16 Psychiatry
Delirium (see also p. 153)
How would you diagnose delirium?
An acute onset and fluctuating course is valuable diagnostically. Delirium represents an acute generalised impairment of cognitive function (see Information box). The primary feature is disorientation in time and place (more rarely person). A well patient should know the day of the week, month and year (people who are well can occasionally get the date and time wrong). They should know that they are in hospital, its name and location, and the name of the ward. Other psychoses do not affect orientation.
• ‘Clouding of consciousness’: refers to the variable level of attention seen in delirium, so that the patient cannot learn information and therefore cannot recall it.
• Visual hallucinations or illusions: are commonly present, so the patient may mistake a curtain movement in a dimly lit ward as a threatening person, resulting in extreme fear and agitation, especially at night.
• Persecutory delusions: are the most common and may make patients refuse food, drink and medicines because they believe that they are being poisoned. Alternatively, these delusions can cause aggression as patients defend themselves against a perceived threat.
What were the predisposing factors in this patient?
• Extremes of age (the young and old)
• Newly prescribed or multiple medications
• Prolonged operative procedure and anaesthesia
• Immobilisation and social isolation
• Dislocation to an unfamiliar environment (such as admission to hospital)
• Sensory deficits (e.g. visual or hearing) and extremes (overload or deprivation).
Specific causes of delirium include:
• Epilepsy (ictal, interictal, postictal)
• Neoplasm (intracranial or extracranial
• Other brain-space-occupying lesions (e.g. abscess)
• Metabolic encephalopathies (e.g. hypoglycaemia, hypoxia, hyponatraemia)
• Infections (intracranial and systemic)
• Drugs and poisons (see p. 519)
• Withdrawal from drugs (e.g. alcohol and sedatives; see p. 521)
• Vascular (cerebral or myocardial)
How would you investigate this patient?
Nursing care
A carefully controlled consistent and balanced environment is essential:
• Windows that do not allow exits
• Minimal stimulation by noise
• Persistent orientation by nurses and notices (a very disturbed patient may require one-to-one nursing temporarily)
• Minimal visitors: only those the patient knows well
• Reverse dehydration and do not neglect nutrition
Management
• Delirium requires urgent management because complications (e.g. falls, pressure ulcers and infections) can exacerbate the condition and contribute to significant mortality, particularly in the elderly.
• Find the cause and reverse it.
• A psychiatric opinion can be useful regarding differential diagnosis (see below) and management.
• Reduce all drug treatments to a minimum (see p. 521). Avoid anti-psychotic drugs unless the patient is a danger to him- or herself (or others), is distressed or if the patient’s general health is suffering.
• Symptomatic treatments include anti-psychotic drugs, initially in small doses, avoiding strong anti-muscarinics.
Drug therapy
• Haloperidol by mouth: 1.5 mg then 1.5–5 mg up to three times a day depending on level of disturbance, sensitivity to drug and response. Note: liquid or tablet form; lowest effective dose; beware extrapyramidal side effects.
• Phenothiazines are best avoided because of their anti-muscarinic and alpha-blocking actions.
If intramuscular medication is required
These drugs should not be given intravenously. If the patient is sensitive to medication and extrapyramidal side effects (EPSEs) are likely or present, use an ‘atypical’ anti-psychotic drug, such as risperidone (starting at 0.5 to 1 mg orally). Check doses carefully. Reversal of acute EPSEs can be achieved with a low dose of an anti-muscarinic drug (e.g. procyclidine 5 mg oral/IM).
Drugs and poisons as causes of delirium
Drugs causing delirium
Therapeutic drugs affecting the brain
Drugs with anti-muscarinic properties (common cause of delerium)
• Atropine and scopolamine: remember eye drops and pre-meds in anaesthesia
• Other topical cycloplegics and mydriatics
• Anti-parkinsonian agents: in patients with both Parkinson’s disease and pseudoparkinson’s, caused by dopamine antagonists
• Anti-depressants: especially tricyclics; amitriptyline most frequently
• Anti-psychotics: commonly the phenothiazines, especially chlorpromazine
How would you treat anti-muscarinic-induced delirium?
• General supportive nursing measures (see p. 517)
• Management usually conservative with observation of vital signs
• IV line and ECG Monitor if symptoms marked
• Oral or IM benzodiazepine (e.g. diazepam 10 mg adult dose) for agitation or seizures
• Cholinergic therapy with an anticholinesterase (physostigmine) is potentially hazardous (heart block, bronchospasm, respiratory failure) and used, if at all, for life threatening cases (uncontrolled seizures, coma, respiratory depression). Discuss with senior and/or poisons unit.
Drug withdrawal
Clinical presentation of sedative withdrawal (beyond delirium)
• Mental: anxiety, irritability, agitation, insomnia, nightmares.
• Arousal: tremor, sweating, tachycardia, sensitivity to light, noise and touch, muscle tension, uncommonly convulsions (with the exception of barbiturate withdrawal).
• Physical: nausea, anorexia, ‘flu-like’ symptoms, metallic taste.
Treatment of sedative withdrawal
• Replace the original class of drug in adequate doses to control the withdrawal symptoms, reducing to the minimum amount to prevent their re-emergence.
• Try to use a long-acting drug (e.g. diazepam), although sometimes the original drug itself is required.
• Therapeutic drug cessation can be achieved gradually later but the patient should be monitored closely and supported. Even patients with long-term dependence can manage some reduction and stabilisation on a reduced dose in the short term.
Dementia
Dementia is a global, acquired, progressive deterioration of intellect, memory and personality. Altered (‘clouded’) consciousness is not usually involved, in contrast to delirium, although dementia is often an underlying predisposition for delirium (see p. 515).
How does dementia present?
• Loss of memory, especially short term
• Episodes of increasing ‘confusion’
• Falls, with or without head injury
• Wandering and getting lost (getting into the wrong bed), especially at night
• Slow recovery and mobilisation after injury (e.g. hip fracture) or illness (e.g. myocardial infarct, pneumonia)
• Difficulty dressing: parietal lesion of dressing dyspraxia
• Behavioural disinhibition: frontal lobe sign
• Severe extra-pyramidal reaction to dopamine antagonists: Lewy body dementia.
What are the causes?
Differential diagnosis
• Amnestic syndrome: relatively specific memory loss, e.g. Wernicke–Korsakoff syndrome (see p. 527).
Investigations
• A corroborative history: duration, presentation, mood, alcohol, past history
• A Mini Mental State Examination (MMSE): a brief, structured bed-side screening test of memory
• Intelligence quotient (IQ) (performed by a psychologist) to confirm cognitive decline
• HIV testing after counselling in at-risk group
• CT/MRI brain scan: tumour, subdural haematoma, normal pressure hydrocephalus and infarcts might confirm generalised cerebral atrophy
• EEG: diffuse slow waves are rare before 75 in normal health. A normal EEG would suggest an alternative diagnosis
Examination
• Cardiovascular, neurological and endocrine system: to exclude secondary causes.
• Simple cognitive screening bedside tests: dementia may be suggested by the quality of the responses, e.g. ‘perseveration’ (repeating a response beyond the relevant question), ‘confabulation’ (inventing recollections to compensate for memory loss).
Information
Simple cognitive screening
• Orientation in time, place and person: ask day, month, year; ward, hospital, town/city, country; identity of relatives or key ward staff
• Attention and concentration: ask patient to recite the days of the week, or the months of the year, backwards (should be 100% accurate)
• Verbal short-term memory: teach patient to immediately recite a name and address accurately (a test of registration: they should be able to do this in two attempts). Then ask the patient to recall the name and address 5 min later (test of memory recall; should recall 95% of the individual items)
• Long-term memory: tests of general information, e.g. recent news, world events or on a subject of their interest
• Premorbid intelligence (necessary to judge whether there has been a deterioration in intellect): establish level of education achieved and occupation
How would you manage a case of dementia?
• Stop anti-muscarinic drugs, if possible.
• Involve a psychiatrist early regarding diagnosis and management.
• Acetyl cholinesterase inhibitors may be indicated in early Alzheimer’s disease (e.g. donepezil, galantamine or rivastigmine) and memantine (affects glutamate transmission) in conjunction with specialist advice from old-age psychiatry team (see p. 155).
• Low-dose haloperidol (e.g. 0.5 mg) can help control agitation and any accompanying delusions.
• Short-acting hypnotics, such as temazepam, can help insomnia.
• While on the ward, ensure adequate fluids, nutrition and treatment of constipation and any other reversible causes of incontinence.
• If possible, discharge home as soon as possible to avoid disorientating experience of admission.
• Involve the nearest relatives only.
• Referral to old-age psychiatry specialist dementia services.
Delirium tremens (DT)
What are the clinical features of DTs?
• Coarse tremor (which may affect the whole body)
• Disorientation in place and time
• Excessive sympathetic drive:
• Hallucinations: classically visual and frightening, but may be tactile or auditory; small animals (insects, spiders, rats) advance menacingly towards and over the patient
How would you treat DTs?
• Admit the patient to an acute medical bed.
• General measures (see Delirium, p. 517).
• Particularly treat electrolyte and fluid imbalances.
• Treat any co-morbid disorder.
• Oral thiamine 200 mg daily even in the absence of Wernicke–Korsakoff encephalopathy, the specific signs of which can be missed in the presence of severe withdrawal symptoms. Treatment must be given early if long-term dementia is to be prevented.
• Parenteral high-dose thiamine is necessary in the presence of a thiamine-related encephalopathy.
Specific drug therapy
• Follow a protocol if your hospital has one.
• Oral treatment is preferred unless the patient is severely distressed and disturbed. Doses suggested below may not be adequate to control the initial condition, and more may be required:
• Chlormethiazole capsules should be avoided because of problems with dependence and adverse effects.
• Doses of chlordiazepoxide up to 200 mg spread over the first 24 hours may be required initially in uncontrolled, severe, life endangering withdrawal with fits. The patient must be monitored constantly with resuscitation facilities available.
• Prophylactic anti-convulsants (e.g. carbamazepine 200 mg × 2 daily) should be given when there is a previous history of withdrawal convulsions or if the current presentation has been complicated by fits.
Depression
Depressive illness is common but often undetected or inadequately treated (see Information box, below). The central symptom is usually low mood. Associated symptoms reflecting effects on an individual’s behaviour, thoughts, perceptions and cognition become more marked as the severity of the condition increases.
In patients presenting acutely, depression can be associated with:
• Suicide attempt or deliberate self-harm (see p. 533)
• Concurrent physical illness (particularly chronic, painful, life-threatening or disfiguring)
• Unpleasant and demanding treatment for physical illness
• Destabilisation of a chronic condition, exacerbation of physical symptoms or excessive functional impairment
• Medical treatment refusal or poor compliance
• Weight loss, poor nutrition, self-neglect or unusual behaviour (e.g. heavy drinking)
• Increased somatic concern and unexplained physical symptoms.
Information
Depression can be broadly categorised:
• Mild: low mood often associated with anxiety symptoms
• Moderate: increasingly low mood, depressive thinking (e.g. suicidal) with biological symptoms (sleep disturbance with early morning waking, mood worse in the morning, reduced appetite, weight and libido)
• Severe: more intense low mood, suicidal thoughts with development of psychotic symptoms, including delusions and hallucinations (most often associated with suicide)
How would you assess this case?
• Accurate diagnosis requires a detailed history, with a reliable corroborative account if possible, and mental state examination.
• Factors that increase vulnerability to develop depression:
Information
Assessment of mental state
Summary of the key areas of observation and enquiry:
• Appearance/behaviour: general state of health, self-care, facial expression, eye contact, rapport, cooperation, posture and movement
• Speech: rate, tone, quantity, volume, spontaneity and form
• Perceptions: auditory or visual hallucinations (a perception in the absence of a stimulus), presence of which may be suggested by abnormalities of general behaviour
• Cognitive assessment (see Information box, p. 525)
• Insight: recognition and attribution of illness/awareness of merits of treatment
How do you identify a severe case?
In moderate to severe depression, mental state examination may reveal:
• Depressed facial appearance, tearfulness, reduced expression, poor eye contact, retardation of movement or agitation.
• Speech: may be slow and impoverished.
• Persistent, pervasive low mood worse in the morning, anhedonia (loss of interest in pleasure), abulia (inability to make decisions), reduced motivation or energy. Note: these complaints are not usually attributable to physical illness alone – psychologically healthy people often cope resiliently with physical illness.
• Suicidal thoughts may be present and should always be enquired for and explored carefully:
Biological symptoms are often present. You should ask about feelings of hopelessness (often associated with suicidal contemplation). Other mood-congruent thoughts that might be present include pessimism, feelings of guilt, worthlessness, self-reproach, persecution, impoverishment. In severe depression thoughts can reach delusional intensity and may be associated with perceptual abnormalities, e.g. condemnatory auditory hallucinations. Tests of cognitive function may be poorly performed due to impaired memory and concentration. In the elderly with fragile but intact cognitive function severe depression may suggest a dementia (‘depressive pseudodementia’).
How would you manage this case?
• Exclude organic cause: this patient has an anaemia. Investigations show an Hb of 76 g/L, MCV 101, ESR 31 mm/hour, white cell count 4200.
• Consider other possible organic causes of depressive symptoms (see Information box, below).
• Specific management depends on the severity:
• Establish if the patient is at risk (see p. 525).
• Refer to psychiatric team but explain this to the patient first.
• Assess capacity if patient is refusing treatment.
• Psychiatric treatment can usually be managed by the liaison team on the medical ward: this is preferable if medical problems require treatment. A psychiatric nurse is required to observe the patient.
• The patient will require regular review.
• Psychiatric treatment or admission using the Mental Health Act is considered on the basis of severity and risk.
• Identify aftercare support from family or professionals having discussed this with the patient.
What medication would you consider and how would you begin treatment?
When prescribing anti-depressants:
• A psychiatric opinion is usually obtained.
• Medication is most effective in moderate and severe depression.
• Compliance is essential and enhanced by good communication. Good prescribing practice includes explanation of:
• Older tricyclic anti-depressants (TCAs) have proven efficacy but significant side effects (e.g. anti-muscarinic, postural hypotension, cardiotoxic in overdose) and have largely been superseded by newer drugs. TCAs are still useful if newer agents aren’t tolerated, sedation is desirable or if the patient has had a previous effective response. Avoid prescribing large quantities for outpatients and on discharge.
• Most commonly prescribed of newer anti-depressants are selective serotonin reuptake inhibitors (SSRIs), which can cause nausea but in general are better tolerated, cause fewer problematic interactions with other drugs and are less toxic in overdose.
• Difficult to predict which anti-depressant will be best tolerated in view of range of side effects and significant individual variation.
• Elderly patients often require lower starting dose and more gradual dose increase.
• As a general rule, treatment should continue for at least 6 months after recovery from acute episode.
Suicide and deliberate self-harm (DSH)
• Escape from overwhelming stress
• To effect a change in personal circumstances (‘cry for help’)
• Wish to die: serious suicidal intent is evident in up to one-fifth of DSH presentations.
Many of the components of the assessment of deliberate self-harm can be applied to patients who describe having ‘suicidal thoughts’.
How would you manage this case of deliberate self-harm?
• Examine the patient, check conscious level (GCS – 15), respiratory rate (15/min), blood pressure (104/72).
• Attend to immediate medical requirements (overdose, see p. 396). Most patients will be admitted to hospital after overdose for specific treatment or observation. Patients may underestimate or understate the number of tablets taken.
• When medical condition is stable, interview if possible with collateral history from reliable informants aiming to:
1 Identify mental illness
• Most completed suicides are associated with a psychiatric diagnosis, most often a depressive illness (see p. 528). Many suicide victims have seen their doctor in the preceding weeks.
• Conversely, clear psychiatric illness is evident in less than one-third of DSH presentations. Most occur after a ‘life event’, with up to half following a relationship problem.
• Most common diagnoses include depression, alcohol dependence, personality disorders (borderline, anti-social).
2 Detect patients at risk of completed suicide
• Serious suicide attempts form a minority of DSH presentations but individuals who harm themselves have a greatly increased risk of suicide compared to the general population.
• A high proportion of suicide victims have a previous history of DSH.
• An indication of risk should be documented in the notes with an appropriate plan of action.
Information
Features associated with increased suicide risk:
• Demographic: socially isolated (divorced, widowed, never married); male (rates in young men increasing steeply); older age, minority groups (e.g. young Asian women); unemployed; low socioeconomic class; certain professions (doctors, dentists, vets, farmers); individuals with access to means (drug users, gun owners)
• The history: present or previous psychiatric diagnosis (particularly depression, schizophrenia), recent hospital discharge, previous DSH, recent life event (e.g. bereavement, retirement, divorce), physical illness (chronic painful illness, CNS disorders (MS, epilepsy), cancer, HIV), family history of psychiatric illness/suicide, alcohol/drug misuse, impulsive personality
• The mental state: agitation, depressed mood, suicidal thoughts, hopelessness, delusions, hallucinations, insight in early schizophrenia
3 Explore suicidal thoughts
• Never avoid detailed but tactful questions concerning suicidal ideas and intentions.
• Responses need to be assessed in the context of the overall presentation, especially if the patient is unforthcoming.
• Establish the patient’s thoughts about the episode of self-harm.
• Find out if the patient wishes to die: ask questions to assess underlying mental state, e.g.:
• Assess plans for further attempts: method, circumstances.
• Identify protective factors: reasons for not wishing to die, e.g. change in circumstances, family, dependants.
Further management: psychiatric liaison referral
• Many hospitals have dedicated staff to assess all deliberate self-harm presentations in liaison with the psychiatric team. Learn to recognise individuals in need of immediate attention or treatment.
• Most patients do not require further psychiatric intervention.
• If a significant psychiatric disorder is identified, management can be initiated as an inpatient or outpatient in communication with the patient’s doctor.
• High-risk cases or those with severe symptoms will require psychiatric admission – if necessary using compulsory detention. Level of risk and nursing observation required should be communicated and documented.
Difficult management problems
1 Repeated presenters (e.g. self-laceration, overdose, actual or threatened)
• Behaviour often associated with personality-related vulnerabilities (e.g. borderline personality), dysfunctional coping and intermittent stress in the absence of other clear psychiatric diagnosis.
• A planned, consistent multidisciplinary response coordinated through the psychiatric team can sometimes help provide containment.
• Reduction in the maladaptive expression of distress may occur with support from a key worker, counselling, psychotherapy or enhanced social support.
• Occasional, psychiatric crisis admissions may be required but these should be kept to a minimum in favour of longer-term strategies.
• Low-dose anti-psychotic medication may help to reduce arousal and subjective distress, avoiding prescriptions for large quantities and identifying a care professional or other reliable, willing carer to help supervise the medication initially if required.
2 Refusal of medical treatment
• Involve senior colleague and/or psychiatrist (to determine if mental disorder impairs capacity).
• Explain clearly the risks of not having treatment.
• Assess capacity to make informed decision and record it (see Information box, below).
• If treatment is considered necessary, attempt persuasion/negotiation, if possible including a friend or relative the patient trusts.
• Continue trying to gain the patient’s trust, explaining merits of treatment and risks of refusal. A patient who is frightened, angry or presenting in crisis may choose to cooperate as his/her distress settles.
• If the patient has capacity and refuses treatment, a second opinion from a senior is advisable.
• It is essential that discussions with the patient, management decisions and their reasons are clearly documented in detail and discussed with a senior colleague.
• The Mental Health Act can be used to detain a patient who is refusing medical treatment in hospital if the patient is exhibiting symptoms of mental disorder that places their health, safety or that of others at risk and provides for the administration of treatment for a mental disorder that might be impairing a patient’s capacity to decide on their medical treatment.
Information
Assessing capacity to withhold consent to examination, investigation or treatment
• Adults are presumed competent to refuse medical advice and treatment
• Decisions with more serious implications require greater capacity
• A patient lacks capacity if some impairment or disturbance of mental functioning causes inability to decide whether to consent to or refuse treatment, which is determined by:
• Temporary incapacity (e.g. due to head injury, altered mood, alcohol) may permit essential life-saving treatment without consent
3 Patients unwilling to remain in hospital for further assessment
• The patient’s capacity to make this decision should be documented.
• If considered at risk, appropriate staff should attempt to detain in hospital under common law to permit an urgent mental health assessment by a psychiatrist and approved social worker. Reasons relating to the patient’s behaviour, mental state and possible risks should be carefully documented.
4 Intoxicated or violent patients
• The assistance of hospital security or the police might be necessary.
• Assessment will be more productive if the patient is given time to sober up (in which case the behaviour may completely settle), as long as the patient or others are not put at risk.
• Consider psychiatric opinion if an underlying psychiatric disorder is thought likely.
Progress.
This patient had taken approximately 20 tablets of paracetamol (10 g) and was given N-acetylcysteine intravenously (p. 401) and her liver function remained normal. This was her first episode of DSH and she realised the seriousness of what she had done and the necessity for future counselling.
Acute anxiety
Differential diagnoses such as a respiratory emergency (e.g. asthma, pulmonary embolus, and pneumothorax) must first be excluded (p. 325). Panic attack (see also p. 332) is suggested by:
• Subjective complaint of difficulty breathing in rather than out
• Respiratory alkalosis (causing tetany and relative hypocalcaemia)
• Arterial blood gases will show hypocapnia but normal oxygen levels
Management
Case history (2)
The nursing staff inform you that a 55-year-old man is refusing to have any more haemodialysis, having just started this treatment. A phobic reaction to dialysis is suggested by avoidance, abnormal fear and sympathetic over-drive, during dialysis or talking about it. Depressive illness is a common association of anxiety and should always be excluded (see p. 333). These phobias are also common in oncology (vomit phobia with chemotherapy).
How would you manage this patient?
• Support and sympathy with explanation of the phobia.
• Minor tranquilliser (see above) short term only: up to 2 weeks of diazepam 5 mg × 3 daily (long-half-life drugs are better).
• Ask a psychologist to consider graded exposure therapy.
• A selective serotonin reuptake inhibitor (sertraline, citalopram, paroxetine, fluoxetine) is often required in the presence of co-morbid depressive illness.
What are the physical symptoms and signs of anxiety?
• Photosensitivity: patient might be wearing dark glasses
• Phonosensitivity: patient cannot bear any noise
• Associated hypocapnia and respiratory alkalosis: causing relative hypocalcaemia (tingling or numbness) in extremities and face, light-headedness and tetany (see p. 333)
Always look for the following associations
• Phobias: abnormal fear and avoidance of particular situations or things
• Depressive illness (see p. 528)
• Obsessive–compulsive disorder: repetitive ruminations that are inconsistent with the personality, along with repeated behaviours; checking excessively or hand-washing because of fears of germs.
Opiate dependence
Effects of opiate use
Heroin addicts are 16 times more likely to die than individuals of equivalent age, chiefly as a result of overdose. They frequently present in the acute hospital setting.
How would you assess this man?
• Attempt to defuse the situation and prevent an escalation of disturbed behaviour.
• Take history of drug use including each drug taken, amount and route.
• Obtain information from other sources:
• Examine for evidence of opiate use: withdrawal symptoms begin within 12 h of last use and increase in severity over the first 48 h. With longer-acting opioids such as methadone, onset of withdrawal symptoms can be delayed and their duration increased. Opiate withdrawal that is uncomplicated by other drugs is subjectively unpleasant but not life-threatening, and can present with:
• Look for evidence of recent drug use, e.g. needle marks, phlebitis, skin abscesses. Subjective complaints include craving, poor sleep (which can last months), abdominal cramps, nausea, diarrhoea, musculoskeletal pain.
How would you manage and treat this patient?
Prescribing methadone
• Oral methadone mixture should be given if you are satisfied a significant habit exists, and this is confirmed by reliable sources or objective evidence of use or withdrawal symptoms.
• If possible, seek advice from local specialist drug unit.
• There are published guidelines on clinical management of drug use and dependence – a copy should be available in the hospital pharmacy.
• Any registered medical practitioner can prescribe methadone.
• Methadone tablets should not generally be prescribed because of their potential for misuse.
• Dose required to control withdrawal can be carefully titrated in hospital. Start at low dose of methadone, e.g. 10 mL (1 mg per 1 mL mixture). Further 10 mL at 4-hourly intervals is used until objective signs of withdrawal are controlled. Establish daily requirement.
• Doses above 40 mL (40 mg) daily should only be taken if there is reliable information that the patient has been receiving higher regular prescription, but even in this case dose should be gradually titrated upwards.
Symptomatic treatment of withdrawal symptoms may be indicated and includes:
How do you proceed?
Urgent cardiorespiratory support should be available.
• Assess evidence of opiate toxicity (an acute medical emergency):
• Examine for other causes of impaired consciousness (e.g. head injury).
• Administer opiate antagonist naloxone (0.8–2 mg): IV naloxone has a high affinity for opiate receptors and reverses the signs of toxicity by displacing ingested opiates. Life-threatening symptoms may recur in view of the relatively short half-life (minutes) of naloxone, which may need to be re-administered depending on the half-life of the opiate taken (e.g. half-life of methadone is over 24 h).
Heroin overdose, causing life-threatening respiratory depression, can occur after a period of abstinence as physical tolerance is reduced.
The disturbed patient
Underlying causes of disturbed behaviour include:
1 Organic mental disorders
• Dementia: patients can be restless, aggressive and may wander because of disorientation. May be exaggerated by coexistent physical conditions, e.g. acute infection, constipation.
• Delirium (see p. 515): arising from a number of causes and commonly associated with disturbed behaviour due to misinterpretation of surroundings. Conscious level is impaired, often with fearfulness, perceptual abnormalities (visual or auditory hallucination) and abnormal thinking (e.g. persecutory delusions).
2 Other psychiatric disorders
• Anxiety and depression (see pp. 538, 528): can be associated with agitation, restlessness and high arousal. Major depression is associated with suicidality and self-harm.
3 Substance use
Alcohol intoxication or withdrawal (see p. 526). Use of other drugs, e.g. stimulants, hallucinogenics, solvents.
Management
• Aim to identify cause and take control of the situation.
• Of paramount concern is the safety of the patient, other patients, yourself and colleagues.
• Disturbed patients should be assessed in a safe area with adequate staff support (medical, nursing, security) and access to a panic alarm.
• Consider the possibility that the patient might be concealing a weapon.
• Specific management depends on the severity of the disturbed behaviour and the cause.
• Clues to the diagnosis can often be found by carefully observing an uncooperative patient even from a distance while awaiting staff support, e.g. impairment of the conscious level may suggest delirium, drug intoxication; a smell of alcohol may be apparent. A major psychotic mental illness may be suggested from the appearance, behaviour and speech, e.g. preoccupation, suspiciousness, over-activity, thought disorder, delusional ideas.
• Additional background information from reliable informants is invaluable but not always possible.
After an initial assessment of the situation, and with appropriate staff support: a further attempt to calm this patient should be made.
Use interpersonal skills/de-escalation
• Approach the patient in a non-confrontational manner, avoiding invasion of their personal space – disturbed patients may misinterpret their surroundings and the motives of others and whereas their behaviour can create fear in those around them they are often defensive and frightened themselves. The likelihood of cooperation is enhanced if the patient feels safe.
• Clear communication with sensitive statements and questions is often helpful.
• Ask the patient what he/she wants; listen and offer advice and reassurance.
• Attempt to interview the patient in a safe, relaxed setting.
• If initial attempts to engage the patient fail, providing the situation has not escalated, give the patient some space and time before trying again. Make sure the patient is appropriately observed. The time can be used to consider alternative management.
Patient remains uncooperative
Medication
• Reduction in arousal can be achieved by a carefully planned regimen of anti-psychotic medication, preferably given orally and in liquid form in the first instance.
• Before deciding on intramuscular medication, all non-invasive measures to calm the patient and secure cooperation should be attempted. Even patients who present as highly disturbed initially may agree to take oral medication when it becomes clear that the situation is under control.
• Giving intramuscular medication to a potentially resistive and aroused patient is not without risk, which must be outweighed by risks of inaction and clearly documented.
• Resuscitation equipment must be available.
• A patient receiving intramuscular medication under restraint should be held in the prone position to protect the airway. The patient is released gently when signs of relaxation and calming become evident and placed under constant observation.
• The dose of anti-psychotic medication can be reduced by combination with a sedating benzodiazepine in the short term.
• Start at low doses and increase gradually depending on response. A suitable regime is:
• Vital signs (pulse, temperature, blood pressure, conscious level) should be monitored every 15 min.
• While the behaviour continues to present a risk, the dose may be repeated at intervals of 30 min to 1 h until the patient is settled, subject to regular monitoring of vital signs.
