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Aim: To raise awareness about the existence of excitated delirium syndrome in a psychotic patient with fever. Case report: A 32-year-old patient was forcibly hospitalized five times in the last 11 years at the Clinic for Psychiatry at the University Hospital Center Rijeka. For the past 14 years, he has undergone sychiatric treatment with the diagnosis of paranoid schizophrenia, and the excitatory delirium syndrome occurred three years after the beginning of the treatment. In the last two involuntary hospitalizations, the patient was presented with a clinical picture of psychosis and impaired consciousness (delirious by description), psychomotor agitation, non-cooperation with symptoms of autonomic hyperreactivity (tachycardia, tachypnea, sweating, increased blood pressure) muscle rigidity. In addition, the patient had a constant need for undressing and a pronounced attraction to mirrors. On the third day of the last hospitalization, there was elevated body temperature which coincided with the administration of a higher dose of antipsychotics. Malignant neuroleptic syndrome was first suspected and antipsychotic therapy was discontinued, but without a significant effect on mental and physical condition. Diagnostic processing did not show a significant increase in creatine phosphokinase levels or the finding of myoglobin in the urine. Taking this into account, antipsychotics were reintroduced in the treatment, and the mental and physical condition of the patient gradually improved, and then a unique excited delirium syndrome was suspected. Conclusion: The occurrence of fever in psychiatric patients is diagnostically and therapeutically challenging. Early consideration of treatment-related hyperthermia syndromes is vital. The diagnostic dilemma between malignant neuroleptic syndrome and excitatory delirium syndrome is significant because different therapeutic approaches are involved, and these are two potentially lethal syndromes. [ABSTRACT FROM AUTHOR]

Background Motor abnormalities are strong transdiagnostic indicators of psychopathology risk that reflect emerging neural network abnormalities. Indeed, motor signs, such as motor slowing and agitation, are widely recognized as core features of both psychosis and depression. However, it is unclear whether these reflect shared or distinct etiology. Methods A sample of 11 878 adolescents completed self-reported clinical measures of rated psychotic-like experiences (PLEs) and depression. Familial risk for psychopathology and the presence of motor signs were drawn from parental reports, including developmental motor delays (eg, sitting, walking), and adolescent motor signs (eg, dyscoordination, psychomotor retardation, and psychomotor agitation). Finally, motor network connectivity in theoretically relevant networks (cortico-striatal, cortico-thalamic, and cortico-cerebellar) were related to symptoms and familial risk for psychopathology. Results Developmental motor delays related to increased PLEs, increased depression symptoms, and greater familial risk. Familial risk for both PLEs and depression showed higher rates of developmental motor delays than all other groups. Adolescent motor signs, however, showed unique patterns of relationships to symptoms and familial risk such that dyscoordination reflected risk for PLEs, both psychomotor agitation and retardation reflected depression risk, and psychomotor agitation reflected transdiagnostic risk. Cortico-striatal connectivity was related to depression and PLEs, but cortico-cerebellar connectivity was linked to PLEs only. Conclusions Motor signs may be a transdiagnostic marker of vulnerability for psychopathology. Early developmental motor delays could belie pluripotent, familial risk features. Unique items, eg, dyscoordination specifically related to PLEs, possibly reflecting processes inherent in distinct emerging forms of psychopathology. [ABSTRACT FROM AUTHOR]

Background and Importance: Agitation of elderly patients in the emergency department (ED) often complicates workup and therapy., Objective: In this study, we investigated if agitation in the ED can be reduced by showing calming video sequences in elderly agitated patients., Designs: Prospective randomized intervention study., Settings and Participants: ED patients aged ≥65 years were screened for the risk of agitation/delirium using the 4-A's test (4-AT) test. In case of ≥4 4-AT points, patients were scored using the Richmond Agitation-Sedation Scale (RASS) and the Nursing Delirium Screening Scale (Nu-DESC). They were included in the study if RASS was ≥+2 and Nu-DESC ≥ 4 after informed consent of the legal representative. Patients were then randomized to the intervention or control group. A total of n  = 57 patients were included in the study., Intervention: Patients in the intervention group were exposed to projections of calming video sequences for 60 min. Patients in the control group received standard care., Outcome Measures and Analysis: Changes in RASS and Nu-DESC were assessed 30 and 60 min after the intervention was started., Main Results: A total of 57 patients were included in the study, with 30 patients in the intervention group and 27 patients in the control group. Before the intervention, the median (interquartile range) RASS scores were comparable between the intervention group [3 (2-3)] and the control group [3 (2-3)]. After 30 min of exposure to calming video sequences, patients in the intervention group showed significantly lower RASS and Nu-DESC scores compared to the control group [RASS: 1 (0-1) vs. 2 (1.5-3), P  < 0.001; Nu-DESC: 3 (2-4) vs. 5 (4-6), P  < 0.001]. This difference persisted at 60 min [RASS: 0 (0-1) vs. 2 (1-2.5), P  < 0.001; Nu-DESC: 2 (2-3) vs. 5 (4-6), P  < 0.001]. Additionally, fewer patients in the intervention group required additional sedating or antipsychotic medication (1/30) compared to the control group (9/27), with this difference being statistically significant ( P  = 0.004)., Conclusion: In this randomized controlled trial, the use of calming video sequences in elderly patients with agitation in the ED resulted in significant reductions in agitation and the need for additional sedative or antipsychotic medication., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

The phenomenon of acute behavioral disturbance is an underrecognized and potentially life-threatening syndrome, and sometimes an emergency in psychiatric settings. Patients presenting to the Italian emergency department (ED) with acute behavioral disturbances account for approximately 3.2% of all ED visits. The spectrum of behaviors and signs overlap with many clinical disease processes. In addition to patients with behavioral problems related to mental disorders or substance abuse, there is also a large group whose behavioral emergencies directly result from medical illness. The complexity of these patients, as well as the interdisciplinary nature of their care, requires a clear and consensual framework for care. A network of Italian scientific societies developed ten reccomendations for good clinical practice. The main purpose is to draw up a document that presents a standardized method for the organization of the care of patients with acute behavioral disorders in ED

ObjectiveTo determine the extent to which states and localities include dementia as a qualifying condition for medical marijuana and how common this indication is.MethodsThe authors reviewed authorizing legislation and medical marijuana program websites and annual reports for the states and localities where medical marijuana is legal.ResultsOf the 24 states and localities where medical marijuana is legal, dementia is a qualifying condition in 10 (41.7%), primarily for agitation of Alzheimer disease. In the five states where information was available regarding qualifying conditions for certification, dementia was the indication for

Introduction and objective: Emergence Delirium (ED), particularly in children, is characterized by mental confusion, irritability, disorientation, and inconsolable crying. ED prolongs the time required in the Post-Anesthesia Care Unit (PACU) and increases concern and anxiety in parents. The present study aimed to determine the effectiveness and safety of low-dose clonidine in preventing ED in children receiving sevoflurane anesthesia for tonsillectomy/adenotonsillectomy. Methods: A randomized, double-blind clinical trial was conducted between November 2013 and January 2014. Sixty-two children aged 2–12 years, scheduled to undergo tonsillectomy/adenotonsillectomy, and classified as American Society of Anesthesiologists (ASA) physical status I/II were included, with 29 being randomized to receive 1 μg.kg-1 clonidine intravenously, and 33 allocated to a control group that received no clonidine. Anesthesia was induced and maintained with sevoflurane. Children with altered state of consciousness, neurological deficit, history of allergy to dipyrone, or receiving other drugs such as preanesthetic agents were excluded from the study. The primary outcome was the presence of ED in the initial 20 minutes in the PACU according to the Pediatric Anesthesia Emergence Delirium (PAED) scale. The Chi-Square test and Fisher’s two-tailed exact test were used for statistical analysis, as applicable. Significance level was set at 5%, and Risk Ratios (RR) and their 95% Confidence Intervals (95% CI) were calculated. Results: The frequency of ED was significantly decreased in the group of children who received clonidine (17.2% vs. 57.6%; RR = 0.30; 95% CI 0.13–0.70; p = 0.001). There was no difference between groups with respect to the frequency of postoperative self-harm (falls and bruises), dislodged catheters, and for most of the other adverse events evaluated. Conclusions: The use of 1 μg.kg-1 intravenous clonidine during anesthesia induction can effectively reduce the incidence of ED in children undergoing elective tonsillectomy/adenotonsillectomy under general inhalation anesthesia with sevoflurane. ClinicalTrials.gov Identifier: NCT02181543.

Islam Shahin,1 Caterina Del Mar Bonnin,2 Elsayed Saleh,3 Khaled Helmy,4,5 Usama M Youssef,6 Eduard Vieta2 1Cairo Mood Center, Cairo, Egypt; 2Barcelona Bipolar Disorders and Depressive Unit, Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; 3Department of Psychiatry, Mansoura University, Mansoura, Egypt; 4Training and Research Unit, New Nozha Hospital, Alexandria, Egypt; 5Ciconia Recovery London (CRL), London, UK; 6Department of Psychiatry, Zagazig University, Zagazig, EgyptCorrespondence: Islam Shahin Tel +201150759876Email ishahin10@yahoo.comBackground: The DSM5-defined mixed features in depression do not include psychomotor agitation, irritability or distractibility because they are considered overlapping symptoms. A growing number of modern psychiatrists have expressed dissatisfaction with this and proposed alternative sets of mixed symptoms that are much more common and clinically relevant. Among such alternative criteria were those proposed by Koukopoulos. He utilized the research diagnostic criteria of agitated depression (RDC-A) as a mixed depression subtype, and validated another form of mixed depression, the Koukopoulos criteria for mixed depression (K-DMX).Purpose: This study provides psychometric validation for the first self-rated scale designed to measure the most common mixed symptoms in depression as proposed by Koukopoulos.Patients and Methods: We conducted a multicenter cross-sectional study of 170 patients with unipolar depression. They completed the Shahin Mixed Depression Scale (SMDS) and underwent expert interviews as a gold standard reference. SMDS’ psychometric properties were assessed, including Cronbach’s alpha, factor analysis, sensitivity, specificity, predictive value and accuracy.Results: We found significant association and agreement between mixity according to SMDS and the gold standard (K-DMX and RDC-A according to expert interview) with good internal consistency (Cronbach’s alpha=0.87), high sensitivity (=91.4%), specificity (=98.0%), positive predictive value (=96.9%), negative predictive value (= 94.2%) and accuracy (=95.2%). Factor analysis identified one factor for psychomotor agitation and another for mixity without psychomotor agitation.Conclusion: SMDS was a reliable and valid instrument for assessing the frequently encountered and clinically relevant mixed features in depression.Keywords: mixed depression, mixed depression scale, major depressive disorder, psychomotor agitation, agitated depression, unipolar depression

Psychomotor agitation (PMA) is a prominent clinical issue frequently observed in various psychiatric and neurological conditions, including schizophrenia, bipolar disorder, Parkinson disease, dementia and substance use disorder. Characterized by motor restlessness, anxiety and irritability, PMA can rapidly escalate into aggression and violence, necessitating prompt intervention to ensure patient and caregiver safety. The prevalence of PMA in psychiatric emergency settings ranges from 4.3% to 10%, imposing a substantial burden on healthcare systems. Despite the critical nature of PMA, there is a lack of standardized treatment protocols, particularly concerning the use of liquid formulations of antipsychotics such as liquid promazine, which may offer unique advantages in emergency care. This review aims to provide a comprehensive analysis of the existing literature on the efficacy, safety and tolerability of liquid antipsychotics, with a particular focus on promazine, in the management of PMA. An extensive literature search was conducted across publicly available databases with no time limitations to ensure the inclusion of all relevant articles. The findings suggest that liquid promazine offers several benefits, including ease of administration, rapid onset of action and improved patient compliance, making it a valuable option in acute PMA management. However, the review also highlights the need for future research, particularly long-term studies and head-to-head comparisons with other antipsychotics, to better establish the clinical utility of liquid promazine. Future research should focus on expanding the evidence base for liquid antipsychotic formulations, which will contribute to improved clinical outcomes in the management of PMA., Competing Interests: Disclosure and potential conflicts of interest: MM and MA have no conflicts of interest to declare. AC has been a consultant for Angelini, Janssen, Lundbeck, Otsuka, Recordati, Pfizer and Viatris; a speaker for Angelini, Aspen, Biogen, Boehringer Ingelheim, GSK, Janssen, Lundbeck, Neuraxpharma, Otsuka, Recordati, Pfizer and Viatris. SDF has received consultation fees from Angelini, Janssen, Lundbeck, Otsuka, Viatris and Janssen; and has been a speaker for Angelini, Janssen, Lundbeck, Otsuka, Viatris and Neuraxpharma. AF has been a consultant for Angelini, Janssen, Lundbeck, Otsuka, Recordati, Pfizer and Viatris; a speaker for Angelini, Apsen, Biogen, Boehringer Ingelheim, Janssen, Lundbeck, Neuraxpharma, Otsuka, Recordati, Pfizer and Viatris; and has received research grants from Janssen, Boehringer Ingelheim, Otsuka, Angelini and Lundbeck. The International Committee of Medical Journal Editors (ICMJE) Potential Conflicts of Interests form for the authors is available for download at: https://www.drugsincontext.com/wp-content/uploads/2024/10/dic.2024-6-5-COI.pdf, (Copyright © 2024 Matrone M, Cuomo A, De Filippis S, Fagiolini A, Amore M.)

Background: A 12-week randomized controlled trial demonstrated that brexpiprazole is efficacious for treating agitation in patients with dementia due to Alzheimer's disease., Objective: To assess the long-term safety and tolerability of brexpiprazole for the treatment of agitation associated with dementia due to Alzheimer's disease., Methods: This 12-week, active-treatment (oral brexpiprazole 2 or 3 mg/day) extension trial ran from October 2018-September 2022 at 66 sites in Europe/US. Patients with agitation in dementia due to Alzheimer's disease in a care facility/community-based setting who completed the randomized trial were eligible (N = 259 enrolled/analyzed for safety; 88.4% completed). Stable Alzheimer's disease medications were permitted. The primary safety endpoint was the frequency and severity of treatment-emergent adverse events (TEAEs). Change in Cohen-Mansfield Agitation Inventory (CMAI) total score was an exploratory efficacy endpoint., Results: Mean (SD) age was 74.3 (7.6) years, 145 patients (56.0%) were female, and 248 (95.8%) were White. TEAEs were reported by 67 patients (25.9%), most commonly headache (3.5%) and fall (2.3%). Most TEAEs were mild or moderate in severity; 5 patients (1.9%) reported a severe TEAE, including 3 severe falls attributed to tripping, misjudging sitting, or dehydration. Twelve patients (4.6%) discontinued due to TEAEs. No patients died. Mean CMAI total score improved by 9.1 points over 12 weeks., Conclusions: Considering the randomized and extension trials together, brexpiprazole 2 or 3 mg was generally well tolerated for up to 24 weeks in elderly patients with agitation associated with dementia due to Alzheimer's disease. Patients showed continued improvement in agitation., Clinicaltrials.gov Identifier: NCT03594123 (registration date: July 11, 2018)., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Saloni Behl, Daniel Lee, and Alvin Estilo were full-time employees of Otsuka Pharmaceutical Development & Commercialization Inc. at the time of this work. Mary Slomkowski, Dalei Chen, Denise Chang, Alpesh Shah, and Mary Hobart are full-time employees of Otsuka Pharmaceutical Development & Commercialization Inc. Nanco Hefting is a full-time employee of H. Lundbeck A/S. Uwa Kalu is a full-time employee of Lundbeck LLC.

We present the case of a 23-year-old man with a complex psychiatric history who was transferred from a community hospital for management of agitation and severe thrombocytopenia. Experts in consultation-liaison psychiatry deconstruct the consultation question in this case. The importance of addressing superficial and hidden aspects of a consultation is reviewed via the concepts of explicit, implicit, and tacit consultation questions., (Copyright © 2024 Academy of Consultation-Liaison Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: In patients presenting to the emergency department (ED) with acute respiratory failure, non-invasive mechanical ventilation (NIMV) is applied when conventional oxygen support is not sufficient. Patients who are agitated often have very low NIMV compliance and a transition to invasive mechanical ventilation (IMV) is often required. To avoid IMV, a suitable sedative agent can be utilized. The aim of this research is to investigate the relationship between ketamine administration to patients who are non-compliant with NIMV due to agitation and the outcome of their intubation., Methods: This retrospective study included patients with acute respiratory failure who were admitted to the ED from 2021 to 2022 and used Richmond Agitation Sedation Scale (RASS) to identify agitation level of patients. The relationship between ketamine administration in this patient group and NIMV compliance and intubation rate was evaluated., Results: A total of 81 patients, including 35 (43.2%) men and 46 (56.8%) women, were included in the study. Of these patients, 46 (56.8%) were intubated despite ketamine administration, while 35 (43.2%) were compliant with NIMV and were not intubated. When evaluating the RASS, which shows the agitation levels of the patients, the non-intubated group was found to be 2.17 ± 0.68, while the intubated group was 2.66 ± 0.73, and it was statistically significant that the NIMV intubated group was higher (p = 0.003)., Conclusion: This study showed that agitation can impair NIMV compliance in patients with acute respiratory failure. However, a significant proportion of this patient group can be avoided through IMV with proper sedative agents., (© 2024. The Author(s).)

Context: Delirium is a significant concern in end-of-life care. Continuous monitoring of agitation levels using objective methods may have advantages over existing measurement scales., Objectives: To examine whether an objective measure of activity scores measured using a sheet-type non-wearable sensor (Nemuri SCAN [NSCAN]) was correlated with agitation levels measured using the modified Richmond Agitation-Sedation Scale (RASS) in terminally ill patients with cancer., Methods: We conducted a single-center, prospective, observational study in a palliative care unit using the NSCAN to measure activity scores and the RASS to assess agitation levels. RASS scores were prospectively measured by ward nurses blinded to the NSCAN variables. A database was created to pair the RASS scores and activity scores at night on the same day., Results: During the observation period, 1209 patients were hospitalized, and 3028 pairs of assessments of 971 patients were analyzed. The NSCAN activity scores significantly increased with increasing RASS scores (Jonckheere-Terpstra test, p < 0.001). The mean values of the activity scores for each RASS score were RASS -5, 28.9; RASS -4, 36.4; RASS -3, 41.7; RASS -2, 57.4; RASS -1, 58.8; RASS 0, 62.6; RASS 1, 79.6; RASS 2, 106.5; and RASS 3, 118.7., Conclusion: The NSCAN activity significantly correlated with modified RASS agitation scores. Real-time NSCAN data on agitation may aid timely interventions for optimal symptom control. To improve outcomes for patients suffering from terminal delirium, more research on monitoring tools is warranted., (Copyright © 2024 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Agitation in Alzheimer's disease (AAD) is a troubling condition experienced by many of the 6.9 million people living with Alzheimer's disease in the United States. The Gerontological Society of America (GSA) initially published an evidence-based care pathway to treat this condition, Agitation in Alzheimer's Disease: A Decision Tree for Healthcare Providers, in 2022 and updated this resource in 2023 with the International Psychogeriatric Association (IPA) consensus definition of agitation. A new, research-informed screening tool launched in November 2023, the Agitation in Alzheimer's Screener for Caregivers (AASC TM ), supports care teams in identifying individuals with AAD who can benefit from the evidence-based care outlined in the decision tree. This column features an interview with interprofessional dementia care experts from Emory Integrated Memory Care who share their insights into AAD, the significance of the condition, and how care teams can use the AASC TM and other strategies to detect AAD. By detecting AAD and implementing person-centered care to address the condition, care teams can improve quality of life for the individual with the condition and their caregiver., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article., (Copyright © 2024 Elsevier Inc. All rights reserved.)