot
ocol
s fo
r A
gita
tion
, Del
iriu
m a
nd P
sych
osis
sum
mar
y (c
onti
nued
)
•tr
eat
alco
hol w
ithdr
awal
with
10
mg
iV/i
m
diaz
epam
, rep
eat
afte
r 15
min
s as
nee
ded
until
res
pons
e, t
hen
repe
at in
6 h
ours
.
•m
onito
r re
spira
tory
rat
e to
avo
id o
verd
ose
•m
alar
ia s
mea
r an
d co
nsid
er e
mpi
ric
trea
tmen
t fo
r m
alar
ia
•lu
mba
r pu
nctu
re a
nd c
onsi
der
empi
ric r
x
with
app
ropr
iate
ant
ibio
tic m
edic
atio
n
Con
side
r C
T be
fore
lP
if a
sym
met
ric
pupi
ls o
r
abno
rmal
ext
ra-o
cula
r m
ovem
ent
or g
ait.
•lp
, as
abov
e
•C
onsi
der
empi
ric r
x w
ith a
ppro
pria
te
antib
iotic
med
icat
ion
Con
side
r tr
eatm
ent
for
toxo
plam
osis
or c
ryto
cocc
us.
•C
onsi
der
addi
tiona
l tes
ts: r
enal
pan
el, l
iver
pane
l, ch
est
x-ra
y
•tr
eat
acco
rdin
gly
trea
t fo
r ne
uros
yphi
lis w
ith p
enic
illin
•Fu
rthe
r ne
urol
ogic
al t
estin
g (s
ee b
ox 3
)
•C
onsi
der
Ct,
EEg
, or
lp
•C
onsu
lt w
ith s
peci
alis
ta
bnor
mal
neu
rolo
gic
exam
rec
ent
onse
t an
d
tem
pera
ture
> 3
8 C
hiV
+ w
ith C
D4
coun
t <
200
posi
tive
rpr
abn
l glu
cose
, ele
ctro
lyte
s,
or o
ther
evi
denc
e of
med
ical
illn
ess
(see
box
4)
ris
k fa
ctor
s fo
r dr
ug o
r
alco
hol w
ithdr
awal
or
into
xica
tion?
(se
e b
ox 5
)
Con
side
r a
prim
ary
psyc
hotic
dis
orde
r
Perf
orm
men
tal H
ealt
h A
sses
smen
t
and
Con
sult
men
tal H
ealt
h Te
am
On
med
icat
ion
caus
ing
psyc
hosi
s? (
see
box
6)
Det
erm
ine
whe
ther
his
tory
of
psyc
hosi
s an
d m
edic
atio
n us
e co
inci
de.
Con
side
r di
scon
tinui
ng m
edic
atio
n.
yes yes
yes
yes
yes
yes
yes
yes
THeN
THeN
box
4: C
omm
on s
yste
mic
Con
diti
ons
that
can
Cau
se/C
ontr
ibut
e to
Psy
chos
is
•m
alar
ia
•El
ectr
olyt
e ab
norm
aliti
es (
sodi
um, c
alci
um)
•m
alnu
triti
on, t
hiam
ine
defic
ienc
y
•th
yroi
d di
seas
e
•a
lcoh
ol w
ithdr
awal
•h
ypox
ia
box
6: m
edic
atio
ns t
hat
can
Cau
se/C
ontr
ibut
e
to P
sych
osis
•C
ortic
oste
riods
•C
yclo
serin
e
•is
onia
zid,
Efa
vire
nz
•C
ortic
oste
roid
s
•ph
enob
arbi
tal
•h
igh
dose
s of
ant
i-ch
olin
ergi
c m
edic
atio
n
box
3: N
euro
logi
cal C
ondi
tion
s th
at C
ause
or
Con
trib
ute
to P
sych
osis
•te
rtia
ry s
yphi
lis
•En
ceph
ilitis
•D
emen
tia (
hiV
, alz
heim
ers)
•pa
rkin
sons
•Br
ain
tum
ors
or o
ther
mas
s le
sion
s (t
B,
lym
phom
a, t
oxop
lasm
osis
)
box
5: A
lcoh
ol W
ithd
raw
al
•h
isto
ry o
f he
avy
alco
hol u
se (
last
drin
k
24 –
28
hour
s pr
ior
to s
ympt
oms)
•se
vere
alc
ohol
with
draw
al:
–W
ithin
a f
ew h
ours
: with
draw
al
trem
ors,
nau
sea,
vom
iting
, sw
eatin
g,
anxi
ety
–W
ithin
a f
ew d
ays:
hal
luci
natio
ns,
seiz
ures
, fev
er, d
isor
ient
atio
n,
hype
rten
sion
Con
tinu
atio
n of
med
ical
Ass
essm
ent
NO
NO
NO
NO
NO
NO
NO
37Partners In Health | partiCipant hanDBOOK | AnnEx
AG
ITA
Te
D P
AT
IeN
T P
RO
TO
CO
l
THR
OU
GH
OU
T v
IsIT
: Ass
essm
ent
•R
eFeR
to
Med
ical
eva
luat
ion
Prot
ocol
s
for
Agi
tati
on, D
elir
ium
and
Psy
chos
is
•R
eCO
RD
on
Agi
tati
on, D
elir
ium
and
Psyc
hosi
s Fo
rm
sAFe
Ty F
IRsT
!
•D
o no
t se
e th
e pa
tient
alo
ne
(ask
for
sec
urity
). r
emai
n
calm
. rem
embe
r th
at p
atie
nts
do n
ot s
udde
nly
beco
me
viol
ent;
the
ir be
havi
or o
ccur
s
alon
g a
spec
trum
.
•m
aint
ain
safe
phy
sica
l dis
tanc
e
from
pat
ient
. Do
not
allo
w
exit
to b
e bl
ocke
d. K
eep
larg
e
furn
iture
bet
wee
n yo
u an
d
patie
nt.
•r
emov
e al
l obj
ects
tha
t ca
n
be u
sed
to h
arm
(ne
edle
s,
shar
p ob
ject
s, o
ther
sm
all
obje
cts)
. Che
ck w
heth
er
patie
nt h
as a
his
tory
of
viol
ence
or
subs
tanc
e ab
use.
•ta
lkin
g to
pat
ient
is s
afe
and
effe
ctiv
e. D
o no
t ye
ll. K
eep
your
voi
ce c
alm
, qui
et, a
nd
frie
ndly
.
•m
ake
eye
cont
act
to s
how
you
care
abo
ut t
he p
atie
nt.
show
sym
path
y an
d em
path
y
(“i u
nder
stan
d yo
u ar
e sc
ared
,
but
i am
her
e to
hel
p. i
will
not
hurt
you
.”)
sTeP
1:
Det
erm
ine
leve
l of
agi
tati
on b
y ob
serv
ing
pati
ent
beha
vior
sTeP
2:
man
age
agit
atio
n
Rem
embe
r:
•sa
fety
: tal
k fir
st, d
o no
t m
edic
ate
first
•m
edic
al H
ealt
h: v
ital s
igns
, phy
sica
l exa
m,
men
tal s
tatu
s, e
xam
to
asse
ss f
or d
eliri
um, l
abs
and
stud
ies
•m
enta
l Hea
lth:
tak
e hi
stor
y
•Fo
llow
-Up:
con
tact
psy
chol
ogis
t/so
cial
wor
ker
mIl
D A
gita
tion
q
wrin
ging
/tap
ping
of
hand
s
q
paci
ng, m
ovin
g re
stle
ssly
q
freq
uent
req
uest
s/de
man
ds
q
loud
or
rapi
d sp
eech
q
low
fru
stra
tion
tole
ranc
e
1. m
anag
e b
ehav
ior/
envi
ronm
ent
q
use
cal
m v
oice
, sim
ple
lang
uage
,
soft
voi
ce, s
low
mov
emen
ts
q
ask
“h
ow c
an i
help
?” a
nd
prob
lem
sol
ve w
ith p
atie
nt;
be e
mpa
thic
q
rem
ove
pote
ntia
lly h
arm
ful
obje
cts
from
are
a
q
ask
abo
ut h
unge
r/th
irst
q
Dec
reas
e st
imul
atio
n/ar
rang
e 1:
1
q
Off
er v
erba
l sup
port
and
unde
rsta
ndin
g
q
allo
w t
he p
atie
nt t
o sh
ow
ange
r/fr
ustr
atio
n
q
Cal
m s
taff
q
if a
gita
tion
due
to d
eliri
um,
cons
ider
hal
dol 1
– 2
mg
pO;
not
in e
lder
ly
1. m
anag
e b
ehav
ior/
envi
ronm
ent
2. C
onsi
der
OR
Al
med
icat
ions
q
Off
er p
O m
edic
atio
ns fi
rst
if
(hal
dol 5
mg
+ d
iphe
nhyd
ram
ine
50 m
g O
r D
iaze
pam
10
mg)
q
if p
atie
nt r
efus
es p
O, g
ive
im
med
icat
ions
(h
aldo
l 5 m
g +
diph
enhy
dram
ine
25 m
g O
r
Dia
zepa
m 1
0 m
g)
q
Wai
t 30
min
utes
; if
patie
nt
rem
ains
agi
tate
d, c
an g
ive
½ t
he
orig
inal
dos
e
q
use
med
icat
ion
Car
d to
mon
itor
side
eff
ects
1. m
anag
e b
ehav
ior/
envi
ronm
ent
2. C
onsi
der
OR
Al
med
icat
ions
3. C
onsi
der
INTR
Am
UsC
UlA
R
med
icat
ions
q
hal
dol 5
–10
mg
im +
diph
enhy
dram
ine
25 m
g im
Or
dia
zepa
m 1
0 m
g im
q
Wai
t 30
min
utes
; if
patie
nt
rem
ains
agi
tate
d, c
an r
e-do
se
with
½ t
he o
rigin
al d
ose
q
use
med
icat
ion
Car
d to
mon
itor
side
eff
ects
q
Deb
rief
with
sta
ff
q
Con
sult
men
tal h
ealth
tea
m if
etio
logy
is p
sych
iatr
ic
mO
DeR
ATe
Agi
tati
on q
verb
al t
hrea
ts
q
yelli
ng/c
ursi
ng
q
does
not
res
pond
to
verb
al
redi
rect
ion
q
does
not
res
pond
to
incr
ease
d
staf
f pr
esen
ce
sev
eRe
Agi
tati
on q
dest
royi
ng p
rope
rty
q
phys
ical
agg
ress
ion
(e.g
.,
hitt
ing,
kic
king
, biti
ng)
q
self-
inju
rious
beh
avio
r (e
.g.,
bitin
g ha
nd, h
ead
bang
ing)
38 Partners In Health | partiCipant hanDBOOK | AnnEx
AGITATION, Del IR IUm AND PsyCHOsIs FORm
1. sAFeTy (Use AGITATeD PATIeNT PROTOCOl)
Patient is: q not agitated (But appears psychotic) q agitated (mild) q aggressive (moderate) q Violent (severe)
History of violence: q no q yes: Describe violent behavior ________________________________________________________________ When did it take place:__________________________________________________________________
q manage Behavior/Environment Completed Does patient need a 1:1? q no q yes:___________
2. meDICAl HeAlTH (Use meDICAl evAlUATION PROTOCOl)
Vital signs: temp:______ pulse:______ Bp:______ rr:______ O2:______ Weight:______
Physical exam Neurological exam
hEEnt: q normal q abnormal:___________ Cranial nerves: q normal q abnormal:___________
Cardiac: q normal q abnormal:___________ motor strength: q normal q abnormal:___________
pulmonary: q normal q abnormal:___________ sensory: q normal q abnormal:___________
abdominal: q normal q abnormal:___________ reflexes: q normal q abnormal:___________
skin/Extremities: q normal q abnormal:___________ gait/Coordination: q normal q abnormal:___________
mental status exam laboratory Tests Ordered
q alert q sleepy q unable to arouse q hemogram q CD4 q hepatic panel
thought process: q normal q Confused:___________ q rpr q tB q renal panel
Can Follow simple Commands: q no q yes q hiV q urinalysis q malaria
hallucinations: q no q yes:__________ Family History of mental Illness: q no q yes
Orientation: person q no q yes medical History: q hiV/aiDs (CD4:_____) q tB
place q no q yes q htn q head injury (with loss of consciousness)
time/Date q no q yes q Epilepsy q Dementia q Other:___________
Friend/Family member q no q yes Alcohol Use: q no q yes: q Daily?
Current medications (names and doses):___________________________ Drug Use: q no q yes:___________
Delirium
q Disturbance of consciousness with reduced ability to focus, sustain or shift attention.
q a change in cognition or the development of a perceptual disturbance (hallucinations) that is not better accounted for by a preexisting, established or evolving dementia.
q the disturbance develops over a short period of time (usually hours to days) and fluctuates during the day
q there is evidence from the history, physical examination or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition.
q no q yes (Patient must meet all four criteria above to make diagnosis)
3. meNTAl HeAlTH
History of mental illness: q no q yes:___________________________________________________________________________________
Has the patient gone to m&k/beudet/other psych facility? q no q yes:_____________________________
Is this the first episode of agitation? q no q yes:_______________ History of suicide attempt: q no q yes:__________________
Post-Ictal Psychosis: q no q yes (episodes of agitation/psychosis only take place after epileptic seizure)Antipsychotic medication (Use Agitated Patient Protocol; give dose and indicate whether PO/Im):
q risperidone:_______________ q haloperidol:_______________ q Other: Diphenhydramine:_______________
4. FOllOWUP
q psychologist contacted about patient
presumed Etiology of agitation/psychosis: q medical problem/Delirium: _______________ q mental health problem:_______________
has haloperidol been given?: q no q yes q Fluids ordered/given q EKg ordered/done
notes: _________________________________________________________________________________________________________________
Patient Name:________________________ sex:____ Phone:_____________ Provider:_________________ Date: dd/mm/yy
39Partners In Health | partiCipant hanDBOOK | AnnEx
1
me
DIC
AT
ION
CA
RD
FO
R A
GIT
AT
ION
, D
el
IRIU
m,
AN
D P
sy
CH
Os
Is
RIs
PeR
IDO
Ne
HA
lOPe
RID
Ol
DIA
ZePA
mC
AR
bA
mA
ZePI
Ne
vA
lPR
OA
Te
1st
Cho
ice:
“A
typi
cal”
Ant
ipsy
chot
ic/M
ood
stab
ilize
r
Use
for
: Psy
chos
is (
wit
h or
wit
hout
man
ia)
2nd
Cho
ice:
“Ty
pica
l”
Ant
ipsy
chot
ic/M
ood
stab
ilize
r
Use
for
: Agg
ress
ive
or v
iole
nt
psyc
hosi
s (w
ith
or w
itho
ut m
ania
)
Ben
zodi
azep
ine
Use
for
: Alc
ohol
wit
hdra
wal
,
acut
e ag
itat
ion
wit
h or
wit
hout
ant
i-ps
ycho
tic
3rd
Cho
ice:
Moo
d st
abili
zer
Do
not
pres
crib
e w
itho
ut
cons
ulti
ng m
enta
l hea
lth
team
Use
for
: man
ia w
itho
ut
psyc
hosi
s
4th
choi
ce: M
ood
stab
ilize
r
Do
not
pres
crib
e w
itho
ut
cons
ulti
ng m
enta
l hea
lth
team
Use
for
: man
ia w
itho
ut
psyc
hosi
s (l
ongs
tand
ing
aggr
essi
on o
r vi
olen
ce in
mal
es)
DO
NO
T U
se IF
•C
autio
n if
child
/ado
lesc
ent
•pr
ior
hist
ory
of d
ysto
nia
on
antip
sych
otic
med
icat
ion
•C
hild
ren
(18
or y
oung
er)
•pa
tient
is d
eliri
ous
•pr
egna
nt/b
reas
tfee
ding
wom
en
•C
hild
ren
(18
or y
oung
er)
•El
derly
(65
or
olde
r)
•Bl
ood
diso
rder
•Ep
ileps
y: a
bsen
ce s
eizu
res
•C
autio
n if
child
•W
omen
of
child
-bea
ring
age/
preg
nant
wom
en
•li
ver
dise
ase
•C
autio
n if
child
mU
sT C
ON
sUlT
m
eNTA
l H
eAlT
H
TeA
m
•Fo
r ps
ycho
sis
due
to d
emen
tia
(incr
ease
d ris
k of
dea
th)
•C
hild
ren
18 o
r yo
unge
r
•pr
egna
nt w
omen
•Fo
r ps
ycho
sis
due
to d
emen
tia
(incr
ease
d ris
k of
dea
th)
•pr
egna
nt w
omen
•Fo
r tr
eatm
ent
of a
ll m
enta
l
illne
ss (
excl
udin
g ep
ileps
y)
•pr
egna
nt o
r br
east
feed
ing
wom
en
•Fo
r tr
eatm
ent
of a
ll m
enta
l
illne
ss (
excl
udin
g ep
ileps
y)
star
ting
Dos
e (A
dult
)Ta
ke a
t ni
ght
due
to s
edat
ive
effe
cts
•Bi
pola
r/ps
ycho
sis
– 0.
5 – 1
mg
•D
eliri
um –
0.2
5 –
0.5
mg
Take
at
nigh
t du
e to
sed
ativ
e ef
fect
s
•Bi
pola
r/ps
ycho
sis
mod
erat
e sx
s: 0
.5 –
2.5
mg
seve
re s
xs: 2
.5 –
5 m
g
•a
lway
s pr
escr
ibe
diph
enhy
dram
ine
25 –
50
mg
daily
with
hal
oper
idol
•D
eliri
um: 0
.5 –
2.5
mg
at n
ight
(Con
side
r lo
w-d
ose
of
rispe
ridon
e fir
st)
•A
ggre
ssiv
e/v
iole
nt P
atie
nts:
see
Agi
tate
d Pa
tien
t Pr
otoc
ol
see
agi
tate
d pa
tient
pro
toco
l
for
guid
elin
es r
egar
ding
use
.
200
mg
twic
e da
ily20
0 –
250
mg
twic
e da
ily
*pat
ient
s re
ceiv
ing
valp
roic
acid
may
req
uire
a z
idov
udin
e
dosa
ge r
educ
tion
to m
aint
ain
unch
ange
d se
rum
zid
ovud
ine
conc
entr
atio
ns
“ste
p” o
f up
titr
atio
na
ntip
sych
otic
s re
quire
4 –
6 w
eeks
to
reac
h fu
ll ef
fect
. if
ther
e ar
e sa
fety
conc
erns
, phy
sici
ans
can
incr
ease
dose
s m
ore
quic
kly
(eve
ry 3
– 7
day
s)
by 0
.5 m
g in
crem
ents
. Del
irium
:
incr
ease
by
0.25
mg
incr
emen
ts.
ant
ipsy
chot
ics
requ
ire 4
– 6
wee
ks t
o
reac
h fu
ll ef
fect
. if
ther
e ar
e sa
fety
conc
erns
, phy
sici
ans
can
incr
ease
dose
s m
ore
quic
kly
(eve
ry 3
– 7
day
s)
by 2
.5 m
g in
crem
ents
.
see
agi
tate
d pa
tient
pro
toco
l
for
guid
elin
es r
egar
ding
use
.
200
mg
tota
l dai
ly25
0 –
500
mg
tota
l dai
ly
max
imum
Dos
e2
mg
Dos
es a
bove
2 m
g da
ily m
ust
be
revi
ewed
with
the
men
tal h
ealth
tea
m.
10 m
g
Dos
es a
bove
10
mg
daily
mus
t be
revi
ewed
with
the
men
tal h
ealth
team
.
10 m
g
Dos
es a
bove
10
mg
daily
mus
t be
rev
iew
ed w
ith t
he
men
tal h
ealth
tea
m.
800
mg
(for
men
tal i
llnes
s)
Dos
es a
bove
800
mg
mus
t
be r
evie
wed
with
the
men
tal
heal
th t
eam
.
1000
mg
(for
men
tal i
llnes
s)
Dos
es a
bove
100
0 m
g m
ust
be r
evie
wed
with
the
men
tal
heal
th t
eam
.
40 Partners In Health | partiCipant hanDBOOK | AnnEx
2
med
icat
ion
Car
d fo
r A
gita
tion
, Del
iriu
m, a
nd P
sych
osis
(co
ntin
ued)
RIs
PeR
IDO
Ne
HA
lOPe
RID
Ol
DIA
ZePA
mC
AR
bA
mA
ZePI
Ne
vA
lPR
OA
Te
Toxi
citi
es*i
f ra
sh, s
top
med
icat
ion
and
retu
rn t
o ho
spita
l
seri
ous
Dys
toni
a (e
spec
ially
of
phar
ynx,
eye
s, n
eck—
tem
pora
ry b
ut p
oten
tially
fat
al),
Tard
ive
Dys
kine
sia
(per
man
ent)
, Aka
this
ia (
rest
less
ness
), D
iabe
tes,
Car
diac
arrh
ythm
ia le
adin
g to
tor
sade
s de
s po
inte
s
Ris
k of
sei
zure
if d
iaze
pam
with
draw
n w
ithou
t ta
per
afte
r re
gula
r us
e at
hig
her
dose
Ras
h, li
ver
failu
re, d
ecre
ased
whi
te b
lood
cou
nt
(Car
bam
azep
ine
can
caus
e hy
pona
trem
ia)
(Val
proa
te c
an c
ause
ser
ious
bir
th d
efec
ts in
pre
gnan
cy)
Com
mon
•se
datio
n
•W
eigh
t g
ain
•la
ctat
ion
•a
men
orrh
ea
•En
ures
is (
for
boys
)
•se
datio
n
•h
eavy
ton
gue
•st
iffne
ss
•a
rrhy
thm
ia (
for
patie
nts
rece
ivin
g
mor
e th
an 1
0 m
g da
ily)
•se
datio
n
•D
epen
denc
e (s
houl
d no
t
be g
iven
for
long
per
iods
of t
ime)
Fatig
ue, d
izzi
ness
, nau
sea/
vom
iting
, inc
oord
inat
ion,
dou
ble
visi
on
(Car
bam
azep
ine
decr
ease
s ef
ficac
y of
ora
l con
trac
eptiv
es;
Valp
roat
e ca
uses
tre
mor
)
mon
itor
ing
•Ba
selin
e: a
ims,
wei
ght,
fas
ting
gluc
ose,
hem
ogra
m, h
epat
ic p
anel
(if a
vaila
ble)
•Ev
ery
visi
t: w
eigh
t, v
ital s
igns
•Ev
ery
6 m
onth
s: a
ims,
fas
ting
gluc
ose,
hep
atic
pan
el, h
emog
ram
•Ba
selin
e: a
ims,
wei
ght,
fas
ting
gluc
ose,
hem
ogra
m, h
epat
ic
pane
l (if
avai
labl
e)
•Ev
ery
visi
t: w
eigh
t, v
ital s
igns
•Ev
ery
6 m
onth
s: a
ims,
fast
ing
gluc
ose,
hep
atic
pan
el,
hem
ogra
m
•m
onito
r fo
r si
gns
of
seda
tion
•m
onito
r fo
r de
pend
ence
(nee
d fo
r in
crea
sed
dose
to a
chie
ve s
ame
effe
ct)
lFts
, CBC
, sod
ium
Wei
ght
gain
, lFt
s, C
BC
hiV
pat
ient
s re
ceiv
ing
valp
roic
acid
may
req
uire
a z
idov
udin
e
dosa
ge r
educ
tin t
o m
aint
ain
unch
ange
d se
rum
zid
ovud
ine
conc
entr
atio
ns.
Tape
ring
/D
isco
ntin
uing
if t
here
is a
life
-
thre
aten
ing/
toxi
c si
de
effe
ct, s
top
imm
edia
tely
.
•C
onsu
lt w
ith
the
men
tal h
ealt
h
team
bef
ore
tape
ring
med
icat
ion.
som
e pa
tien
ts m
ay n
eed
to
cont
inue
ris
peri
done
inde
fini
tely
.
•if
the
pat
ient
has
oth
er s
igni
fican
t
side
eff
ects
, con
side
r de
crea
sing
the
dose
slo
wly
(by
0.2
5 –
0.5
mg
incr
emen
ts)
and
mon
itorin
g cl
osel
y.
Can
als
o co
nsid
er c
hang
ing
to
halo
perid
ol.
•C
onsu
lt w
ith
the
men
tal h
ealt
h
team
bef
ore
tape
ring
med
icat
ion.
som
e pa
tien
ts m
ay n
eed
to
cont
inue
hal
oper
idol
inde
fini
tely
.
•if
the
pat
ient
has
oth
er s
igni
fican
t
side
eff
ects
, con
side
r de
crea
sing
the
dose
slo
wly
(by
2.5
mg
incr
emen
ts)
and
mon
itorin
g
clos
ely.
Can
als
o co
nsid
er
chan
ging
to
rispe
ridon
e.
•O
nly
used
for
the
man
agem
ent
of
agita
ted/
viol
ent
patie
nts
and
alco
hol w
ithdr
awal
.
•it
sho
uld
not
be
cont
inue
d fo
r m
ore
than
seve
ral d
ays.
red
uce
by s
teps
abo
ve e
very
2 –
4 w
eeks
.
red
uce
by s
teps
abo
ve e
very
2 –
4 w
eeks
.
•Fo
r de
liriu
m, s
top
the
med
icat
ion
afte
r m
edic
al il
lnes
s is
tre
ated
.
•Fo
r ch
roni
c ps
ycho
sis
due
to m
enta
l illn
ess:
if t
he p
atie
nt is
sho
win
g
impr
ovem
ent
in s
ympt
oms
and
has
no m
ajor
sid
e ef
fect
s, d
o no
t st
op t
he
med
icat
ion.
•Fo
r ac
ute
psyc
hosi
s du
e to
men
tal i
llnes
s: c
onsi
der
slow
ly t
aper
ing
the
med
icat
ion
afte
r pa
tient
is s
ympt
om-f
ree
for
3 –
6 m
onth
s.
bre
astf
eedi
ngD
o no
t pr
escr
ibe
to p
regn
ant
or
brea
stfe
edin
g pa
tient
s w
ithou
t
cons
ultin
g w
ith t
he m
enta
l hea
lth
team
; giv
e fo
lic a
cid
4 m
g Q
D
thro
ugh
preg
nanc
y.
Do
not
pres
crib
e to
pre
gnan
t or
brea
stfe
edin
g pa
tient
s w
ithou
t
cons
ultin
g w
ith t
he m
enta
l hea
lth
team
; giv
e fo
lic a
cid
4 m
g Q
D
thro
ugh
preg
nanc
y.
Con
trai
ndic
ated
Do
not
pres
crib
e (f
or m
enta
l
illne
ss)
to p
regn
ant
or
brea
stfe
edin
g pa
tient
s w
ithou
t
cons
ultin
g th
e m
enta
l hea
lth
team
; giv
e fo
lic a
cid
4 m
g Q
D
thro
ugh
preg
nanc
y.
Do
not
initi
ate.
if a
lread
y on
,
mak
e su
re t
akin
g 4
mg
folic
acid
QD
.
41Partners In Health | partiCipant hanDBOOK | AnnEx
3
TR
eA
Tm
eN
T F
OR
AN
TIP
sy
CH
OT
IC m
eD
ICA
TIO
N s
IDe
eF
Fe
CT
s
esP
(ex
TRA
PyR
Am
IDA
l sy
mTO
ms)
TAR
DIv
e D
ysk
INes
IAN
eUR
Ole
PTIC
mA
lIG
NA
NT
syN
DR
Om
e (N
ms)
AC
UTe
Dy
sTO
NIA
Ak
ATH
IsIA
man
ifes
tati
onm
uscl
e rig
idity
(po
tent
ially
incl
udin
g:
eye
mus
cles
, thr
oat,
neck
, ton
gue,
bac
k)
EM
ER
GEn
CY
psyc
hom
otor
res
tless
ness
invo
lunt
ary
orof
acia
l mov
emen
ts (
may
be p
erm
anen
t)
Con
fusi
on, d
eliri
um, s
tiffn
ess
(like
a
lead
pip
e), s
wea
ting,
hyp
erpy
rexi
a,
auto
nom
ic in
stab
ility
, dro
olin
g,
elev
ated
WBC
, ele
vate
d C
pK, d
eath
EM
ER
GEn
CY
Trea
tmen
tD
iphe
nhyd
ram
ine
50 –
75
mg
im o
r
pO d
aily
seve
ral l
iters
of
iV o
r pO
flui
ds d
aily
prop
rano
lol 1
0 –
20 m
g ti
D
Can
als
o de
crea
se t
he d
ose
of
med
icat
ion
Dis
cont
inue
neu
role
ptic
or
low
er d
ose
Con
side
r V
itam
in C
(50
0 –
1000
mg/
d)
+ V
itam
in E
(12
00 –
160
0 iu
/d)
1. D
isco
ntin
ue o
ffen
ding
med
icat
ion.
2. m
edic
al e
valu
atio
n an
d su
ppor
t
(con
side
r iV
flui
ds)
3. h
ospi
taliz
e
4. C
onsi
der
dopa
min
e ag
onis
ts o
r
dant
role
ne t
o im
prov
e ou
tcom
e.
Toxi
citi
esse
riou
sa
naph
ylax
is, a
nem
ia, a
rrhy
thm
iaa
rrhy
thm
ia, b
ronc
hosp
asm
, ste
vens
-
John
son
synd
rom
e
Com
mon
Dro
wsi
ness
, diz
zine
ss, h
eada
che,
dry
mou
th, t
achy
card
ia, c
onst
ipat
ion,
blur
red
visi
on
Fatig
ue, d
izzi
ness
, nau
sea,
dep
ress
ion,
inso
mni
a