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Management of psychomotor agitation: audit of clinical practice


Journal of Psychology & Clinical Psychiatry
Mustafa Abdul Karim, Yassin El Torki, Inas Felfel, Sali El Hoseny, Hazem Hashem

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Abstract

Background: Psychomotor agitation (PMA) is encountered in different psychiatric settings, with prevalence ranging between 4.3 and 10%. According to The Maudsley Prescribing Guidelines in Psychiatry, stepwise management of PMA starts with behavioral intervention, followed by parenteral rapid tranquillization and physical restraint as last resorts. Our primary aim is to determine whether we follow the stepwise management of PMA. Our secondary aims are to assess the type and frequency of different psychotropics used to manage PMA, and the rate antipsychotic combination. 
Methods: We enlisted all patients who were prescribed psychotropics, ordered as “PRN for Agitation”, both in the emergency department and psychiatry inpatient units, between January the 7th and March the 4th of 2018, and retrospectively analyzed their electronic medical records for documentation of PMA and behavioral interventions implemented. In addition, we assessed the type and frequency of different psychotropics used for chemical restraint.
Results: 76 patients met our criteria. PMA was documented in 32.4 % of the cases, with five presenting with severe agitation. 21 instances of PMA occurred while patients were in the emergency department (ED), pending admission to psychiatry inpatient units. Behavioral intervention was only documented in 9.5% of the cases in the ED, compared to 48% in the inpatient units. The most frequently prescribed regimen for managing PMA was the combination of Intramuscular (IM) Haloperidol and Diphenhydramine, at a rate of 66%, followed by IM Haloperidol and Lorazepam (19.12%) and IM Haloperidol and Promethazine (8.82%). Compliance with the route of administration was only observed in 26% of cases, and the rate of neuroleptic co-administration was 68%. 
Conclusion: In managing PMA, there is insufficient documentation of behavioral intervention. Compliance with psychotropic route of administration for chemical restraint was poor, as parenteral tranquillizers were the preferred agents, without initially resorting to oral psychotropics. In addition, most of our patients were prescribed more than one antipsychotic. Through a multidisciplinary approach, our goal is to improve compliance with the proposed guidelines in managing PMA, and minimize the rate of neuroleptic co-administration.
Background: Psychomotor agitation (PMA) is encountered in different psychiatric settings, with prevalence ranging between 4.3 and 10%. According to The Maudsley Prescribing Guidelines in Psychiatry, stepwise management of PMA starts with behavioral intervention, followed by parenteral rapid tranquillization and physical restraint as last resorts. Our primary aim is to determine whether we follow the stepwise management of PMA. Our secondary aims are to assess the type and frequency of different psychotropics used to manage PMA, and the rate antipsychotic combination. 
Methods: We enlisted all patients who were prescribed psychotropics, ordered as “PRN for Agitation”, both in the emergency department and psychiatry inpatient units, between January the 7th and March the 4th of 2018, and retrospectively analyzed their electronic medical records for documentation of PMA and behavioral interventions implemented. In addition, we assessed the type and frequency of different psychotropics used for chemical restraint.
Results: 76 patients met our criteria. PMA was documented in 32.4 % of the cases, with five presenting with severe agitation. 21 instances of PMA occurred while patients were in the emergency department (ED), pending admission to psychiatry inpatient units. Behavioral intervention was only documented in 9.5% of the cases in the ED, compared to 48% in the inpatient units. The most frequently prescribed regimen for managing PMA was the combination of Intramuscular (IM) Haloperidol and Diphenhydramine, at a rate of 66%, followed by IM Haloperidol and Lorazepam (19.12%) and IM Haloperidol and Promethazine (8.82%). Compliance with the route of administration was only observed in 26% of cases, and the rate of neuroleptic co-administration was 68%. 
Conclusion: In managing PMA, there is insufficient documentation of behavioral intervention. Compliance with psychotropic route of administration for chemical restraint was poor, as parenteral tranquillizers were the preferred agents, without initially resorting to oral psychotropics. In addition, most of our patients were prescribed more than one antipsychotic. Through a multidisciplinary approach, our goal is to improve compliance with the proposed guidelines in managing PMA, and minimize the rate of neuroleptic co-administration.

Keywords

multidisciplinary approach, antipsychotics, tranquilizer, hallucinations, neuroleptic combination, antipsychotic regimens, oral tranquillizers

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