Agitation antipsychotics

Antipsychotic medications are indicated in the treatment of acute and chronic psychotic disorders. These include schizophrenia, schizoaffective disorder, and manic states occurring as part of a bipolar disorder or schizoaffective disorder. The co-adminstration of antipsychotic medication with antidepressants has also been shown to increase the remission rate of severe depressive episodes that are accompanied by psychotic symptoms. Antipsychotic medications are frequently used in the management of agitation associated with delirium, dementia, and toxic effects of both prescribed medications (e.g. L-dopa used in Parkinson s disease) and illicit dtugs (e.g. cocaine, amphetamines, andPCP). They are also indicated in the management of tics that result from Gilles de la Tourette s syndrome, and widely used to control the motor and behavioural manifestations of Huntington s disease. 

Behavioral changes may also occur with the use of the antipsychotic drugs. These changes include an increase in the intensity of the psychotic symptoms, lethargy, hyperactivity, paranoid reactions, agitation, and confusion. A... 

Antipsychotics are not indicated for the treatment of withdrawal, except when hallucinations or severe agitation are present (Naranjo and Sellers 1986), in which case they should be added to a benzodiazepine. In addition to their potential to produce extrapyramidal side effects, antipsychotics lower the threshold for seizures, which is particularly problematic during alcohol withdrawal. 

Other sedative-hypnotic medications, such as barbiturates, may play a useful role in severe withdrawal from this group of drugs. For example, in a case series of GBL withdrawal, use of intravenous pentobarbital in the range of 1-2 mg/kg/hour lowered the total requirement for intravenous lorazepam (Sivilotti et al. 2001). Antipsychotic medications are often used to reduce psychotic agitation. However, because antipsychotic medications lower the seizure threshold and may contribute to loss of central control of temperature leading to hyperthermia or neuroleptic malignant syndrome (NMS), they are not indicated as first-line medications for GHB withdrawal delirium (Dyer and Roth 2001 McDaniel and Miotto 2001 Sharma et al. 2001). If anti-... 

The atypical antipsychotics are the preferred agents for the treatment of psychosis (hallucinations, delusions, and suspiciousness) and the disruptive behaviors (agitation and... 

Cocaine or stimulant intoxication may require administration of a small dose of a short-acting benzodiazepine (e.g., lorazepam 1 to 2 mg) for agitation or severe anxiety. Antipsychotics (e.g., haloperidol 2 to 5 mg) should be used only if psychosis is present. If hyperthermia is present, initiate cooling measures. 

The typical antipsychotic drugs, which for 50 years have been the mainstay of treatment of schizophrenia, as well as of psychosis that occurs secondary to bipolar disorder and major depressive disorder, affect primarily the positive symptoms[10]. The behavioral symptoms, such as agitation or profound withdrawal, that accompany psychosis, respond to the antipsychotic drugs within a period of hours to days after the initiation of treatment. The cognitive aspects of psychosis, such as the delusions and hallucinations, however, tend to resolve more slowly. In fact, for many patients the hallucinations and delusions may persist but lose their emotional salience and intrusiveness. The positive symptoms tend to wax and wane over time, are exacerbated by stress, and generally become less prominent as the patient becomes older. 

Oxazepam and other benzodiazepines have been used to treat anxiety, agitation, and aggression, but they generally show inferior efficacy compared with antipsychotics. They can also worsen cognition, cause disinhi-bition, and increase the risk of falls. 

First, optimize current mood stabilizer or initiate mood-stabilizing medication lithium,0 valproate,0 or carba-mazepine0 Consider adding a benzodiazepine (lorazepam or clonazepam) for short-term adjunctive treatment of agitation or insomnia if needed Alternative medication treatment options carbam-azepine0 if patient does not respond or tolerate, consider atypical antipsychotic (e.g., olanzapine, quetiapine, risperidone) or oxcarbazepine. 

High-potency benzodiazepines (e.g., clonazepam and lorazepam) are common alternatives to or in combination with antipsychotics for acute mania, agitation, anxiety, panic, and insomnia or in those who cannot take mood stabilizers. Lorazepam IM may be used for acute agitation. A relative contraindication for long-term benzodiazepines is a history of drug or alcohol abuse or dependency. 

Both typical and atypical antipsychotics are effective in approximately 70% of patients with acute mania associated with agitation, aggression, and psychosis, and atypical antipsychotics are better tolerated. 

IM antipsychotic administration (e.g., ziprasidone 10 to 20 mg, olanzapine 2.5 to 10 mg, or haloperidol 2 to 5 mg) can be used to calm agitated patients. However, this approach does not improve the extent of response, time to remission, or length of hospitalization. 

Intramuscular (IM) lorazepam, 2 mg, as needed in combination with the maintenance antipsychotic may actually be more effective in controlling agitation than using additional doses of the antipsychotic. 

Cocaine and other CNS stimulants Monitor cardiac function Lorazepam 2-4 mg IM every 30 minutes to 6 hours as needed for agitation Haloperidol 2-5 mg (or other antipsychotic agent) every 30 minutes to 6 hours as needed for psychotic behavior B2 B3... 

Cocaine intoxication is treated pharmacologically only if the patient is agitated and psychotic. Low-dose antipsychotics can be used short-term if necessary for psychotic symptoms. 

Antipsychotics, needed 2.5-5 mg q 4 h Agitation unresponsive to benzodiazepines, hallu-... 

Medications may be necessary for patients with delirium especially in patients with severe behavioural disturbances and agitation. Any medications used may however be hazardous and actually lengthen the condition. A continuous reassessment of the need for theses kind of drugs should be done. Antipsychotic drugs may be needed especially if vision hallucinations and agitated behaviour are predominant. Short-acting benzodiazepines may be used for a limited time. There is no... 

When brief psychotic disorder is diagnosed, treatment with antipsychotic medication and supportive therapy should be instituted. During treatment, however, the patient should be frequently reassessed for the presence of a mood disorder that was not easily recognizable in the initial agitated and psychotic state. 

When an antipsychotic is needed, we prefer using one of the newer atypical agents olanzapine, ziprasidone, risperidone, quetiapine, or aripiprazole. Each of these medications reliably reduces agitation and is well tolerated. In particular, they decrease the potential for acute dystonic reactions and tardive dyskinesia caused by the typical antipsychotics. Both ziprasidone and olanzapine are now available in an injectable form that is very rapidly acting and effective in this setting. 

Benzodiazepines are preferred by many for the management of agitation in nonpsychotic bipolar patients, though antipsychotics are effective as well. The most widely used benzodiazepines for this purpose are lorazepam and clonazepam. Lorazepam is perhaps the most versatile of the benzodiazepines. It has an intermediate duration of action, does not tend to accumulate and thereby cause confusion or excessive drowsiness, and can be administered by mouth, intramuscular injection, or intravenous injection. Lorazepam should be administered on an as-needed basis several times daily at 0.5-2mg per dose. The calming effects of lorazepam are usually evident within 20-30 minutes and will last for several hours. 

Pimozide (Orap). Pimozide is probably the most potent of all antipsychotics, but it is seldom used to treat schizophrenia. Instead, pimozide is most often used to treat Tourette s syndrome. There is actually no reason why pimozide can t be used to treat psychosis and no reason why other antipsychotics are not effective in Tourette s syndrome. Pimozide was simply used first in controlled clinical trials to treat Tourette s syndrome, and the physicians who routinely treat that illness became accustomed to using it. Pimozide is only available in an oral form. The lack of an injectable form to treat agitated patients as well as the lack of availability of data from controlled trials in schizophrenia patients likely explains why it has not been used very often in the treatment of schizophrenia. 

Atypical Antipsychotics. The so-called atypical antipsychotics are not well studied in the treatment of ADHD. However, a few case reports have indicated that risperidone (Risperdal) may reduce the impulsivity and hyperactivity of ADHD. There is also preliminary evidence that risperidone may be effective in treating tics. Although the usefulness of risperidone and other atypical antipsychotics in treating ADHD needs more study, this may prove another viable treatment alternative for patients with ADHD and tics or agitation. 

Antipsychotics. Antipsychotic medications are also called major tranquilizers. It is for the tranquilizing effect that they have been used to treat agitation. The earliest antipsychotics, especially thioridazine (Mellaril), proved to be effective in reducing agitation however, this comes at the price of further impairing cognition due to its profound anticholinergic effects. 

Atypical antipsychotics may be helpful in managing the delusions and agitated behavior that can accompany dementia. These medications, include risperidone (Risperdal), quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify), and olanzapine (Zyprexa). All antipsychotics, typical and atypical, appear to increase the risk of death in patients with dementia and psychosis. This appears as a warning in the package inserts of the newer drugs. A prudent approach is to discuss this risk with the caregiver, use the lowest effective dose, and monitor for effectiveness. 

Benzodiazepines. These medications are also known as minor tranquilizers. In general, they have been found less effective than antipsychotics in treating agitation over the long term. However, their relatively quick onset of action makes them effective for acute episodic agitation. 

Lithium is somewhat effective for the treatment of agitation however, elderly patients do not tolerate it well. In particular, demented patients are at risk for lithium toxicity, and this toxicity may not be easily detected in these patients. Despite its effectiveness, lithium has been abandoned in the treatment of agitation due to the availability of several effective and better-tolerated treatments, including the atypical antipsychotics described earlier. 

Carbamazepine is more widely used for treating chronically agitated dementia patients. Its onset of action is delayed by several days to a couple of weeks therefore, other tranquilizing medications such as antipsychotics may need to be used when first starting carbamazepine. Carbamazepine doses have problematic side effects that require blood monitoring, and it also interacts with many medications. 

The medication of choice was for many years haloperidol (Haldol), a high potency antipsychotic, that can be given orally or by injection. When used, haloperidol should be administered in low doses (0.5-1.0mg) and only on an as-needed basis. Due to concerns regarding the tolerability of haloperidol in patients with dementia, its role in the management of agitation associated with delirium has largely been supplanted by atypical antipsychotics. A number of atypical antipsy-chotics are available by either an oral or intramuscular (injection) route of administiation. 

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