Curriculum · Mental Health / Psychiatry
Acute agitation and rapid tranquillisation
What it is
Control of behavior in an agitated patient is a separate question from treatment of the episode behind it, and the drug is not the same. In a manic patient the atypical antipsychotic that is more effective as first line for the acute manic episode, for example olanzapine or quetiapine, is not for control of behavior; control of behavior in a manic patient is with a benzodiazepine, lorazepam or diazepam. Benzodiazepines may be useful when there is prominent agitation in acute mania, and electroconvulsive therapy has also been shown to be effective in mania.
How it is treated
Delirium runs the other way, and it is a common trap. Delirium is a medical emergency and is best managed in the medical floor. Its core feature is clouding of consciousness, and the course is episodic and usually worsens at the evening, which is called sundowning syndrome. Diazepam and other long acting benzodiazepines may worsen the symptoms and cause more confusion, so they must be avoided, unless they are used to treat alcohol related withdrawal symptoms. Haloperidol is commonly used to treat agitation, and lorazepam, a short acting benzodiazepine, can be used to treat insomnia. Not every difficult behaviour is agitation, and telling the two apart decides whether a drug is given at all. Wandering is a common symptom associated with major neurocognitive disorder: a woman who has been wandering into other people's rooms and has tried to leave the nursing home a few times, but who on examination is pleasant and physically healthy and is neither agitated nor psychotic, is best managed by providing a safe environment in which she can engage in the behaviour, rather than by trying to prevent it with chemical or physical restraints. Using physical or chemical restraints to constrain wandering behaviours can easily result in injury to the patient, so lorazepam, haloperidol, risperidone and physical restraint are all the wrong answer there.