PartiCiPant handbook Introduction to Agitation, Delirium, and … · 2020-02-12 · II Partners In...

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Introduction to Agitation,

Delirium, and Psychosis

Curriculum for Physicians

PartiCiPant handbook

IPartners In Health | PartiCiPant handbook

Introduction to Agitation, Delirium, and Psychosis Curriculum for Physicians

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, 2015Photographs: Partners in health

design: ayanna ashley doiron and Partners in health

II Partners In Health | PartiCiPant handbook


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


Table of Contents

Introduction to Agitation, Delirium, and Psychosis

introduction...........................................................................1

objectives .............................................................................3

Epidemiology, the treatment gap, and stigma.......................4

the Psychosis system of Care and the Four Pillars of Emergency Management of agitation, delirium, and Psychosis ........................................................................8

safety and Management of agitated Patients ......................13

Medical Evaluation and Management of agitation, delirium, and Psychosis .......................................................16

Medication Management for agitation, delirium, and Psychosis ......................................................................20

Follow-Up and documentation ...........................................28

advanced Practice – Using mhgaP for Psychosis and bipolar disorder ............................................................30

review ................................................................................32

notes ..................................................................................37

IV Partners In Health | PartiCiPant handbook


Annex

Psychosis Care Pathway.......................................................39

agitation, delirium, and Psychosis Checklist ........................40

Medical Evaluation Protocol for agitation, delirium, and Psychosis ......................................................................41

agitated Patient Protocol ....................................................43

agitation, delirium, and Psychosis Form ..............................44

Medication Card for agitation, delirium, and Psychosis .......45

aiMs Examination Procedure ...............................................48

abnormal involuntary Movement scale (aiMs) ...................49

Partners In Health | PartiCiPant handbook 1


Introduction to Agitation, Delirium, and Psychosis

INTRODUCTION

Psychotic disorders refer to a category of severe mental illnesses that produce a loss of contact

with reality, including distortions of perception, delusions, and hallucinations. The most

common psychotic disorders are schizophrenia and bipolar disorder, which together affect 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 The

stigma and discrimination against people living with severe mental illnesses 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 to be psychotic and are, therefore,

immediately referred to mental health facilities. However, often 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, physicians can learn how to manage agitated patients safely and provide complete

medical evaluation so they can properly treat delirium. Furthermore, within Zanmi Lasante,

physicians have the opportunity to work with psychologists and social workers who assist

them in making proper diagnoses and managing agitated, delirious, and psychotic patients.

Community health workers and nurses also participate in this process. Psychotic disorders are

treatable and for some, completely curable. With the right training and a system of coordinated

care, people with psychosis can receive effective treatment and lead rich, productive lives.

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


In this training, you will learn how to manage agitated patients safely and effectively. You will

also learn how to distinguish between delirium and a psychotic disorder caused by mental

illness. Ultimately, you 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. Describe the Psychosis Care Pathway and its collaborative care approach.

e. 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.

f. Explain the four pillars of emergency management of agitation, delirium, and psychosis.

g. Describe how a physician should use the biopsychosocial model when managing a patient with agitation, delirium or psychosis.

h. Describe the identification, triage, referral, and non-pharmacological management of an agitated patient through the use of the Agitated Patient Protocol and the Agitation, Delirium, and Psychosis Form.

i. Define medical delirium.

j. Describe the importance of proper medical evaluation for an agitated, delirious or psychotic patient.

k. Explain how to conduct a medical evaluation of an agitated, delirious or psychotic patient.

l. Determine the necessary pharmacological treatment of agitation, delirium, and psychosis using the Medication Card for Agitation, Delirium, and Psychosis.

m. Provide comprehensive psychoeducation messages to patients and their families around medication management.

n. Evaluate and document antipsychotic medication side-effects using the Abnormal Involuntary Movement Scale.

o. Explain how to provide follow-up for people living with psychotic disorders and severe mental illnesses.

p. Describe the importance of documentation during patient follow-up.

q. Describe how to use mhGAP for the management of Psychosis and Bipolar Disorder.

r. Describe how to use mhGAP for the management of self-harm/suicide.

s. Apply the use of mhGAP for self-harm/suicide to prior trainings delivered for depression, epilepsy, and psychosis.



Epidemiology, the Treatment Gap, and Stigma

Severe Mental Illness

Severe mental illnesses are mental illnesses of longer duration, longer treatment and have significant impact on the activities of daily living. Severe mental illness includes psychosis and mood disorders. The two most common severe mental illnesses are schizophrenia and bipolar disorder.

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




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




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.


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



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. Physicians 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. Physicians 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 and contagious. 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.”



The Psychosis System of Care and the Four Pillars of Emergency Management of Agitation, Delirium, and Psychosis

The Psychosis System of Care

Physicians’ main roles in the Zanmi Lasante system of care are:

a. to ensure safety for the patient and others;

b. to rule out a treatable medical illness and to prevent further harm;

c. to provide treatment with appropriate medication;

d. to provide follow-up by educating the patient and families and coordinating care with the psychologist.

The physician’s responsibilities in the care pathway align with the four pillars of managing a patient with psychotic symptoms.

Four Pillars of the emergency management of Agitation, Delirium and Psychosis

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

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 physician’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

Physicians are just one important element in the collaborative care approach; to provide the quality care they need to work closely with other team members that include psychologists, social workers, nurses, and community health workers.

World health organization: World Mental health report, 2001: p. 20

biological factors

Psychological factors

Mental and behavioural

disorders

social factors



CAse sTUDy

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.

bIO PsyCHO sOCIAl



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



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.



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 Forms assist physicians in recording vital information related to determining if an agitated patient is delirious or psychotic.

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



When Managing an Agitated Patient: Safety and Talking First!

Often physicians and other health providers are unsure what to do when there is an agitated patient. By talking to the patient, the physician can evaluate the risk of violence, begin the medical evaluation and calm the patient.

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



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 medication recently?

• 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 PlAy

CAse: 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.



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. It can be a symptom of medical illness or 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



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/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)

You should be using the Medical Evaluation Protocols and Agitated Patient Form when trying to decide if a patient has a medical illness or mental illness.



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?



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. the nurse has 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?



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. For physicians, identifying a delirium rather than a mental illness is the most important diagnosis that they can make. It can be life-saving.

Prescribing Principles for Agitation, Delirium and Psychosis

The primary tools that can be used to guide prescribing practices are:

• Zanmi Lasante Formulary

• 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.



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 will need to evaluate and manage antipsychotic medications’ side-effects.

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.



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 the physician can catch tardive dyskinesia early, they can intervene. Movements can include:

• 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.

Before performing the exam:

• Choose a quiet place. Distraction can cause anxiety, and anxiety can worsen movements.

• You will need two chairs side by side, one for you, in an area large enough for walking. The chair to be used in this examination should be a hard, firm and without arms.

• The AIMS exam begins before you actually begin talking to the patient.

• Look at the patient informally and unobtrusively, when the patient walks into the room.

A positive AIMS score does not mean that the person has tardive dyskinesia. Schizophrenia itself can be associated with dyskinetic movements and a positive AIMS score. This is why it is important to use the AIMS at the beginning of treatment, before initiating the medication. Other conditions that are associated with tardive dyskinesia include: Huntington’s disease, Wilson’s Disease, Lupus, Thyrotoxicosis, heavy metal exposure and dopaminergic medication. If there is an AIMS Score that indicates that abnormal movements are developing, it is important to have a conversation with the patient about what the AIMS indicates, and what the options are for the patient and the medication. With an AIMS score suggesting tardive dyskinesia, there are three choices for the clinician:

1. 50% of people improve if the medication is stopped. This is possible if the clinical condition allows it.

2. Another possibility is to lower the dose.

3. Another possibility is to change to another antipsychotic class (from haloperidol to risperidone, for example).



Treatment Monitoring

In addition to monitoring patients for tardive dyskinesia you need to monitor and measure the possible metabolic effects of antipsychotics.

ReCOmmeNDeD sCHeDUle FOR mONITORING meTAbOlIC eFFeCTs OF ANTIPsyCHOTICs*

baseline 4 weeks 8 weeks 12 weeks Quarterly Annuallyevery

5 years

Personal/Family History

X X

Weight X X X X X

Waist Circumference X X

blood Pressure X X X

Fasting Glucose X X X

Fasting lipid X X X

*risk greatest for aripiprazole, chlorpromazine, clozapine, paliperidone, quetiapine, resperidone, ziprasidoneJClin Psychiatry 65:2, February 2004



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?

3a. 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. What level of agitation does he have (mild, moderate or severe)?



meDICATION RevIeW WORksHeeT (continued)

3b. According to the Agitated Patient Protocol Form, which medication should you give the patient? Give the medication name, dose, and form. Do you agree with this recommendation? Why or why not?

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 would you prescribe for her?

5. A 50-year-old man comes to a local clinic and is clearly psychotic. He receives a comprehensive medical evaluation that showed no evidence of medical illness. He is thought to have a psychotic disorder due to mental illness. Due to his significant functional impairment, you decide to start medication for him. Which medication would you start (give a name, dose and form)?



AIms ROle PlAy

Clinician: “hello samuel, it’s great to see you. thank you for coming in for your follow-up appointment.”

Patient: greets clinician.

Clinician: “samuel, are you still taking the risperidone 2 mg at night?”

Patient: “yes i am.”

Clinician: “are you taking any other medication?”

Patient: “no.”

Clinician: “good. i know that last time we did this exam it was about six months ago. so i’ll explain again: this brief exam is to look for abnormal physical movements. it is a routine diagnostic tool we use to ensure that the medication you are taking is not causing too much of a problem. if there is a problem we are able to measure it and think of ways to help with the problem. this will take less than ten minutes. are you ready to begin?”

Patient: “yes.”

Clinician: “is there anything in your mouth, like gum or candy? if so, will you please remove it?”

Patient: “ok.” takes out gum.

Clinician: “how are you teeth feeling? do you wear dentures?”

Patient: “My teeth are feeling ok, although one tooth hurts a little bit.”

Clinician: “thanks for letting me know. have you been noticing any movements in your mouth, face, hands or feet?”

Patient: “What do you mean?”

Clinician: “any movements that were not there before. these movements usually are hard to control or might seem unusual.”

Patient: “no, i don’t think so.”

Clinician: “great. Please sit in your chair with your hands on your knees, legs slightly apart and put your feet flat on the floor.” the clinician should model this pose to the patient.

Patient: Moves to sit in the chair with hands on knees, legs slightly apart and feet flat on the floor.

Clinician: “Please sit with your hands hanging unsupported between your legs.” the clinician should model this pose to the patient.

Patient: sits with hands hanging unsupported, between his legs.



AIms ROle PlAy (continued)

Clinician: “Please open your mouth and relax your tongue.” (observe the tongue at rest within mouth.)

Patient: opens mouth.

Clinician: “i now want you to close your mouth, and then open it again, please.”

Patient: Closes and opens mouth.

Clinician: “Can you please stick your tongue out?”

Patient: Protrudes tongue.

Clinician: “i’m now going to ask you to tap your thumb with each finger as rapidly as possible for 10 – 15 seconds.” the clinician models the behavior.

Patient: “is this right?” taps thumb, with each finger, as rapidly as possible for 10 – 15 seconds with the right hand.

Clinician: “yes, great job. Can you please do the same thing with the left hand now?” the clinician observes the facial and leg movements.

Clinician: “i’m now going to flex both your arms. Please relax your arms.” Flex and extend the patient’s left and right arms, one at a time.

Patient: relaxes arms and allows them to be flexed.

Clinician: “Can you please stand up? i want to observe your entire body.”

Patient: stands up.

Clinician: “While you are standing, can you please extend both arms with arms outstretched in front of you, with palms down?” the clinician models the behavior.

Patient: Extends both arms with palms down.

Clinician: “great, thank you. now, if you could please walk a few steps, turn and walk back to this chair. i’m going to observe how you walk.”

Patient: Walks a few paces, turns and walks back to the chair.

Clinician: “Can you do that again?”

Clinician: “thank you samuel. i’m just going to take a moment to record my observations.”



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.

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

Documentation

The documentation for psychosis, including the Zamni Lasante Follow-Up Form and the Agitation, Delirium, and Psychosis Form, will allow physicians to provide better care to patients. All the forms will be collected and managed by the psychologist and will ultimately go into the patient’s file.



Follow-Up Chart

TesTs/AssessmeNTs TO PeRFORm

HOW TO DeTeRmINe A PATIeNT’s ImPROvemeNT IN symPTOms

FORms TO COmPleTe?



Advanced Practice – Using mhGAP for Psychosis and Bipolar DisorderThe mhGAP Intervention Guide is a document developed by the World Health Organization that outlines the diagnosis and management of various mental health disorders. It is designed to serve as a guide for clinicians around the world. It is an important resource to help guide decision-making for non-specialist providers such as physicians. The effective training of non-specialists is how the global treatment gap will be narrowed.

The mhGAP chapters on psychosis and bipolar disorder can be used to guide assessment and management of all these different disorders. mhGAP organizes psychotic disorders separately from bipolar disorder because bipolar disorder is considered a mood disorder. However, both bipolar disorder and depression can have psychotic features.

Signs and Symptoms of Psychosis

The various signs and symptoms associated with psychosis can be grouped into two major categories: positive and negative.

A ‘Positive’ symptom – something is present that shouldn’t be:

• Hallucinations

• Delusions

• Disorganized speech

• Disorganized or catatonic behavior

A ‘Negative’ symptom – disruption to normal emotions or behavior:

• Flattening of affect

• Social withdrawal

• Loss of motivation

• Cognitive impairments

Sometimes it is not obvious what symptoms a patient may have. By asking these questions, the physician may be able to better determine if a patient has psychotic features.

•“Have you ever heard voices, even when nobody is present? Do you currently hear voices? Are you bothered or harassed by these voices? What did the voices tell you? Can other people hear the voices too? Do you think that I can hear them?”

•“Have you ever seen things that may not actually be present?”

•“Have you ever felt that your mind or body was being secretly controlled or somehow controlled against your will?”



•“Have you ever felt that others wanted to hurt you or really get you for some special reason, maybe because you had secret or special powers of some sort?”

Determining Chronic vs. Acute Psychosis

By asking the patient or caregiver about the onset of the psychotic episode and any prior episodes, you will be able to determine if the person has acute psychosis or chronic psychosis. This is important because it can have an impact on the duration of treatment with antipsychotic medication. For acute psychosis, the provider will want to stop the medication at some point to see if the patient can recover without the medication. Medication can have potentially significant side-effects, and we want to minimize the use of medication as much as possible.

Self-Harm and Suicide

During your work with depressed patients, epileptic patients and psychotic patients, you might come across a patient that has self-injurious behavior or suicidal ideation. It is critical to assess safety and risk of suicide for all patients for whom there is a mental health concern. By asking someone if they are thinking about hurting or killing themselves, physicians will not increase the risk of the patient doing so. Asking about thoughts of self-harm is an important responsibility of every provider: physician, nurse, community health worker, social worker and psychologist. For the physician assessing a patient for self-harm, mhGAP can assist the physician to take the appropriate next steps.

No matter the condition of the patient, it is important not to leave the patient alone. Self-harm and suicide can be attempted by anyone who might have mental health issues, including depression, epilepsy, psychosis and bipolar disorder.

For Further Information

mhGAP Intervention Guide http://www.who.int/mental_health/publications/mhGAP_intervention_guide/en/

ROle PlAy

CAse

a mother has come to you with her 19-year-old son. he was just diagnosed with schizophrenia by the Zanmi lasante psychologist. he has been referred to you for treatment. after careful consideration, you have decided to prescribe him a low dose of risperidone. you have already described to him how and when to take his medication, and the possible side-effects. What additional psychosis-specific psychoeducation messages would you give to the patient and his mother?



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. you are available to evaluate the patient. the patient does not seem agitated.

1. What would you do to determine if she has a psychotic disorder or a medical illness? What forms would you use to assist you?

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.

2. What would you say to the two sons?

3. What additional tests would you perform? What form would you use to assist you?

Review: Case Studies



CAse sTUDy 1 (continued)

after performing various tests, you have determined that the patient has encephalitis.

4. What medication would you prescribe, and how would you ensure that the patient and her family are supported as she recovers?



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? If so, what do you do first? What forms would you use to assist you?

after a few minutes of speaking calmly with the patient you leave the room, and identify someone to keep an eye on the patient to ensure his safety and that of others (1:1). you have been able to calm the patient without giving any medication and have done an initial medical evaluation. he denies wanting to hurt himself or others. his lab tests have come back normal.

2. What would you do next? What forms would you be utilizing to guide your work?

after the patient has seen the psychologist, the psychologist diagnoses the patient with a chronic psychotic illness. the patient has been referred back to you for medication to manage the psychosis.

3. What medication would you prescribe for the patient and why? What are some important messages to give to the patient about this medication?



CAse sTUDy 2 (continued)

4. When would you schedule to see the patient next? What other providers would you include in the follow-up plan, and what would their role be?



CAse sTUDy 3

during the past year you have been seeing a young, 18-year-old woman with a recent episode of psychosis. she was prescribed risperidone. today during her monthly follow up visit, approximately eight months since the initiation of medication, you notice that she appears restless, frequently wringing her hands.

1. What do you do? How would you document this?

during her appointment, when you ask her how things are going, 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?



NOTes

38 Partners In Health | PartiCiPant handbook | AnnEx

Annex

39Partners In Health | PartiCiPant handbook | AnnEx

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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


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


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


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)


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


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

.


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

.


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


AIms eXAmINATION PROCeDURe

sHOUlD be COmPleTeD beFORe eNTeRING THe RATINGs ON THe AIMS FORm

Either before or after completing the Examination Procedure, observe the patient unobtrusively at rest (e.g. in waiting room).

The chair to be used in this examination should be a hard, firm one without arms.

1. ask patient whether there is anything in his/her mouth (i.e., gum, candy, etc.) and if there is, to remove it.

2. ask patient about the current condition of his/her teeth. ask patient if he/she wears dentures. do teeth or dentures bother patient now?

3. ask patient whether he/she notices any movements in mouth, face, hands, or feet. if yes, ask to describe and to what extent they currently bother patient or interfere with his/her activities.

4. have patient sit in chair with hands on knees, legs slightly apart, and feet flat on floor. (look at entire body for movements while in this position).

5. ask patient to sit with hands hanging unsupported. if male, between legs, if female, and wearing a dress, hanging over knees. (observe hands and other body areas.)

6. ask patient to open mouth. (observe tongue at rest within mouth.) do this twice.

7. ask patient to protrude tongue. (observe abnormalities of tongue movement.)

8. *ask patient to tap thumb, with each finger, as rapidly as possible for 10 –15 seconds: separately with right hand, then with left hand. (observe facial and leg movements.)

9. Flex and extend patient's left and right arms, one at a time. (note any rigidity and rate it.)

10. ask patient to stand up. (observe in profile. observe all body areas again, hips included.)

11. *ask patient to extend both arms outstretched in front with palms down. (observe trunk, legs, and mouth.)

12. *have patient walk a few paces, turn, and walk back to chair. (observe hands and gait.) do this twice.

*activated movements.


AbNORmAl INvOlUNTARy mOvemeNT sCAle (A Ims)

Facial and Oral movements

1. Muscles of Facial Expression e.g., movements of forehead, eyebrows, periorbital area, cheeks; include frowning, blinking, smiling, grimacing

2. lips and Perioral area e.g., puckering, pouting, smacking

3. Jaw e.g., biting, clenching, chewing, mouth opening, lateral movement

4. tongue rate only increases in movement both in and out of mouth, not inability to sustain movement

extremity movements

5. Upper (arms, wrists, hands, fingers) include choreic movements (i.e., rapid, objectively purposeless, irregular, spontaneous); athetoid movements (i.e., slow, irregular, complex, serpentine). do not include tremor (i.e., repetitive, regular, rhythmic)

6. lower (legs, knees, ankles, toes) e.g., lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and eversion of foot

Trunk movements

7. neck, shoulders, hips e.g., rocking, twisting, squirming, pelvic gyrations

Overall severity

8. severity of abnormal movements

9. incapacitation due to abnormal movements

10. Patient's awareness of abnormal movements (rate only patient's report)

Dental status

11. Current problems with teeth and/or dentures?

12. does patient usually wear dentures?

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Patient’s Name: _________________________________________________________ Date: _____________________________________

Provider’s Name: ________________________________________________________ Phone Number: ____________________________

CURReNT meDICATIONs AND TOTAl mG/DAy

medication #1: ____________________ Total mg/Day: _________ medication #2: Total mg/Day:

INsTRUCTIONs: COmPleTe THe eXAmINATION PROCeDURe beFORe eNTeRING THese RATINGs.

sCORING:

• score the highest amplitude or frequency in a movement on the 0 – 4 scale, not the average;

• a PositiVE aiMs EXaMination is a sCorE oF 2 in tWo or MorE MoVEMEnts or a sCorE oF 3 or 4 in a singlE MoVEMEnt

• do not sum the scores: e.g. a patient who has scores 1 in four movements doEs not have a positive aiMs score of 4.

Comments: ________________________________________________________________________________________________________

examiner's signature ___________________________________________________________ Next exam Date_______________________

guy W: ECdEU assessment Manual for Psychopharmacology - revised (dhEW Publ no adM 76-338), Us department of health, Education, and Welfare; 1976

dd/mm/yy

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