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Mechanical ventilation is rarely a simple matter. Skill and knowledge are required to operate the ventilator modes, choose the optimal settings, and understand many monitored variables. Supporting the patient safely and effectively is the top priority in providing mechanical ventilation. This article discusses mechanical ventilation in adults. [ABSTRACT FROM AUTHOR]

Research has shown that meditation is beneficial for chronic pain, stress, and many physical and mental conditions. The definition of meditation has many forms, is culturally influenced, and is practiced globally. This literature review seeks to report current literature on meditation related to therapeutic outcomes and create a globally informed definition of meditation for health-related purposes. From a western perspective, mindfulness-based stress relief (MBSR) is widely researched. Therefore, 15 studies from peer-reviewed research from 2015 and 2020 were used to examine various forms of meditation and describe a broader range of meditation practices other than MBSR. The different forms of meditation are: Acceptance and Commitment Therapy (Portugal), Active Engagement (Portugal), Adapted Mindfulness Program (Brazil), Adapted Mindfulness Program (Brazil), Cognitively-based Compassionate Training, Loving-kindness (United States, US), Mantra Meditation (US), Mindfulness-based stress reduction (US), Mindfulness-based cognitive therapy (South Korea), Osho (India), Psychoneuroendocrinoimmunology (Italy), Transcendental Meditation (Italy), Spiritual/Secular (US), Sufi (Pakistan), and Vipassana (Australia). The review was completed using a literature search method, and all meditation approaches report positive therapeutic outcomes for all participants (n = 768). This outcome enabled the creation of a broader therapeutic definition of meditation that can be applied in clinical practice [ABSTRACT FROM AUTHOR]

New onset of agitation during pregnancy is an obstetric and behavioral emergency that demands careful evaluation and prompt treatment. This article provides an overview of clinical evaluation and types of nonpharmacologic and pharmacologic interventions when managing acute agitation during pregnancy. Rapid clinical evaluation and behavioral management are keys to preventing detrimental maternal and fetal complications. Clinicians must seek out medical etiologies of agitation and always attempt verbal de-escalation before initiating chemical or physical restraints. Should medication be necessary, first-generation antipsychotics, second-generation antipsychotics, antihistamines, or benzodiazepines may be considered. Managing agitation in pregnancy is a challenging dilemma due to the fear of adverse maternal and neonatal outcomes as well as the legal risk involved. Nevertheless, clinicians should continue to assess the patient without delay, differentiate underlying causes of agitation, treat the mother and fetus aggressively, and consult obstetric and psychiatric services early. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study was tomeasure the short- and long-term impact of a virtual disability education curriculum associated with a 2-wk mandatory physical medicine and rehabilitation clerkship for fourth-year medical students. Design: A prospective pre-post intervention survey-based study measuring the impact of a virtual disability education series at 1-wk and 6-mo time points after a mandatory physical medicine and rehabilitation clerkship including 8 hrs of virtual didactics with an emphasis on physical disabilities. The surveys assessed the overall virtual curriculum, perceived benefit of a virtual encounter, and the long-term applicability of the information learned from the clerkship. Results: The physical medicine and rehabilitation clerkship was effective in improvingmedical students' perceived comfort and clinical knowledge regarding treatment of persons with disabilities (P < 0.01). Therewere no statistical differences at the 6-mo time point, indicating sustained benefit and integration of knowledge in the long term (P > 0.05). In addition, 84% of students reported using the information in clinical experiences at 6 mos. Conclusions: The physical medicine and rehabilitation clerkship including a virtual disability education curriculum improved long-term perceived medical student comfort and knowledge of treating persons with disabilities, with a focus on those with physical disabilities. Virtual encounters with persons with disabilities are viable and impactful avenues to provide this education. [ABSTRACT FROM AUTHOR]

Background: Violence against nurses is a growing problem. Minimizing violence against nurses will contribute to a safer clinical environment. Local Problem: An increase in violence against nurses was identified at a regional medical center in the Midwest. Methods: A clinical nurse leader (CNL)–led behavior management consult team was developed to support the clinical team with aggressive, disruptive, or violent patients. The team consulted, assigned interventions to address potential source(s) of agitation, provided clinical support and guidance, and developed clinical tools to manage future patients with similar behavior patterns. Results: Between April 2019 and January 2023, a total of 108 behavior management consults were completed. Staff appreciated the additional support from the team. Conclusions: Implementation of a CNL-led behavior management consult team was found to be beneficial; other health care systems should consider implementing a similar consult team. [ABSTRACT FROM AUTHOR]

Introduction: Behavioural and psychological symptoms of dementia are very common in acute care. Agitation and aggressive behaviours are the most common symptoms and are challenging to manage. Early detection and a nonpharmacological approach are recommended. Objectives: To implement evidence-based recommendations for the prevention and management of aggression/agitation in patients with dementia in an acute geriatric care unit. Methods: The project used the JBI Practical Application of Clinical Evidence System and Getting Research into Practice audit and feedback tool. A baseline audit was conducted with seven audit criteria based on evidence summaries. It was followed by the implementation of an action plan and a follow-up audit. Results: Results showed moderate improvements in compliance with best practice recommendations. The second audit indicated an improvement up to 46% with the identification of factors/triggers that precipitate aggression/ agitation and completion of a risk assessment. The highest improvement was the training of the nursing team (79%). Compliance with the involvement of patients and their families in the care planning improved slightly (14%). The lowest improvement was for the development and implementation of individualized care plans (10%). Conclusion: The project implementation achieved some positive changes. A formalized process for preventing aggression/agitation is in place. The interprofessional collaboration, the support given to the nursing team and the basket of nonpharmacological interventions were strengthened. The electronic documentation and a limited collaboration of the nursing team were challenging. As further strategies were implemented, further audit would be required to assess achievement in change and/or demonstration of improved care provided for this vulnerable population. [ABSTRACT FROM AUTHOR]

Background: Care interactions are verbal or nonverbal interactions between staff and residents during social or physical care activities. The quality of care interactions could be positive, negative, or neutral. Purpose: The purpose of this study was to examine the resident- and facility-level factors associated with the care interactions in assisted living (AL). Methods: Regression analysis was performed using a stepwise method utilizing baseline data of 379 residents from 59 AL facilities recruited in a randomized trial. Results: Accounting for 8.2% of variance, increased resident agitation was associated with negative or neutral quality interactions while for-profit ownership was associated with positive quality interactions. Conclusions: To promote positive care interactions, findings suggest the need to educate staff about strategies to minimize resident agitation (eg, calm posture and respectful listening) and work toward optimizing care interactions in nonprofit settings. Future research could further explore the influence of staff-level factors on care interactions. [ABSTRACT FROM AUTHOR]

Background: Despite data supporting the reduction of interactions with patients during nighttime, bed bathing is sometimes performed within this period in sedated patients unable to manage their own hygiene care. Objectives: To compare patient physiologic variables and adverse effect incidence between night and day bed baths. Methods : This was a single-center prospective observational study in a 12-bed intensive care unit during 2 months. Night period was defined to run from 10 PM to 6 AM. Night bed baths were provided to sedated ventilated patients whatever their sedation, if their Richmond Agitation Sedation Scale score was -2 or deeper. Bed bath-induced changes in physiological variables, treatments, and related unscheduled events were registered during both night and day bed baths. Results : Twenty-one patients (aged 62.9 [52.5-73.2] years, 14 male patients) were included. We registered 97 night bed baths and 95 day bed baths. Heart rate increased only after day bed baths (85 beats/min [bpm] [69-97 bpm] vs 88 bpm [73-98 bpm], P =.02). Increase in Richmond Agitation Sedation Scale score occurred, respectively, during 13 (13.4%) and 8 (8.4%) night and day bed baths, without significant differences. Body temperature significantly decreased during both night and day bed baths (respectively, 37[degrees]C [36.6[degrees]C-37.4[degrees]C] vs 36.6[degrees]C [36.2[degrees]C-37.2[degrees]C], P <.0001; and 36.9[degrees]C [36.5[degrees]C-37.2[degrees]C] vs 36.7[degrees]C [36.2[degrees]C-37.2[degrees]C], P =.0006). Overall, unscheduled events, whether physiologic changes, pain, or calling a physician in rescue occurred in 97 procedures (50.5%), irrespective of their timing (night vs day, respectively 53% [54.6%] vs 44% [46.3%], P =.31). Discussion : Although unscheduled events occurred in half of bed baths, differences evidenced between nighttime and daytime bed baths were scarce. The appropriateness of nighttime bed bathing remains questionable. [ABSTRACT FROM AUTHOR]

Medically hospitalized individuals have high rates of comorbid psychiatric, substance abuse, and behavioral disorders. Disruptive and sometimes aggressive behaviors may arise when mental health needs of patients go unrecognized or are inadequately addressed. Health care workers experience the most workplace violence compared with other professions, with nurses and nursing aides at highest risk. A Behavioral Emergency Support Team (BEST) model can be an effective approach to providing a customized response to a patient's agitation through identification of underlying clinical and environmental contributors to the onset of aggression as well as to provide behavioral education and support of nursing staff. Results from 2 years of BEST model use resulted in 124 events among 96 patients of whom 19 had repeated events. The most common reasons for codes were aggression (79%) and elopement threat/attempt (45%), and the most frequent patient diagnosis was cognitive impairment (54%). Development of a BEST model provides support to nurses that is not otherwise available for events that are disruptive to care in inpatient medical settings and help minimize the occurrence of workplace violence. [ABSTRACT FROM AUTHOR]

The article discusses research published in the issue of the "British Medical Journal" which reviewed the U.S. Food and Drug Administration's (FDA) approval of brexpiprazole, an antipsychotic drug for treatment of agitation associated with dementia due to Alzheimer's disease, that failed to show benefit but raised the risk of death.

The aim of this pilot, feasibility study was to assess health improvements in 16 institutionalized older people with Alzheimer's disease, after the Biodanza intervention, a nonpharmacological dance movement-based treatment. Biodanza significantly decreased agitated and neuropsychiatric behaviors. Effectiveness studies will be performed in order to assess the implication of such interventions. [ABSTRACT FROM AUTHOR]

Mitragyna speciosa, a tropical tree also known as kratom, is an emerging substance of abuse with dose-dependent stimulant and opioid-like effects. Kratom may be purchased legally in the United States and is marketed online as a safe alternative to opioids and a cheap alternative to opioid replacement therapy. However, adverse reactions to ingestion are largely unknown and may pose a significant public health risk. This article describes a man with an intracerebral hemorrhage possibly secondary to kratom ingestion. [ABSTRACT FROM AUTHOR]

The Food and Drug Administration has approved brexpiprazole (Rexulti), an atypical antipsychotic, for the treatment of agitation associated with dementia from Alzheimer disease, making it the first approved treatment option for this condition. Brexpiprazole is not approved for the treatment of patients with dementia-related psychosis without agitation from Alzheimer disease. The drug is a daily maintenance drug, not an "as needed" drug. [ABSTRACT FROM AUTHOR]

A case study of a 73-yr-old man with a history of coronary artery disease, depression, and colon cancer status after colectomy presented to inpatient rehabilitation (IPR) with a severe traumatic brain injury (TBI) and multiple rib fractures after an all-terrain vehicle accident. It mentions that encephalopathy improved with completion of antibiotics, but his cognitive function remained limited with ongoing aphasia as a result of his brain injury.

Supplemental digital content is available in the text. Thalamic dementia is an uncommon type of stroke that presents with disorientation, behavioral changes, and impairment of executive functions, with relative preservation of motor functions. It is typically caused by paramedian territory infarctions of the thalamus, most often due to ischemic insult at the tip of the basilar artery. In this report, we present a case of bilateral thalamic infarcts resulting in thalamic dementia with severe behavioral manifestations in a 64-yr-old man with no preexisting neuropsychiatric comorbidities. A trial of amantadine, a dopamine-promoting agent, in the acute rehabilitation unit in an attempt to manage his agitation led to multiple weeks of dramatic behavioral improvement and increased participation in therapies. Dopamine receptors are believed to be present at increased densities in thalamic nuclei with mesolimbic projections, suggesting that they are able to modulate limbic functions such as arousal, emotion, and memory. This case report, aimed both to increase the awareness of this uncommon stroke syndrome and describe the observed effect of amantadine, will ultimately help clinicians properly recognize thalamic dementia, minimize unnecessary investigations, and develop effective neurorehabilitation strategies in these patients. [ABSTRACT FROM AUTHOR]

Agitation is a common, treatable symptom that profoundly impacts quality of life and exacerbates caregiver fatigue in the hospice setting for patients with dementia. The objective of this study was to analyze the efficacy of tailored nonpharmacological interventions for mitigation of unwanted behaviors in the population of patients with behavioral and psychological symptoms in dementia while receiving hospice care. The 4-domain Pittsburgh Agitation Scale (PAS; Motor, Verbal, Aggressive, Resistance to Care) was used for multiple baseline and posttest measurements of agitation. Effectiveness of nonpharmacological interventions was evaluated using analysis of variance for repeated measures for the total PAS score. Motor agitation was the presenting problem with highest-rated severity compared with Verbal, Aggression, and Resistance to Care domains. Analysis of variance demonstrated no difference between baseline referral and pretest total PAS measures (P =.8), but a significant drop in total PAS agitation after intervention (P <.001). The best outcomes, however, were with patients receiving both nonpharmacological and standard pharmacological interventions as opposed to nonpharmacological interventions alone (P =.034). For patients with dementia presenting with behavioral and psychological symptoms, selected nonpharmacological interventions provide significant mitigation of agitation. [ABSTRACT FROM AUTHOR]

To determine the impact of Healing Touch on vital signs, adult intensive care unit patients were recruited from multiple hospital sites. Both pain and agitation improved and there was a significant change in hemodynamics that reflected a calming effect. Healing Touch may be considered a respected addition to symptom management. [ABSTRACT FROM AUTHOR]

West Nile neuroinvasive disease (WNND) is a rare and severe manifestation of West Nile virus (WNV) infection that occurs in less than 1% of infected persons. It should be considered in patients who present with fever, neurological symptoms, and a history of recent outdoor activity where mosquitoes were active. This article highlights a case of a 55-year-old man whose history and symptoms of WNND were confounded with an alternate diagnosis, acute alcohol withdrawal. An overview of WNV infections, and important historical clues and objective findings characteristic of neuroinvasive disease, is discussed to increase readers' knowledge of WNV and awareness of when to consider WNND in the diagnostic differential. [ABSTRACT FROM AUTHOR]

In this article, we discuss the literature behind the use of paralytics, sedation, and steroids in acute respiratory distress syndrome. We explore the controversies and discuss the recommendations for the use of these agents. [ABSTRACT FROM AUTHOR]

Background: In recent years, the incidence of delirium has grown to epidemic proportions in the intensive care setting with up to 80% of mechanically ventilated patients being affected. This can lead to adverse patient outcomes such as increased lengths of hospital stay, increased mortality rates, and increased long-term cognitive impairment. Objectives: The objective of this project is to determine whether a quality improvement project can increase adherence to an existing pain, agitation, and delirium (PAD) protocol for enhanced patient outcomes. Methods: Chart audits were conducted to determine baseline compliance, use of the PAD protocol was measured, and the type of medications administered to each mechanically ventilated patient was assessed. Using the Knowledge-to-Action framework, a multidisciplinary, multidimensional educational module was then developed and implemented that included an online tutorial, point-of-care reminders, written materials, and verbal coaching. A 3-month postimplementation chart audit was conducted to determine whether increased protocol competence was achieved. Results: Protocol use unexpectedly decreased from 74% to 41% (P < .01); however, compliance with medication recommendations did increase despite the decrease in use. Intravenous opioid use increased from 12% to 40% (P ≤ .001), whereas sedative propofol infusions decreased from 82% to 35% (P ≤ .001). Conclusions: The implementation of a multidimensional, multidisciplinary project was successful in increasing compliance to the clinical practice guidelines for the management of PAD in adult intensive care unit patients, despite a decrease in protocol use. This unanticipated decrease in protocol use indicates the need for additional research in this area. Future recommendations also include a review of the existing PAD protocol to determine whether revisions could be made to better suit the needs of the staff while also improving patient outcomes in the arena of delirium experienced during critical care stays. [ABSTRACT FROM AUTHOR]

The article provides an executive summary of the 2018 Pain, Agitation/sedation, Delirium, Immobility (rehabilitation/mobilization), and Sleep (disruption) (PADIS) clinical practice guidelines, and it mentions updates to the 2013 pain, agitation, and delirium prevention and management guidelines. Medical protocols are examined, along with opioid therapy and the therapeutic use of drugs such as acetaminophen, nefopam, and ketamine.

The purpose of this study was to assess Richmond Agitation Sedation Scale (RASS) goal implementation in mechanically ventilated patients sedated in the emergency department (ED), compliance with RASS, and goal achievement. This study was a retrospective chart review at a large Level I trauma academic medical center. Patients who were intubated in the ED or en route to the ED between October 1, 2013, and October 1, 2014, were eligible for inclusion if they met the following criteria: aged 18 years or older, 24 hr or more on mechanically ventilated support receiving continuous sedation and/or analgesia during the first 48 hr of admission, and a hospital stay of 6 days or more. There were 205 patients identified; 104 failed inclusion, 101 were enrolled, and 62 were excluded. Thirty-nine patients (94.9%) had an RASS goal implemented in the ED, of which 37 patients (81.1%) had an RASS goal set by an ED physician. Assessment of the RASS was found to be inconsistent, as 56.8% of patients were evaluated by an ED nurse within 1 hr of sedative initiation. Of the 37 patients who had an RASS goal in the ED, 18.9% achieved their goal in the ED. A review of sedation prescribing revealed that 39% received a regimen of varied combinations of continuous infusions of propofol, dexmedetomidine, and midazolam throughout admission, 33% received a regimen of 2 of the aforementioned drugs, and 28% received only propofol. Median extubation time was 129 hr. Seven patients expired within 180 days of admission. The assessment of the RASS was a common practice, but there were inconsistencies in measurement. A limited number of patients achieved their RASS goal in the ED. These results support a provider and nursing knowledge deficit regarding RASS goal setting, proper documentation of RASS measurement, and the need for appropriate assessments. [ABSTRACT FROM AUTHOR]

Background: The aging of society is a global trend, and care of older adults with dementia is an urgent challenge. As dementia progresses, patients exhibit negative emotions,memory disorders, sleep disorders, and agitated behavior. Agitated behavior is one of the most difficult problems for family caregivers and healthcare providers to handle when caring for older adults with dementia. Purpose: The aim of this study was to investigate the effectiveness of white noise in improving agitated behavior,mental status, and activities of daily living in older adults with dementia. Methods: An experimental research design was used to study elderly participants two times (pretest and posttest). Six dementia carecenters incentral andsouthernTaiwanwere targeted to recruit participants. There were 63 participants: 28 were in the experimental group, and 35 were in the comparison group. Experimental group participants received 20 minutes ofwhite noise consisting of ocean, rain, wind, and running water sounds between 4 and 5 P.M. daily over a period of 4 weeks. The comparison group received routine care. Questionnaires were completed, and observations of agitated behaviors were collected before and after the intervention. Results: Agitated behavior in the experimental group improved significantly between pretest and posttest. Furthermore, posttest scores on the Mini-Mental Status Examination and Barthel Index were slightly better for this group than at pretest. However, the experimental group registered no significant difference in mental status or activities of daily living at posttest. For the comparison group, agitated behavior was unchanged between pretest and posttest. Conclusions: The results of this study support white noise as a simple, convenient, and noninvasive intervention that improves agitated behavior in older adultswith dementia. These resultsmay provide a reference for related healthcare providers, educators, and administrators who care for older adults with dementia. [ABSTRACT FROM AUTHOR]

Mechanical ventilation is a common life-support intervention for critically ill patients that can cause stressful psychological symptoms. Animal-assisted interactions have been used in a variety of inpatient settings to reduce symptom burden and promote overall well-being. Because of the severity of illness associated with critical care, use of highly technological equipment, and heightened concern for infection control and patient safety, animal-assisted interaction has not been widely adopted in the intensive care unit. This case study of the therapeutic interaction between a canine and a mechanically ventilated patient provides support for the promotion of animal-assisted interactions as an innovative symptom management strategy in the intensive care unit. [ABSTRACT FROM AUTHOR]

Synthetic marijuana use is an emerging public health problem in the United States, and can cause agitation, severe psychosis, bizarre hallucinations, and possibly death. This article describes these products, which are unregulated and can vary widely in composition, and how clinicians can recognize patients with synthetic cannabinoid toxicity and treat them appropriately to minimize morbidity and mortality. [ABSTRACT FROM AUTHOR]

Agitation is one of the most common issues that critically ill patients experience. Medications used to manage agitation are often administered intravenously or intramuscularly in the acutely agitated, critically ill patient. However, a multimodal approach that utilizes multiple routes of administration may be appropriate. This review summarizes the available literature on oral antipsychotics, clonidine, and valproic acid to manage agitation in critically ill patients while also focusing on their pharmacology and appropriate monitoring. Despite inconclusive findings from different studies, antipsychotics, clonidine, and valproic acid may provide benefit for specific patient populations. As more evidence emerges, these agents may start playing a greater role in the management of agitation, which is not amenable to first-line agents. As health care professionals, it is prudent to be familiar with their dosing regimens, common adverse effects, and the monitoring required to maximize patient benefits and minimize harms. [ABSTRACT FROM AUTHOR]

Negative symptoms at the end of life are distressing for both the patient and family. Effective management of both physical and psychological symptoms improves quality of life and well-being, but intervention strategies are not always effective or feasible and often are exclusively pharmacologic. Developing treatment plans to meet symptom management needs is critical. A 2-site research study was conducted in southwest Ohio assessing effectiveness of Starlight Therapy in treating the negative symptoms associated with end of life. The study of 40 patients found the Starlight Therapy effective in treating the symptoms of anxiety, agitation, dyspnea, insomnia, and pain in 90% of the patients within a 30-minute period. The therapy was ineffective in only 4 patients. Physiological symptoms were measured upon initiating Starlight Therapy, 30 minutes after therapy, and 2 hours after therapy. Results found heart rate and respiratory rate significantly different from baseline to 30 minutes and from baseline to 2 hours (P > .05). Heart rate and respiratory rate were not significantly different from 30 minutes to 2 hours (P > .05). Further research is required to explore additional types of care, subjects, and sites, which could benefit from Starlight Therapy. [ABSTRACT FROM AUTHOR]

Background: Societal guidelines exist for the management of pain, agitation, and delirium (PAD) in critically ill patients. This contemporary practice aims for a more awake and interactive patient. Institutions are challenged to translate the interrelated multivariable concepts of PAD into daily clinical practice and to demonstrate improvement in quality outcomes. An interdisciplinary goal-directed approach shows outcomes in high-acuity surgical critical care during the early stages of implementation. Methods: This study was a prospective preintervention and postintervention design. A formal PAD clinical practice guideline targeting standardized assessment and "light" levels of sedation was instituted. All mechanically ventilated patients admitted to a 24-bed surgical intensive care unit (ICU) at an academic medical center during a 6-month period were included (3 months before and 3 months after implementation). Sedation and agitation were measured using the Richmond Agitation Sedation Scale (RASS), pain measured using a Behavioral or Numeric Pain Scale (NPS/BPS), and delirium using the Confusion Assessment Method for the Intensive Care Unit. Total ventilator days with exposure to continuous opioid or sedative infusions and total ICU days where the patient received a physical activity session exercising out of bed were recorded. Results: There were 106 patients (54 at preintervention and 52 at postintervention). Mean percentage of RASS scores between 0 to -1 increased from 38% to 50% postintervention (P < .02). Mean percentage of NPS/BPS scores within the goal range (<5 for BPS and <3 for NPS) remained stable, 86% to 83% (P = .16). There was a decrease in use of continuous narcotic infusions for mechanically ventilated patients. This was reported as mean percentage of total ventilator days with a continuous opioid infusing: 65% before implementation versus 47% after implementation (P < .01). Mean percentage of ICU days with physical activity sessions increased from 24% to 41% (P < .001). Overall mean ventilator-free days and ICU length of stay were 5.4 to 4.5 days (P = .29) and 11.75 to 9.5 days (P = .20), respectively. Conclusion: Measureable patient outcomes are achievable in the early stages of PAD guideline initiatives and can inform future systems-level organizational change. Pain, agitation, and delirium assessment tools form the foundation for clinical implementation and evaluation. High-acuity surgical critical care patients can achieve more time at goal RASS, decreased ventilator days, and less exposure to continuous opioid infusions, all while maintaining stable analgesia. [ABSTRACT FROM AUTHOR]

Background: Despite the high prevalence of dementia among residents living in long-term care facilities in Taiwan, most care providers in these facilities have not received adequate training to deal with the behavioral and psychological symptoms of dementia (BPSD). An original care and management model for BPSD has been developed, and model-based recommendations for an education and training program have been made. However, empirical testing has not yet been conducted to determine the efficacy of this program. Purpose: This study was designed to evaluate the feasibility of using the Watch–Assess–Need intervention–Think (WANT) education and training program for BPSD in long-term care settings. Methods: A mixed-method design was used. Twenty care providers and 20 corresponding care receivers (residents with dementia) from a nursing home in southern Taiwan were enrolled. Data were collected using a variety of measurement tools, including the Cohen-Mansfield Agitation Inventory, Cornell Scale for Depression in Dementia, Attitude towards Dementia Care Scale, and Dementia Behavior Disturbance Self-efficacy Scale. Qualitative data, including care-provider perspectives on the efficacy of the WANT education and training program, were also collected. Repeated measures were conducted on the results of quantitative data analysis, whereas content analysis was performed on the results of qualitative data analysis. Results: Findings indicate that the program relieves agitated behavior (p =.01), alleviates depression in those with dementia (p <.001), and enhances care-provider attitudes toward dementia care (p =.01). However, no significant improvement was found in self-efficacy among the care providers (p =.11). In terms of qualitative outcomes, care providers indicated they perceived improved self-efficacy in managing BPSD, improved ability to view problems from a more need-centered perspective, improved attitudes toward dementia and patients' BPSD, and decreased care burden and stress. Conclusions/Implications for Practice: The study found the WANT education and training program to be feasible in clinical practice. Because of this program's simple and easy-to-remember characteristics, it is recommended that it be vigorously promoted to care providers in both long-term institutional and home care settings to help them effectively address the BPSD. [ABSTRACT FROM AUTHOR]

The article discusses public health threats of synthetic cannabinoid drugs and presents a case study of cannabinoid poisoning. Topics include reference to development of synthetic cannabinoid by chemistry professor John Huffman, research hijacking to market drugs under names such as fake weed or Yucatan fire as well as delta-9-tetrahydrocannabinol (THC) psychoactive constituent of marijuana. Also mentioned are information from U.S. Centers for Disease Control (CDC) on smoking inhalations.

In the acute care setting, pain, agitation, and delirium (PAD) often occur as interrelated parts of a syndrome rather than as separate entities. Because the three facets of PAD may be similar in presentation, it is often difficult for clinicians to recognize the syndrome and to assess and treat it. The challenge is particularly great in older patients, who are more likely than their younger counterparts to have such comorbid conditions as dementia, which may impair the ability to report pain, or age-related physiologic changes that may affect the metabolism and clearance of certain medications. This article provides an overview of each aspect of PAD, discusses clinical considerations related to the assessment and treatment of the syndrome in older adults receiving acute care, and illustrates the application of published PAD guidelines through the use of a hypothetical patient scenario. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the clinical effectiveness, safety, and cost of dexmedetomidine for the treatment of agitated delirium refractory to haloperidol in nonintubated critically ill patients.Design: Nonrandomized, controlled trial.Setting: Intensive care department of a tertiary care nonprofit hospital.Patients: All consecutive admissions to a medical-surgical ICU with a diagnosis of agitated delirium.Interventions: Initial haloperidol titration: all patients received IV bolus doses of haloperidol until agitation was controlled (Richmond Agitation Sedation Scale scoring range, 0 to -2) or reaching the maximum daily dose. Group comparison: patient responders to haloperidol (control group) were compared with nonresponders (dexmedetomidine group).Measurements and Main Results: A total of 132 nonintubated patients were treated with haloperidol in the initial haloperidol titration phase. Forty-six patients (34.8%; 95% CI, 26.0-43.1%) did not respond to haloperidol, and 86 patients (65.2%; 95% CI, 56.3-73.0%) were responders. During the group comparison phase, dexmedetomidine achieved a higher percentage of time in satisfactory sedation levels than did haloperidol (92.7% [95% CI, 84.5-99.8%] vs 59.3% [95% CI, 48.6-69.3%], respectively; p = 0.0001). Haloperidol was associated with 10 cases (11.6% [95% CI, 6.5-21.2%]) of oversedation and two (2.0% [0.4-8%]) of corrected QT lengthening. Direct cost of dexmedetomidine was 17 times greater than haloperidol, but it achieved a mean savings of $4,370 per patient due to the reduction in length of ICU stay.Conclusions: In the study conditions, dexmedetomidine shows to be useful as a rescue drug for treating agitation due to delirium in nonintubated patients in whom haloperidol has failed, and it seems to have a better effectiveness, safety, and cost-benefit profile than does haloperidol. [ABSTRACT FROM AUTHOR]

As the prevalence of Alzheimer disease and related dementias increases, dementia-related behavioral symptoms present growing threats to care quality and safety of older adults across care settings. Behavioral and psychological symptoms of dementia (BPSD) such as agitation, aggression, and resistance to care occur in nearly all individuals over the course of their illness. In inpatient care settings, if not appropriately treated, BPSD can result in care complications, increased length of stay, dissatisfaction with care, and caregiver stress and injury. Although evidence-based, nonpharmacological approaches to treating BPSD exist, their implementation into acute care has been thwarted by limited nursing staff expertise in behavioral health, and a lack of consistent approaches to integrate behavioral health expertise into medically focused inpatient care settings. This article describes the core components of one evidence-based approach to integrating behavioral health expertise into dementia care. This approach, called STAR-VA, was implemented in Veterans’ Health Administration community living centers (nursing homes). It has demonstrated effectiveness in reducing the severity and frequency of BPSD, while improving staff knowledge and skills in caring for people with dementia. The potential for adapting this approach in acute care settings is discussed, along with key lessons learned regarding opportunities for nursing leadership to ensure consistent implementation and sustainability. [ABSTRACT FROM AUTHOR]

Objectives: The Sequential Organ Failure Assessment and other severity of illness scales rely on the Glasgow Coma Scale to measure acute neurologic dysfunction, but the Glasgow Coma Scale is unavailable or inconsistently applied in some institutions. The objective of this study was to assess the validity of a modified Sequential Organ Failure Assessment that uses the Richmond Agitation-Sedation Scale instead of Glasgow Coma Scale.Design: Prospective cohort study.Setting: Medical and surgical ICUs within a large, tertiary care hospital.Patients: Critically ill medical/surgical ICU patients.Interventions: We calculated daily Sequential Organ Failure Assessment scores by using electronic medical record-derived data. By using bedside nurse-recorded Glasgow Coma Scale and Richmond Agitation-Sedation Scale measures, we calculated neurologic Sequential Organ Failure Assessment scores using the original Glasgow Coma Scale-based approach and a novel Richmond Agitation-Sedation Scale-based approach, converting the 10-point Richmond Agitation-Sedation Scale to a 4-point neurologic Sequential Organ Failure Assessment score. We assessed construct validity of Richmond Agitation-Sedation Scale-based Sequential Organ Failure Assessment by analyzing correlations with established severity of illness constructs (Acute Physiology and Chronic Health Evaluation II and Glasgow Coma Scale-based Sequential Organ Failure Assessment) and predictive validity by using logistic regression to determine whether Richmond Agitation-Sedation Scale-based Sequential Organ Failure Assessment predicts ICU, hospital, and 1-year mortality. We assessed discriminative performance with c-statistics.Measurements and Main Results: Among 513 patients (5,199 patient-days), Richmond Agitation-Sedation Scale-based Sequential Organ Failure Assessment was strongly correlated with Acute Physiology and Chronic Health Evaluation II acute physiology score at enrollment (r = 0.583; 95% CI, 0.518-0.642) and daily Glasgow Coma Scale-based Sequential Organ Failure Assessment scores (r = 0.963; 95% CI, 0.956-0.968). Mean Richmond Agitation-Sedation Scale-based Sequential Organ Failure Assessment scores predicted ICU mortality (areas under the curve = 0.814)-as did mean Glasgow Coma Scale-based Sequential Organ Failure Assessment (0.799)-as well as hospital and 1-year mortality. Admission Sequential Organ Failure Assessment scores, whether using Richmond Agitation-Sedation Scale or Glasgow Coma Scale, were less accurate predictors of mortality; areas under the curves for ICU mortality for Richmond Agitation-Sedation Scale-based and Glasgow Coma Scale-based Sequential Organ Failure Assessment, for example, were 0.622 and 0.608, respectively.Conclusion: A modified Sequential Organ Failure Assessment score that uses bedside Richmond Agitation-Sedation Scale when Glasgow Coma Scale data are not available is a valid means of assessing daily severity of illness in the ICU and may be valuable for risk-adjustment and benchmarking purposes. [ABSTRACT FROM AUTHOR]

The article discusses the pain and agitation management in the pediatric intensive care unit (PICU). Topics discussed the postoperative period for pediatric patients after cardiothoracic surgery (CTS), utilization of benzodiazepines in PICU patients, and occurrence of pulmonary hypertension and low cardiac output syndrome after CTS.

OBJECTIVE: To compare the clinical, ultrasonographic, and operative characteristics of premenarchal and post-menarchal patients with surgically verified ovarian torsion. METHODS: A retrospective cohort study of all patients with surgically verified ovarian torsion operated on at a single university-affiliated tertiary medical center during 1997-2013. Age at presentation, presenting symptoms, diagnostic studies, surgical procedure, and pathologic findings were analyzed. RESULTS: A total of 41 premenarchal and 208 postmenarchal patients were diagnosed with ovarian torsion during the study period. Median ages were 9 and 27 years, respectively. Median duration of symptoms before first presentation was longer among the premenarchal patients (24.0 compared with 8.0 hours, P<.001) as was the median interval from hospital admission to surgery (9.5 compared with 4.6 hours, P<.001). Premenarchal girls had a higher rate of restlessness, fever, and evidence of pelvic mass at presentation and a similar rate of ultrasonographic signs for torsion (78.5% compared with 73.1% P=.53). During surgery, a finding of a black-bluish ovary was more common in premenarchal girls (61.0% compared with 41.3%, P=.02). CONCLUSION: Ovarian torsion in premenarchal girls is associated with a longer interval from onset of symptoms and an increased rate of fever and pelvic mass at presentation compared with postmenarchal patients. These data may aid the physician in the evaluation of abdominal pain in premenarchal girls. [ABSTRACT FROM AUTHOR]

The article focuses on the safety spotter program, an innovative program involving the education of unlicensed assistive personnel (UAP) to serve as Safe Patient Observation Technicians or spotters in the U.S. Topics discussed include the establishment of the earlier sitter program, the leadership team for patients in need of constant observation, and the transition from sitters to spotters.

Elderly population account for more than 50% of all intensive care admissions, and during their stay, up to 87% of them suffer from delirium. There is a large body of evidence demonstrating increased mortality and worse cognitive function for elderly patients who become delirious during their intensive care unit stay. Although the cause of delirium is multifactorial, inappropriate and outdated sedation methods are preventable causes. We review the current best evidences and provide what we believe are the best sedation strategies that are in line with the Society of Critical Care Medicine's Pain, Agitation and Delirium best practice guideline to reduce the incidence of intensive care unit-associated delirium. [ABSTRACT FROM AUTHOR]

The article focuses on a study conducted in Taiwan which aims to investigate the prevalence and predictors of hyperphagic behaviors in institutionalized patients with dementia. Topics include participation of 179 patients with dementia in the study, use of the Cohen-Mansfield Agitation Inventory, the Cognitive Abilities Screening Instrument, and a dementia patient demographic characteristics datasheet for collecting data and importance of transdisciplinary case meeting for dementia patients.

Background: Differences in short-term cognitive function between mechanically ventilated patients treated with multicomponent interventions and those receiving routine nursing care have not been established because of the lack of follow-up in previous studies. Purpose: This study was designed to evaluate the effects of the pain, agitation, and delirium (PAD) care bundle on delirium occurrence and clinical outcomes, specifically in terms of short-term cognitive function, in mechanically ventilated patients. Methods: Data on 243 patients with mechanical ventilation were analyzed from January 2017 to February 2019. The eligible patients were divided randomly into two groups. The control group (n = 120) received usual care, whereas the intervention group (n = 123) received the PAD bundle, including pain monitoring and management, light sedation and daily awakening, early mobility, sleep promotion, and delirium monitoring. The incidence and duration of delirium, ventilator time, and intensive care unit (ICU) length of stay were compared between the two groups. Upon discharge from the ICU and at 3 and 6 months after discharge, cognitive function was assessed using the Montreal Cognitive Assessment scale and compared between the two groups. Results: The incidence of delirium was reduced significantly in the intervention group, and significant decreases in the duration of delirium, ventilator time, and ICU length of stay were found. Cognitive impairment in the intervention group was significantly lower at the 3-month follow-up assessment. Conclusions/Implications for Practice: The PAD bundle was shown to be associated with a lower incidence of delirium and improved clinical outcomes. Short-term cognitive impairment occurred in fewer patients who were managed with the PAD bundle after ICU discharge. Our findings indicate that the PAD bundle has the potential to improve clinical outcomes. The administrative staff of ICUs should use strategies, such as interdisciplinary teamwork, to facilitate the buy-in and implementation of interventions. [ABSTRACT FROM AUTHOR]

The article offers drugs news briefs accross the U.S. Topics include Food and Drug Administration (FDA) approved Igalmi sublingual film for the acute treatment of agitation associ- ated with schizophrenia or bipolar I or II disorder in adults; ozempic 2 mg dose approved for additional glycemic control; and FDA granted emergency use authorization for InspectIR COVID-19 Breathalyzer.

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 methodological design, the 21-item Agitation Severity Scale was utilized to assess 270 adult psychiatric patients in the emergency setting in a prospective, observational fashion. Reliability analysis, item analysis, exploratory factor analysis, and validity assessments 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 α = 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 aimed at decreasing agitation, and as a research tool. [ABSTRACT FROM AUTHOR]

The article offers in initial response to a distressed patient, that helps in nonverbal and verbal communication. It offers information on patient escalation and intervene with de-escalation techniques. It mentions that detection and early intervention helps in achieving desirable deescalation outcomes.

The article focuses on the study which examines the decreasing agitation in hospitalized patients with cognitive impairment, suicidal ideation, and other behavior-altering condition. The study involved observation of patients' behavior using a tool that identifies their interests, abilities, and individualized therapeutic activities. Results show the effectiveness of the intervention in reducing patients' agitation levels.

Agitation, pain, and delirium are focal points for targeted pharmacologic therapy in the intensive care unit. Understanding how to treat these essential entities necessitates fundamental understanding of the pharmacology of sedation, analgesia, and antipsychotics. Monitoring the effectiveness of these medications is crucial to optimize therapeutic outcomes and minimize untoward effects. Agents used in the management of agitation include drugs that target γ-aminobutyric acid A such as benzodiazepines and propofol and those with other targets such as dexmedetomidine and ketamine. Analgesia in the intensive care unit is controlled primarily using intravenous opioids, which differ on the basis of their potencies and pharmacokinetics. The management of delirium involves preventing its occurrence, removing potential causes, and pharmacotherapy with antipsychotics. Finally, the introduction of paralysis with the use neuromuscular blockers is often necessary in critically ill patients in various situations. In addition to understanding pharmacologic principles associated with the treatment of agitation, pain, and delirium, familiarization with the plethora of assessment tools used to guide therapy in these critically ill patients is mandated. This review focuses on the pharmacology of therapeutic agents used for sedation, analgesia, delirium, and neuromuscular blockade. Significant focus is given to the various assessment tools often used in practice today. [ABSTRACT FROM AUTHOR]

Objective: This pilot study was designed to identify which contextual factors facilitate/hinder the implementation of the awakening, breathing, coordination, delirium, and early mobility (ABCDE) bundle for guidance in future studies. Design: The sources of data for this study included document review, planned site visits (including interviews and observations), a brief online contextual factors survey, and self-reported process and outcome data. Patients: All patients in the four participating SF Bay Area lCUs were eligible to be included in this pilot study. Setting: This study took place in the four San Francisco Bay Area ICUs participating in the ICU Clinical Impact Interest Group, funded by the Gordon and Betty Moore Foundation from January 2012 through June 2013. Interventions: This was a pilot evaluation study to identify factors that facilitated/hindered the implementation of the ABCDE bundle, interventions designed to decrease the prevalence of ICU-acquired delirium and muscle weakness. The ABCDE bundle consists of spontaneous awakening trials, spontaneous breathing trials, coordination of awakening and breathing trials, choice of sedation, delirium screening and treatment, and early progressive mobility. Measurements: Process data related to bundle element compliance were collected at baseline and monthly during the intervention period. Outcome data (average ICU length of stay and average days on mechanical ventilation) were collected at baseline and quarterly during the intervention period. Hospital-specific results of the online contextual factors survey and information gathered through interviews and observations during site visits also contributed to the analysis. Main Results: Factors related to structural characteristics of the ICU, an organizational-wide patient safety culture, an ICU culture of quality improvement, implementation planning, training/support, and prompts/documentation are believed to have facilitated the rate and success of ABCDE bundle implementation. Excessive turnover (both in project and ICU leadership), staff morale issues, lack of respect among disciplines, knowledge deficits, and excessive use of registry staff are believed to have hindered implementation. Conclusions: Successful implementation of the elements of the ABCDE bundle can result in significant improvements in ICU patient care. The results of this study highlight specific structural and cultural elements of ICUs and hospitals that can positively and negatively influence the implementation of complex care bundles like the ABCDE bundle. Further research is needed to assess the influence of these contextual factors across a broader variety of ICUs and hospitals. [ABSTRACT FROM AUTHOR]

Objective: The awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle is an evidence-based interprofessional multicomponent strategy for minimizing sedative exposure, reducing duration of mechanical ventilation, and managing ICU-acquired delirium and weakness. The purpose of this study was to identify facilitators and barriers to awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle adoption and to evaluate the extent to which bundle implementation was effective, sustainable, and conducive to dissemination. Design: Prospective, before-after, mixed-methods study. Setting: Five adult ICUs, one step-down unit, and a special care unit located in a 624-bed academic medical center Subjects: Interprofessional ICU team members at participating institution. Interventions and Measurements: In collaboration with the participating institution, we developed, implemented, and refined an awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle policy. Over the course of an 18-month period, all ICU team members were offered the opportunity to participate in numerous multimodal educational efforts. Three focus group sessions, three online surveys, and one educational evaluation were administered in an attempt to identify facilitators and barriers to bundle adoption. Main Results: Factors believed to facilitate bundle implementation included: 1) the performance of daily, interdisciplinary, rounds; 2) engagement of key implementation leaders; 3) sustained and diverse educational efforts; and 4) the bundle's quality and strength. Barriers identified included: 1) intervention-related issues (e.g., timing of trials, fear of adverse events), 2) communication and care coordination challenges, 3) knowledge deficits, 4) workload concerns, and 5) documentation burden. Despite these challenges, participants believed implementation ultimately benefited patients, improved interdisciplinary communication, and empowered nurses and other ICU team members. Conclusions: In this study of the implementation of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle in a tertiary care setting, clear factors were identified that both advanced and impeded adoption of this complex intervention that requires interprofessional education, coordination, and cooperation. Focusing on these factors preemptively should enable a more effective and lasting implementation of the bundle and better care for critically ill patients. Lessons learned from this study will also help healthcare providers optimize implementation of the recent ICU pain, agitation, and delirium guidelines, which has many similarities but also some important differences as compared with the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. [ABSTRACT FROM AUTHOR]

Objective: In 2013, the American College of Critical Care Medicine published a revised version of the pain, agitation, and delirium guidelines. The guidelines included an ICU pain, agitation, and delirium care bundle designed to facilitate implementation of the pain, agitation, and delirium guidelines. Design: Review article. Setting: Multispecialty critical care units. Patients: Adult ICU patients. Interventions: This article describes: 1) the ICU pain, agitation, and delirium care bundle in more detail, linking pain, sedation/agitation, and delirium management in an integrated and interdisciplinary fashion; 2) pain, agitation, and delirium implementation strategies; and 3) the potential synergistic benefits of linking pain, agitation, and delirium management strategies to other evidence-based ICU practices, including spontaneous breathing trials, ICU early mobility programs, and ICU sleep hygiene programs, in order to improve ICU patient outcomes and to reduce costs of care. Results: Linking the ICU pain, agitation, and delirium management strategies with spontaneous awakening trials, spontaneous breathing trials, and early mobility and sleep hygiene programs is associated with significant improvements in ICU patient outcomes and reductions in their costs of care. Conclusions: The 2013 ICU pain, agitation, and delirium guidelines provide critical care providers with an evidence-based, integrated, and interdisciplinary approach to managing pain, agitation/sedation, and delirium. The ICU pain, agitation, and delirium care bundle provides a framework for facilitating implementation of the pain, agitation, and delirium guidelines. Widespread implementation of the ICU pain, agitation, and delirium care bundle is likely to result in large-scale improvements in ICU patient outcomes and significant reductions in costs. [ABSTRACT FROM AUTHOR]