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11. Mental/psychical disorders in adults
Agitation
P a tie nts w ith a nxie ty or p s yc hotic or p e r s ona lity d is or d e r s , or m e nta l c onfus ion
m ay
ha v e p e r iod s of p s yc hom otor a gita tion.
A git a t ion is a ls o c om m on in a c ut e in t oxic a t ion ( a lc oh ol/ d r ugs ) a n d
w it h d r a w a l
s ynd r om e (e .g. d e lir ium tr e m e ns or a br up t inte r r up tion of a ntid e p r e s s a nt
the r a p y).
It m a y be a c c om p a nie d by op p os itiona l be ha v iour , v iole nc e or fle e ing.
Management
C lin ic a l e v a lua tion is be s t p e r for m e d in p a ir s , in a c a lm s e tting, w ith or w ithout
th e
p e r s on‟s fa m ily/ fr ie nd s , d e p e nd ing on the s itua tion.
I t m a y be n e c e s s a r y t o a d m in is te r diazepam 1 0 m g P O t o r e d uc e th e
a gita tion a n d
c ond uc t the c linic a l e xa m .
If the p a tie nt is v iole nt or d a nge r ous , ur ge nt s e d a tion is r e q uir e d : diazepam I M 1 0
m g, to
be r e p e a te d a fte r 3 0 to 6 0 m inute s if ne c e s s a r y.
P hys ic a l r e s tr a int m a y be r e q uir e d in c e r ta in c ir c um s ta nc e s . H ow e v e r , its
us e s hould be
v ie w a s a te m p or a r y m e a s ur e , a lw a ys in c om bina tion w ith s e d a tion a nd
c los e m e d ic a l
s up e r v is ion.
D e te r m ine w he the r or not the p a tie nt is c onfus e d ; look for a n und e r lying c a us e ,
e .g.,
ne ur ologic a l, m e ta bolic , e tc . (s e e p a ge 2 9 4 ). M a na ge m e nt d e p e nd s on the
und e r lying c a us e .
I f the a gita tion is a s s oc ia te d w ith a n xie ty, s e e p a ge 2 9 1 ; if a s s oc ia te d w ith
p s yc h otic
d is or d e r s , s e e p a ge 3 0 0 .
A lc oholic p a tie nts c a n e xp e r ie nc e w ithd r a w a l s ym p tom s w ithin 6 to 2 4 hour s
a fte r the y
s top d r inking. I n the e a r ly p ha s e ( p r e - d e lir ium tr e m e ns ) , th e m a nife s ta tions
inc lud e
ir r ita bility, a ge n e r a l fe e lin g of m a la is e , p r ofus e s w e a tin g a n d s h a kin g.
W ith d r a w a l
s yn d r om e s h ould be ta ke n in to c on s id e r a tion in p a tie n ts w h o a r e
hos p ita lis e d a n d
the r e for e for c e d to s top d r inking a br up tly.
A t a m or e a d v a n c e d s t a ge ( d e lir ium t r e m e n s ) , a git a tion is a c c om p a n ie d
by fe v e r ,
m e nta l c onfus ion a nd v is ua l ha lluc ina tions (zoop s ia ).
P r e - D T s ym p t om s c a n be p r e v e n t e d or t r e a t e d w it h : diazepam P O ( 4 0
m g/ d a y in
4 d iv id e d d os e s 6 hour s a p a r t for 1 to 3 d a ys , the n r e d uc e a nd s top ov e r 7
d a ys ) + or a l
hyd r a tion (3 litr e s of w a te r / d a y) + thiamine I M (1 0 0 m g/ d a y for a t le a s t 3 d a ys ).
In p os t-op e r a tiv e p a tie nts , s ta r t w ith the p a r e nte r a l r oute : diazepam s low I V , 5 to
10 m g
Agitation
P a tie nts w ith a nxie ty or p s yc hotic or p e r s ona lity d is or d e r s , or m e nta l c onfus ion
m ay
ha v e p e r iod s of p s yc hom otor a gita tion.
A git a t ion is a ls o c om m on in a c ut e in t oxic a t ion ( a lc oh ol/ d r ugs ) a n d
w it h d r a w a l
s ynd r om e (e .g. d e lir ium tr e m e ns or a br up t inte r r up tion of a ntid e p r e s s a nt
the r a p y).
It m a y be a c c om p a nie d by op p os itiona l be ha v iour , v iole nc e or fle e ing.
Management
C lin ic a l e v a lua tion is be s t p e r for m e d in p a ir s , in a c a lm s e tting, w ith or w ithout
th e
p e r s on‟s fa m ily/ fr ie nd s , d e p e nd ing on the s itua tion.
I t m a y be n e c e s s a r y t o a d m in is te r diazepam 1 0 m g P O t o r e d uc e th e
a gita tion a n d
c ond uc t the c linic a l e xa m .
If the p a tie nt is v iole nt or d a nge r ous , ur ge nt s e d a tion is r e q uir e d : diazepam I M 1 0
m g, to
be r e p e a te d a fte r 3 0 to 6 0 m inute s if ne c e s s a r y.
P hys ic a l r e s tr a int m a y be r e q uir e d in c e r ta in c ir c um s ta nc e s . H ow e v e r , its
us e s hould be
v ie w a s a te m p or a r y m e a s ur e , a lw a ys in c om bina tion w ith s e d a tion a nd
c los e m e d ic a l
s up e r v is ion.
D e te r m ine w he the r or not the p a tie nt is c onfus e d ; look for a n und e r lying c a us e ,
e .g.,
ne ur ologic a l, m e ta bolic , e tc . (s e e p a ge 2 9 4 ). M a na ge m e nt d e p e nd s on the
und e r lying c a us e .
I f the a gita tion is a s s oc ia te d w ith a n xie ty, s e e p a ge 2 9 1 ; if a s s oc ia te d w ith
p s yc h otic
d is or d e r s , s e e p a ge 3 0 0 .
A lc oholic p a tie nts c a n e xp e r ie nc e w ithd r a w a l s ym p tom s w ithin 6 to 2 4 hour s
a fte r the y
s top d r inking. I n the e a r ly p ha s e ( p r e - d e lir ium tr e m e ns ) , th e m a nife s ta tions
inc lud e
ir r ita bility, a ge n e r a l fe e lin g of m a la is e , p r ofus e s w e a tin g a n d s h a kin g.
W ith d r a w a l
s yn d r om e s h ould be ta ke n in to c on s id e r a tion in p a tie n ts w h o a r e
hos p ita lis e d a n d
the r e for e for c e d to s top d r inking a br up tly.
A t a m or e a d v a n c e d s t a ge ( d e lir ium t r e m e n s ) , a git a tion is a c c om p a n ie d
by fe v e r ,
m e nta l c onfus ion a nd v is ua l ha lluc ina tions (zoop s ia ).
P r e - D T s ym p t om s c a n be p r e v e n t e d or t r e a t e d w it h : diazepam P O ( 4 0
m g/ d a y in
4 d iv id e d d os e s 6 hour s a p a r t for 1 to 3 d a ys , the n r e d uc e a nd s top ov e r 7
d a ys ) + or a l
hyd r a tion (3 litr e s of w a te r / d a y) + thiamine I M (1 0 0 m g/ d a y for a t le a s t 3 d a ys ).
In p os t-op e r a tiv e p a tie nts , s ta r t w ith the p a r e nte r a l r oute : diazepam s low I V , 5 to
10 m g
