Consensus document: model of integrated management of the patient with psychomotor agitation

SUMMARY. Psychomotor agitation (APM) represents a heterogeneous clinical picture, the result of a variety of different pathological processes, on whose correct evaluation and management the scientific literature and the guidelines currently available present a considerable inhomogeneity and lack of standardization, in particular regarding to drug therapies. Starting from this deficiency, and from the awareness of the need for a multidisciplinary approach to this condition, which includes aspects common to different healthcare professionals as well as factors related to pharmacoeconomics and risk management skills, a project was undertaken to develop a shared model of integrated patient management with APM. This model, based on the work of a scientific board and a multidisciplinary panel of experts, called to reach a consensus through the Delphi-RAND methodology, is proposed as an indication of good clinical practice in the management of these patients. This document reports the results of this process of consent, whose fundamental principles are the centrality of the patient considered as an active and participating subject, the need to intervene early with non-containing actions able to avoid symptomatic escalation and allow the continuation of the ‘diagnostic-therapeutic process, the use of pharmacological treatments appropriate to the degree of severity of the symptoms and the importance of integrating and harmonizing the interventions of the various professionals involved.

SUMMARY. Psychomotor agitation (PMA) is a heterogeneous clinical syndrome associated with a widenumber of pathological conditions. The currently available recommendations and guidelines on PMA correct assessment and management are significantly dishomogeneous and suffer from a lack of standardization, especially regarding pharmacological interventions. Based on this deficiency, and on multidisciplinary nature of PMA, that includes factors shared by different health professionals other than pharmacoeconomic and risk management aspects, we started a project aimed to elaborate a shared model of integrated management for PMA patients. The model, developed by a scientific board and a multidisciplinary panel using the consensus Delphi-RAND method, aims to give indications of good clinical practice for the management of these patients. The present document reports the results of this consensus process, whose main principles are the centrality of the patient, as an active and collaborating subject, the importance of prompt and not coercive interventions able to block the escalation to violence and to allow a correct diagnostic and therapeutic workup, the appropriate use of pharmacological interventions based on the severity of symptoms and the importance of an integrated and harmonized approach by the different professionals involved in PMA management.

KEY WORDS: psychomotor agitation, agitation assessment, pharmacological treatment, psychiatric emergency, de-escalation.

Psychomotor agitation (APM), defined in the DSM-5 as “excessive motor activity associated with a sensation of internal tension” 1, is a clinical (or symptomatic) picture resulting from a variety of different pathological processes. The main features described in patients with agitation include, among others, the inability to remain still, with an excess of non-productive or afinalistic motor activity (walking, rubbing hands, pulling clothes), irritability, high responsiveness to internal stimuli and external and an unstable course of symptoms over time 2. Although aggression and violence do not necessarily represent the core elements of agitation, the evolution of the severity of symptoms can lead to aggressive and violent behavior. An important feature of the APM, whatever the cause and whatever the severity of the underlying condition, is in fact that it is located along a continuum that from situations of simple ideational and behavioral activation can reach the most acute and violent episodes3-5.
In general, despite the numerous definitions produced to characterize APM, it remains a multiform and multifactorial syndrome, potentially associated with different conditions, including properly psychiatric pathologies (mainly schizophrenia and bipolar disorder), numerous medical conditions and intoxication / withdrawal syndromes6 . To a similar multiform etiopathogenesis corresponds a multiplicity of clinical settings potentially involved in the management of patients with APM, which can reach medical observation not only in health structures of strictly psychiatric competence – such as Psychiatric Diagnosis and Care Services (SPDC), Centers of Mental Health (CSM) and territorial structures – but also, often, in different non-specialist contexts – General First Aid (PS), medical and surgical departments, home -, with the involvement, alongside psychiatrists, of other health professionals, including in particular the doctors and nurses of PS 6.
Data on the epidemiology of APM are scarce and derive mainly from studies carried out in specific settings and on selected samples. Prevalence rates of agitation ranging from 4 to 10% 7-9 have been reported in psychiatric emergency services, while it has been calculated that 20-50% of visits to these services concern patients potentially at risk of agitation, as suffering from schizophrenia, bipolar disorder or dementia10,11. In the context of non-psychiatric facilities, a recent Spanish study conducted on over 355,000 hospital discharge forms reports a diagnosis of APM in 1.5% of patients12.
In view of the clinical relevance and epidemiological impact of this syndrome, the scientific literature and the guidelines currently available for the correct evaluation and management of APM show a considerable inhomogeneity and a lack of standardization, in particular with regard to the pharmacological therapies to be practiced. in emergency conditions 13-16.
The guidelines of the American Association for Emergency Psychiatry as part of the BETA Project (2012) recommend the preferential use of oral drugs over the parenteral route “if the patient is collaborative” 17, the NICE recommendations (2005) prefer oral treatments “as far as possible” 18. The very recent consensus document of the World Federation of Societies of Biological Psychiatry (WFSBP) (2016) underlines how inadequate agitation management can lead to an excessive and unnecessary use of coercive measures, an escalation towards violence with possible harm to personnel healthcare and patients, as well as significant economic costs for the healthcare system. The document proposes a series of recommendations based on non-pharmacological interventions, focused on avoiding symptomatic escalation, and on pharmacological treatments (typical and atypical antipsychotics and / or benzodiazepines), the first objective of which must be to quickly calm the agitated patient without sedate him excessively 19. In the absence of solid literature on the subject, substantial uncertainties remain about the evaluation scales that can be used to determine the severity of agitation in the various clinical settings (despite the number of tools proposed) 3, on the use of interventions not pharmacological and especially on the choice of drugs and optimal administration routes in the different clinical pictures. In particular, as regards the attempt to standardize and make the evaluation of patients with APM more objective, in recent decades numerous scales have been developed, applicable in different clinical contexts, characterized by greater or lesser complexity. Although the actual applicability of these tools in real clinical practice is a lot