Psychomotor agitation in major depressive disorder is a predictive factor of mood-switching. The expert consensus guideline series. Treatment of behavioral emergencies 2005. Are Low Doses of Antipsychotics Effective in the Management of Psychomotor Agitation? A Randomized, Rated-Blind Trial of 4 Intramuscular Interventions Nonpharmacological therapeutic techniques to decrease agitation in geriatric psychiatric patients with dementia. Psychometric Testing of the Agitation Severity Scale for Acute Presentation Behavioral Management Patients in the Emergency Department Does psychomotor agitation in major depressive episodes indicate bipolarity? [Patients in a state of agitation at the admission service of a Rouen hospital emergency department]. Efficacy of nonpharmacologic interventions for agitation in advanced dementia: a randomized, placebo-controlled trial. Assessment of agitation in Alzheimer's disease: the agitated behavior in dementia scale. Alzheimer's Disease Cooperative Study. The response of agitated behavior to pain management in persons with dementia. A comparison of two novel antipsychotics in first episode non-affective psychosis: one-year outcome on symptoms, motor side effects and cognition The effect of staff training on agitation and use of restraint in nursing home residents with dementia: a single-blind, randomized controlled trial. Targeted Interdisciplinary Model for Evaluation and Treatment of Neuropsychiatric Symptoms: A Cluster Randomized Controlled Trial. Symptomatic predictors of ECT response in medication-nonresponsive manic patients. The relationships of environment and personal characteristics to agitated behaviors in nursing home residents with dementia. Early onset of antipsychotic response in the treatment of acutely agitated patients with psychotic disorders Validation of the behavioural activity rating scale (BARS): A novel measure of activity in agitated patients
BACKGROUND The relationship between psychomotor agitation in unipolar depression and mood-switching from depression to manic , hypomanic and mixed states has been controversial . We investigated the future risk of initial mood-switching as a function of psychomotor agitation in unipolar depression . METHODS We identified 189 participants diagnosed with major depressive disorder ( MDD ) . We divided all patients with MDD into two categories ( 1 ) agitated patients ( n=74 ) , and ( 2 ) non-agitated patients ( n=115 ) . These groups were prospect ively followed and compared by time to mood-switching . Kaplan-Meier survival curves , log-rank test for trend for survivor functions , and Cox proportional hazard ratio estimates for a multivariate model were conducted to examine the risk of mood-switching by psychomotor agitation . RESULTS During follow-up , mood-switching occurred in 20.3 % of the agitated patients and 7.0 % of the non-agitated patients . In the Kaplan-Meier survival estimates for time to incidence of mood-switching with agitated or non-agitated patients , the cumulative probability of developing mood-switching for agitated patients was higher than those for non-agitated patients ( log-rank test : χ(2)=7.148 , df=1 , p=0.008 ) . Survival analysis was also performed using Cox proportional hazards regression within a multivariate model . The agitation remained significantly associated with incidence of mood-switching ( HR=2.98 , 95 % CI : 1.18 - 7.51 ) . LIMITATIONS We did not make a clear distinction between antidepressant-induced mood-switching and spontaneous switching . CONCLUSIONS The main finding demonstrated that MDD patients with agitation were nearly threefold as likely to experience mood-switching , suggesting that psychomotor agitation in MDD may be related to an indicator of bipolarity OBJECTIVES Due to inherent dangers and barriers to research in emergency setting s , few data are available to guide clinicians about how best to manage behavioral emergencies . Key constructs such as agitation are poorly defined . This lack of empirical data led us to undertake a survey of expert opinion , results of which were published in the 2001 Expert Consensus Guidelines on the Treatment of Behavioral Emergencies . Several second-generation ( atypical ) antipsychotics ( SGAs ) are now available in new formulations for treating behavioral emergencies ( e.g. , intramuscular [ i.m . ] olanzapine and ziprasidone ; rapidly dissolving tablets of olanzapine and risperidone ) . Critical questions face the field . The SGAs are significantly different from the FGAs and from each other and have not been studied in unselected patients as were the FGAs . Can the SGAs can be thought of as a class , do all antipsychotics have similar anti-agitation effects in different conditions , and , if equally effective , what limits might their safety profiles impose ? Should antipsychotics be used more specifically to treat psychotic conditions , while benzodiazepines ( BNZs ) alone are used nonspecifically ? Few data are available concerning combinations of SGAs and BNZs , and findings concerning the traditional combination of haloperidol plus a BNZ may not be relevant to combinations with SGAs . The culture is also evolving with more emphasis on patient involvement in treatment decisions . An international consensus has been developing that calming rather than sedation is the appropriate endpoint of behavioral emergency interventions . We undertook a new survey of expert opinion to up date recommendations from the earlier survey . METHOD A written survey of 61 questions ( 1,020 options ) was mailed to 50 experts in the field , 48 ( 96 % ) of whom completed it . The survey sought to define level of agitation at which emergency interventions are appropriate , scope of assessment depending on urgency and patients ' ability to cooperate , guiding principles for selecting interventions , and appropriate physical and medication strategies at different levels of diagnostic confidence for a variety of provisional diagnoses and complicating conditions . A modified version of the R AND Corporation 's 9-point scale for rating appropriateness of medical decisions was used to score most options . Consensus was defined as a non-r and om distribution of scores by chi-square " goodness-of-fit " test . We assigned a categorical rank ( first line/preferred , second line/alternate , third line/usually inappropriate ) to each option based on the 95 % confidence interval around the mean . Ratings were used to develop guidelines for preferred strategies in key clinical situations . This study received financial support from multiple sponsors , with the panel kept blind to sponsorship to reduce possible bias . Medication ratings were based on responses of only those respondents with direct experience with each drug . In reporting practice patterns , the panel was asked to respond based on actual data rather than estimates . RESULTS The expert panel reached consensus on 78 % of the options rated on the 9-point scale . The responses suggest that physicians can make provisional diagnoses with some confidence and that pharmacological and nonpharmacological interventions are selected differentially based on diagnosis and other salient demographic and medical features . BNZs are recommended when no data are available , when there is no specific treatment ( e.g. , personality disorder ) , or when they may have specific benefits ( e.g. , intoxication ) . No single SGA emerges as a nonspecific replacement for haloperidol ; instead , different SGAs are preferred in various circumstances consistent with current evidence . To the degree that haloperidol is recommended , it is almost always in combination with a BNZ ; haloperidol alone is preferred only in the medically compromised . In contrast , the SGAs are more often recommended for use alone , and the panel would avoid combining BNZs with some SGAs . Oral risperidone alone or combined with a BNZ receives strong support in a variety of situations . Oral olanzapine was rated very similarly to risperidone , with slightly higher ratings than risperidone in situations where it has been studied ( e.g. , schizophrenia , mania ) and slightly lower ratings where it has not been studied or safety may be a concern ; there was less support for combining oral olanzapine with a BNZ . For oral treatment of agitation related to schizophrenia or mania , olanzapine alone , risperidone alone or combined with a BNZ , and haloperidol plus a BNZ are first line , with strong support also for combining divalproex with the antipsychotic for presumed mania . Oral ziprasidone and quetiapine generally received similar second-line ratings in most situations . If a parenteral agent is needed , i.m . olanzapine alone received somewhat more support than i.m . ziprasidone alone ; however , there was more support for i.m . ziprasidone alone or combined with a BNZ than for i.m . olanzapine plus a BNZ , probably reflecting safety concerns . For example , for a provisional diagnosis of schizophrenia , first-line parenteral options are i.m . olanzapine or ziprasidone alone or i.m . haloperidol or ziprasidone combined with a BNZ . Neither of the new parenteral formulations received as much support as traditional agents ( i.m . BNZs , i.m . haloperidol ) when no data are available or the diagnosis involves medical comorbidity or intoxication . When initial intervention with risperidone , ziprasidone , or haloperidol is unsuccessful , the panel recommended adding a BZD to the antipsychotic . However , when initial treatment with olanzapine or quetiapine is unsuccessful , increasing the dosage is recommended . Perphenazine was consistently rated second line and droperidol and chlorpromazine received third-line ratings throughout . CONCLUSIONS Within the limits of expert opinion and with the expectation that future research data will take precedence , these guidelines suggest that the SGAs are now preferred for agitation in the setting of primary psychiatric illnesses but that BNZs are preferred in other situations Background Psychomotor agitation can be associated with a wide range of medical conditions . Although clinical practice advocates the use of several drugs for the management of psychomotor agitation , there are still very few controlled studies comparing the profiles of action and the adverse effects of different drugs that induce tranquilization . Objectives The purpose of this study was to compare the efficacy and safety of 4 low-dose pharmacological interventions used to control psychomotor agitation guided by the clinical response . Methods Using a r and omized , rated-blind design , 100 agitated patients were assigned to receive 1 of 4 treatments : haloperidol ( 2.5 mg ) + promethazine ( 25 mg ) ( HLP + PMZ ) , haloperidol ( 2.5 mg ) + midazolam ( 7.5 mg ) ( HLP + MID ) , ziprasidone ( 10 mg ) ( ZIP ) , or olanzapine ( 10 mg ) ( OLP ) . Patients were evaluated just before the intervention and after 30 , 60 , and 90 minutes , using the Agitation-Calmness Evaluating Scale . Adverse effects were assessed within 24 hours after the intervention , using selected items from the UKU Scale ( Ugvalg Klinisk Undersgelser Side Effect Scale ) . According to the clinical indication , medication could be repeated twice after the first injection . Data were analyzed using general linear model with repeated measures and logistic regression . Results All treatment options promoted a reduction in agitation , without causing excessive sedation , although a lower reduction in agitation was observed with HLP + PMZ and ZIP compared with HLP + MID and OLZ . The need for an additional dose of medication was observed in 22 patients , and only 8 remained agitated during the entire 90-minute period . A higher risk for the development of extrapyramidal symptoms within the following 24 hours was observed with HLP + PMZ . Discussion Low doses of haloperidol combined with midazolam can be as effective as olanzapine in reducing psychomotor agitation without increasing the risk of extrapyramidal effects . Because of the higher risk for the occurrence of extrapyramidal symptoms , the combination of haloperidol with promethazine should be considered a second-line treatment option Agitation is not only a frequent and disturbing behavior for many patients with dementia , but it also troubles their caregivers and families . Many serious problems and side effects are associated with the use of medications to treat agitation ; therefore , alternative approaches to treating agitation must be assessed . The current article presents results from a quality improvement pilot project that examined the usefulness of a specially design ed , multisensory room intervention for geriatric psychiatric in patients with mild to moderate agitation . Thirty-two visits to the sensory room were made by 13 in patients with dementia . A significant decrease occurred in the Pittsburgh Agitation Scale ( PAS ) total scores over time from pre-room to post-room intervention , as well as 1-hour post-room intervention ( F = 95.3 , p < 0.001 ) . Significant effects were found for all PAS subscales ( i.e. , aberrant vocalizations , motor agitation , and resistance to care ) , with the exception of the aggression subscale . The multisensory room intervention was effective in decreasing some symptoms of agitation in the geriatric psychiatric patient , thus contributing to positive patient , family , and nursing outcomes Agitation is a vexing problem frequently observed in emergency department acute psychiatric patients , yet no instruments to measure agitation in this setting and population were found upon review of the literature . Previously developed agitation rating scales are limited by the length of observation they require , their need for participation by the patient , complexity in scoring , and a lack of validity in this setting and population . The purpose of this study was to psychometrically evaluate and refine an observation-based agitation scale for use with emergency department acute psychiatric patients . Using a method ological design , the 21-item Agitation Severity Scale was utilized to assess 270 adult psychiatric patients in the emergency setting in a prospect i ve , observational fashion . Reliability analysis , item analysis , exploratory factor analysis , and validity assessment s were completed . The relationship between Agitation Severity Scale scores and scores on the previously established Overt Agitation Severity Scale was evaluated . The instrument was reduced to 17 items representing four factors ( Aggressive Behaviors , Interpersonal Behaviors , Involuntary Motor Behaviors , and Physical Stance ) that accounted for nearly 70 % of observed variance , Cronbach 's & agr ; = 0.91 . Evidence of internal consistency reliability , equivalence reliability , construct validity , and convergent validity was established . Through this study , the 17-item Agitation Severity Scale demonstrated acceptable levels of reliability and validity when used with acute psychiatric patients in the emergency setting . This instrument holds promise as a method of enhancing clinical communication about agitation , evaluating the efficacy of interventions aim ed at decreasing agitation , and as a research tool Abstract Background Kraepelin ’s partial interpretation of agitated depression  as a mixed state of “ manic-depressive insanity ” ( including the current concept of bipolar disorder ) has recently been the focus of much research . This paper tested whether , how , and to what extent both psychomotor symptoms , agitation and retardation in depression are related to bipolarity and anxiety . Method The prospect i ve Zurich Study assessed psychiatric and somatic syndromes in a community sample of young adults ( N = 591 ) ( aged 20 at first interview ) by six interviews over 20 years ( 1979–1999 ) .  Psychomotor symptoms of agitation and retardation were assessed by professional interviewers from age 22 to 40 ( five interviews ) on the basis of the observed and reported behaviour within the interview section on depression . Psychiatric diagnoses were strictly operationalised and , in the case of bipolar-II disorder , were broader than proposed by DSM-IV-TR and ICD-10 . As indicators of bipolarity , the association with bipolar disorder , a family history of mania/hypomania/cyclothymia , together with hypomanic and cyclothymic temperament as assessed by the general  behavior inventory  ( GBI ) [ 15 ] , and mood lability ( an element of cyclothymic temperament ) were used . Results Agitated and retarded depressive states were equally associated with the indicators of bipolarity and with anxiety . Longitudinally , agitation and retardation were significantly associated with each other ( OR = 1.8 , 95 % CI = 1.0–3.2 ) , and this combined group of major depressives showed stronger associations with bipolarity , with both hypomanic/cyclothymic and depressive temperamental traits , and with anxiety . Among agitated , non-retarded depressives , unipolar mood disorder was even twice as common as bipolar mood disorder . Conclusion Combined agitated and retarded major depressive states are more often bipolar than unipolar , but , in general , agitated depression ( with or without retardation ) is not more frequently bipolar than retarded depression ( with or without agitation ) , and pure agitated depression is even much less frequently bipolar than unipolar . The findings do not support the hypothesis that agitated depressive syndromes are mixed states . Limitations The results are limited to a population up to the age of 40 ; bipolar-I disorders could not be analysed ( small N ) OBJECTIVE To determine the incidence and causes of agitation states in patients presenting at the Rouen University Hospital emergency room and to analyze the management scheme . PATIENTS AND METHOD A prospect i ve study was conducted over a 9 month period in 100 consecutive patients presenting a state of agitation assessed using the Overt Aggression Scale . A pre-planned management protocol was applied . RESULTS The incidence of states of agitation was 0.56 % . There were 43 women and 57 men , mean age 33 years . Most of the agitated patients were admitted between 6 p.m. and 4 a.m. ( 69 % ) . Over the 9 month period , 2 patients were admitted twice for agitation and 2 absconded . Low glucose level was the cause of agitation in 4 cases . Alcohol and /or drug use concerned 73 % of the agitated patients and was the most frequently observed triggering factor ( 17 % ) . Only 6 % of the patients had a regular employment . Physical restraining measures and sedation were required in 86 % and 84 % of the cases respectively . Among 67 patients given loxapine for sedation , 2 developed acute dyskinesia and 9 low blood pressure . One out of 4 patients were referred to a psychiatric unit . CONCLUSION Patients in a state of agitation are young , often female , and in a difficult socio-economic situation . Hypoglycemia is the main differential diagnosis . A triggering factor can often be identified . A state of agitation is not a repetitive condition but occurs as a short-lived episode in the patientís history . Such patients need rapid care to avoid further aggravation and disruption of the emergency room activity , and to prevent the patient from fleeing . Loxapine provides effective sedation but requires regular monitoring of blood pressure and can provoke acute dyskinesia in young subjects BACKGROUND A r and omized , placebo-controlled clinical trial was undertaken to determine the efficacy of nonpharmacologic individualized interventions ( individualized to address unmet needs such as boredom or pain ) in decreasing agitation in persons with dementia . METHOD Agitated nursing home residents with advanced dementia ( from 9 nursing homes in 5 locations in Maryl and , United States ) were r and omized into an  intervention group ( n = 89 ) and a  placebo control group ( n = 36 ) . On the basis of data from baseline assessment , a systematic methodology for individualizing nonpharmacologic interventions , Treatment Routes for Exploring Agitation ( TREA ) , was used with the intervention group : an unmet need was hypothesized , a corresponding treatment category was identified , and specifics of the treatment were chosen to fit the person 's need , past identity , preferences , and abilities . ( Unmet needs were hypothesized based on physician evaluations , structured staff interviews , relative question naires , direct observations of agitation with the Agitation Behavior Mapping Instrument [ the primary outcome measure ] and affect with Lawton 's Modified Behavior Stream [ the secondary outcome measure ] , and resident assessment s. ) TREA interventions were implemented for 2 weeks , and observations of agitation and affect were recorded . The study was conducted from June 2006 until December 2011 . RESULTS Relative to a control group , TREA interventions for unmet needs produced statistically significant declines in total ( P < .001 ) , physical nonaggressive ( P < .001 ) , and verbal agitation ( P = .004 ) and significant increases in pleasure ( P < .001 ) and interest ( P < .05 ) . CONCLUSIONS This is the first large r and omized controlled trial to demonstrate the efficacy of TREA and one of only a few such trials of nonpharmacologic interventions for agitation in persons with dementia . The translation of these findings into practice is sorely needed and would require structural changes dedicating staff time to observing each agitated resident , determining unmet needs , obtaining appropriate intervention material s , conducting the individualized nonpharmacologic interventions , and evaluating results . TRIAL REGISTRATION Clinical Trials.gov identifier : NCT00820859 OBJECTIVES To develop and evaluate the psychometric properties of a new measure of agitation , the Agitated Behavior in Dementia scale ( ABID ) . The ABID consists of 16 items design ed specifically to evaluate frequency of and caregiver reaction to common agitated behaviors in community-residing dementia patients . DESIGN The ABID was administered at the baseline assessment of a multi-site controlled treatment study to reduce agitation in Alzheimer 's Disease ( AD ) . Reliability was assessed by evaluating internal consistency and test-retest correlations . Validity was assessed by examining correlations with other constructs , including demographics , cognitive status , and overall behavioral disturbance . SETTING Twenty-one sites across the US , comprising the Alzheimer 's Disease Cooperative Study , contributed subjects to the investigation . PARTICIPANTS A total of 148 community-residing AD patients , living with a spouse or adult relative who acted as an informant . Mean age was 75 years , and mean Mini-Mental State Exam ( MMSE ) score was 13 . MEASUREMENTS Cognitive status was assessed using the MMSE . Behavioral disturbance was assessed using the Behavior Rating Scale for Dementia of the Consortium to Establish a Registry for Alzheimer 's Disease , the Revised Memory and Behavior Problems Checklist , and the Cohen-Mansfield Agitation Inventory . RESULTS Reliability of the ABID was excellent , with internal consistency of 0.70 and test-retest reliability of 0.60 to 0.73 . Validity was confirmed by correlations with related measures and lack of correlation with unrelated constructs . CONCLUSIONS The ABID is brief , easy to administer , and provides objective ly anchored observations of problems . It is a promising measure for studies of community-residing AD patients OBJECTIVES Behavioral disturbances and pain are common in nursing home ( NH ) patients with dementia . An association between pain and increased agitation has been suggested , and recently a significant reduction of agitation has been demonstrated by pain treatment in patients with moderate to severe dementia . We now examined which specific agitated behaviors respond to individualized pain treatment . DESIGN Cluster r and omized clinical trial . SETTING 60 clusters ( i.e. , clusters defined as single independent NH units ) in 18 NHs within five municipalities of Western Norway . PARTICIPANTS 352 patients with moderate to severe dementia and clinical ly significant behavioral disturbances . INTERVENTION The control group received usual treatment and care . According to a predefined scheme for 8 weeks , all patients in the intervention group received individual daily pain treatment with acetaminophen , extended release morphine , buprenorphine transdermal patch , and /or pregabaline . MEASUREMENTS Cohen-Mansfield Agitation Inventory subscales and items . RESULTS Analyses demonstrated that Factor 3 ( Verbally agitated behaviors ) showed the largest significant difference ( DF = 1204.0 , t = -4.308 , p < 0.001 ) , followed by Factor 2 ( Physically non-aggressive behaviors ) ( DF = 1198.0 , t = -2.672 , p = 0.008 ) , and Factor 1 ( Aggressive behaviors ) ( DF = 1196.0 , t = -2.093 , p = 0.037 ) after 8 weeks , by a linear r and om intercept mixed model in two-way repeated- measures configuration with adjustment for heteroscedasticity . CONCLUSION We found that verbal agitation behaviors such as complaining , negativism , repetitious sentences and questions , constant request for attention , and cursing or verbal aggression responded to pain treatment . In addition , restlessness and pacing were sensible to analgesics . Such behaviors should therefore lead to an assessment of pain , and pain treatment . Further studies comparing how pain treatment should be balanced against other strategies including psychotropic drugs are needed The main objective of this study was to compare 1-year outcome on symptoms , extrapyramidal side effects ( EPS ) , positive and negative symptoms , and domains of cognition in first episode psychosis ( FEP ) patients . Drug-naive FEP patients , who were similar on a number of characteristics likely to affect outcome , were treated with only one antipsychotic ( risperidone or olanzapine ) for at least 1 year and compared at baseline and after 1 year of treatment . Differences in outcome were assessed using an analysis of co-variance with change scores between initial assessment and after 1 year of treatment on levels of psychotic , disorganization and psychomotor poverty symptoms , EPS ( parkinsonism , akathesia and dyskineisa ) and domains of cognition as the dependent variable , respective baseline scores as covariates , and drug group as the independent variable . While patients in both groups showed substantial improvement , there were no significant differences in the magnitude of change in reality distortion , disorganization and psychomotor poverty symptoms . Trends in change in EPS favouring olanzapine and on some domains of cognition ( processing speed and executive functions ) favouring risperidone failed to reach statistical significance . The failure to confirm previous cl aims of greater improvement on either risperidone or olanzapine in patients with a first episode of psychosis may be the result of method ological bias introduced by unequal dosing between the two drugs or the use of chronically ill and treatment-refractory patients in previous studies INTRODUCTION Agitation is common in dementia and is associated with use of restraints and use of psychotropic drugs . The aim of this study was to determine whether an education and supervision intervention could reduce agitation and the use of restraints and antipsychotic drugs in nursing homes . METHOD Four Norwegian nursing homes were r and omly allocated to receive either treatment as usual or an intervention consisting of a 2-day educational seminar and monthly group guidance for 6 months . One hundred forty-five residents with dementia ( based on medical records and corroborated with a Functional Assessment Staging score > or= 4 ) completed baseline and 6-month intervention assessment s and were included in the analyses . The co- primary outcome measures were the proportion of residents subject to interactional restraint and the severity of agitation using the Cohen-Mansfield Agitation Inventory ( CMAI ) . Patients were assessed at baseline , immediately after completion of the intervention at 6 months , and 12 months after baseline . Comparison of change in the 2 groups was made using repeated- measures analysis of variance ( CMAI ) and Mann-Whitney test ( restraints ) . The study was conducted from 2003 to 2004 . RESULTS The proportion of residents starting new restraint was lower in the intervention than in the control group at 6-month evaluation ( P = .02 ) , but no statistically significant differences were found at 12-month assessment ( P = .57 ) . The total CMAI score declined from baseline to 6 and 12 months ' follow-up in the intervention homes compared to a small increase in the control homes ( F2,176 = 3.46 , P = .034 ) . There were no statistically significant differences in use of antipsychotic drugs . CONCLUSIONS A brief 2-day staff education program followed by continued monthly guidance was able both to improve quality of care by reducing the frequency of interactional restraints and to reduce severity of agitation OBJECTIVE To determine the effectiveness of the Targeted Interdisciplinary Model for Evaluation and Treatment of Neuropsychiatric Symptoms ( TIME ) for treatment of moderate to severe agitation in people with dementia . METHODS In a single-blinded , cluster r and omized controlled trial in 33 nursing homes ( clusters ) from 20 municipalities in Norway , 229 patients ( 104 patients in 17 nursing homes and 125 patients in 16 nursing homes ) were r and omized to an intervention or control group , respectively . The intervention group received TIME , and the control group received a brief education-only intervention . TIME is an interdisciplinary multicomponent intervention and consists of a comprehensive assessment of the patient with the goal to create and put into action a tailored treatment plan . The primary outcome was the between-group difference in change at the agitation/aggression item of the Neuropsychiatric Inventory Nursing Home version between baseline and 8 weeks . Secondary outcomes were the between-group difference in change at the agitation/aggression between baseline and 12 weeks in other neuropsychiatric symptoms , quality of life , and use of psychotropic and analgesic medications between baseline and 8 and 12 weeks . RESULTS A significant between-group difference in reduction of agitation at both 8 weeks ( 1.1 ; 95 % confidence interval : 0.1 - 2.1 ; p = 0.03 ) and 12 weeks ( 1.6 ; 95 % confidence interval : 0.6 - 2.7 ; p = 0.002 ) in favor of the TIME intervention was found . CONCLUSION The implementation of TIME result ed in a significant reduction of agitation  among nursing homes patients with dementia . These results should inform training programs for care staff in Norway and internationally BACKGROUND Relations between pretreatment symptom ratings and ECT outcome were examined in acute manic patients admitted at a state psychiatric center who were nonresponsive to medication . METHOD One or 2 days after undergoing pretreatment clinical ratings , patients were r and omly assigned to intensive pharmacotherapy , right unilateral ECT , left unilateral ECT , or bilateral ECT .  Patients who failed to respond to any of the first three treatment conditions were assigned to crossover bilateral ECT .  Patients who failed to respond to a primary treatment condition other than bilateral ECT but refused crossover bilateral ECT  and those in whom ECT was terminated due to an organic brain syndrome were not considered for this study . No psychotropic drugs were prescribed for 4 - 7 days before , or during , the course of ECT . Of the 24 patients who entered the study , 18 patients completed the protocol . Based on independent clinical assessment s by two research psychiatrists , a favorable treatment response was defined as a complete recovery from manic episode that was sustained for 1 week during which no psychotropic medications were prescribed . RESULTS ECT nonresponders were significantly more angry , irritable , and suspicious than ECT responders . Severity of mania and depression ratings at baseline were not related to ECT response . CONCLUSION Symptoms associated with poor response to ECT may overlap with those that have been reported to predict nonresponse to treatment with lithium . Our evidence also may support the view that differential symptom patterns may predict treatment outcomes to ECT and carbamazepine , respectively , in manic patients who do not respond to treatment with lithium or neuroleptics OBJECTIVE To explore the impact of personal attributes , environmental attributes , and the presentation of 9 categories of stimuli on agitation in nursing home residents with dementia . METHOD Participants in this r and omized , controlled , observational cross-sectional study were 193 residents of 7 nursing homes , all with a diagnosis of dementia , for whom we obtained data pertaining to cognitive functioning ( via the Mini-Mental State Examination ) , performance of activities of daily living ( Minimum Data Set ) , and role-identity/activities of past interest ( Self-Identity Question naire ) .  Environmental attributes (  eg ,  noise , lighting )  and  direct observations of agitation  ( primary outcome ) were recorded via the Agitation Behavior Mapping Inventory .  Engagement was measured using the Observational Measurement of Engagement . Both agitation and engagement were assessed for each stimulus ( including a control condition ) . RESULTS Univariate findings ( ie , for 1 explanatory variable at a time ) showed agitation to be related to several personal attributes -- ie , female gender was related to verbal agitation ( P < .0001 ) ; low cognitive function was related to total , verbal , and physical agitation ( P < .001 for each ) ; low performance of activities of daily living was significantly related to all types of agitation ( P < .01 for total agitation and P < .05 for each type of agitation ) ; and unclear speech was significantly related to total agitation ( P < .01 ) . Eight of the 9 stimulus categories were significantly related to decreased levels of agitation , with ORs ranging from 0.37 ( live human stimuli , P < .001 ) to 0.79 ( inanimate social stimuli , P < .05 ) . Higher levels of engagement were related to lower levels of agitation ( P < .001 for total agitation ) . In the multivariate analyses , higher cognitive function ( P < .001 ) , male gender ( P < .05 ) , level of engagement with stimuli ( eg , duration of engagement for 3 minutes or longer , P < .05 ) , and all 9 stimulus categories , with the exception of music , were independently predictive of lower levels of agitation ( P < .001 ) . CONCLUSIONS The finding that both type of stimuli and engagement level with the stimuli were significant predictors of agitation underscores the importance of engagement as a determinant of agitation levels OBJECTIVE While the efficacy of antipsychotic medications for the treatment of psychosis is generally established , the speed of onset of antipsychotic action remains controversial . The objective of this study was to evaluate the early response ( within the first 24 h ) in psychosis with ziprasidone IM treatment , and to determine whether this early effect is distinct from a reduction in agitation symptoms . METHODS In a 24-h , double-blind study , hospitalized patients with psychotic disorder and acute agitation were r and omized to treatment with fixed doses of IM ziprasidone : 2 mg ( N=38 ) or 20 mg ( N=41 ) . Efficacy assessment s were based on the PANSS positive subscale and PANSS early psychosis factor score ( conceptual disorganization , hallucinatory behavior , and unusual thought content ) at 4 and 24 h. RESULTS Ziprasidone IM demonstrated a significant dose-related effect ( 20 mg vs. 2 mg ) on both the PANSS early psychosis factor score and the PANSS positive subscale at the first post-baseline time point ( 4 h ) , and at 24 h ( all p<0.05 ) . There was a significant direct effect of ziprasidone IM on early psychosis at 24 h ( p<0.05 ) , distinct from improvement in agitation symptoms . CONCLUSIONS These findings suggest , in addition to an early reduction in acute agitation , ziprasidone IM may be associated with a more rapid improvement in psychotic symptoms than previously reported , thus lending further support to the emergent hypothesis of early psychosis improvement in antipsychotic treatment We report psychometric results of the  Behavioural Activity Rating Scale ( BARS ) using data from three Phase III clinical trials of intramuscular ziprasidone in acutely agitated patients with psychosis ( Studies 1 and 2 ) or in stable psychotic patients ( Study 3 ) . Convergent validity and divergent validity were assessed with baseline data from Studies 1 and 2 in subjects with acute agitation . To investigate convergent validity , we sought Pearson and Spearman correlation of BARS scores with scores on the Clinical Global Impression of Severity ( CGI-S ) Scale and a predefined cluster of agitation-related items from the Positive and Negative Syndrome Scale ( PANSS ) . For divergent validity , we sought Pearson and Spearman correlation between BARS scores and a predefined cluster of PANSS items measuring negative symptoms . Discriminant validity was investigated with the help of subjects with moderate psychopathology ( Study 3 ) . Wilcoxon rank-sum and two- sample t tests determined whether mean ( or median ) BARS scores differed between subjects with acute agitation ( Studies 1 and 2 ) and moderate psychopathology ( Study 3 ) . Responsiveness to treatment effect and rater reliability were also evaluated . In Study 2 , Pearson correlation coefficients of BARS scores with PANSS agitation items and CGI-S were moderate ( convergent validity ) and statistically significant ( P<0.005 ) . The correlation between BARS scores and PANSS negative component scores was low ( divergent validity ) . Treatment effect size was larger for BARS than for PANSS agitation items and CGI-S ( responsive to treatment differences ) . Virtually perfect inter- and intra-rater reliability was achieved . Study 1 produced similar results . BARS showed psychometrically valid properties for measurement of behavioral activity in acutely agitated patients with psychosis
For its management , experts agreed in considering  verbal de-escalation  and  environmental modification techniques  as first choice , considering physical restraint as a last resort strategy .
BACKGROUND Psychomotor agitation is associated with different psychiatric conditions and represents an important issue in psychiatry .
Current recommendations on agitation in psychiatry are not univocal .
Actually , an improper assessment and management may result in unnecessary coercive or sedative treatments .
A thorough and balanced review plus an expert consensus can guide assessment and treatment decisions .