UNASSIGNED: This review explores delirium in critically ill patients in the inpatient setting, focusing on its prevention and management. It evaluates the efficacy of both current pharmacological and non-pharmacological interventions, aiming to provide a comprehensive overview.
UNASSIGNED: A systematic literature search was conducted to identify relevant studies investigating the prevention and management of delirium resulting in a final sample of 26 articles for analysis.
UNASSIGNED: Of the 26 articles analyzed for this review (N = 8,831 participants) of controlled trials, 16 studies examined the prevention of delirium, 9 explored the treatment of delirium, and 1 investigated both prevention and treatment of delirium.
UNASSIGNED: Among the reviewed studies, there is evidence that non-pharmacologic methods are effective in the prevention of delirium. Evidence regarding pharmacological interventions for delirium prevention is varied and inconclusive, with some indication that atypical antipsychotics like aripiprazole and quetiapine may reduce the incidence of delirium. Regarding the treatment of delirium, there is limited evidence supporting the use of pharmacological agents. Additional double-blinded, randomized, placebo-controlled clinical trials are needed to investigate the efficacy of pharmacologic agents for diverse hospitalized populations.

Background: Patients in intensive care units experience high symptom burden during mechanical ventilation (MV). Pharmacologic symptom management is associated with side effects and increased morbidity. Music-based interventions (MBIs) have been associated with reductions in both anxiety in MV adults and pain for critically ill adults, yet their use for the management of other burdensome symptoms has not been evaluated. The purpose of this scoping review is to map the state of evidence for the use of prerecorded music listening MBIs for symptom management in MV adults. Methods: A systematic search of the literature was conducted across four electronic databases (PubMed, EMBASE, CINAHL, and Web of Science) for experimental designed studies that measured the efficacy of MBIs for the management of physical and psychological symptoms including anxiety, sedation/agitation, dyspnea, distress, delirium, sleep, stress, fear, loneliness, or depression in critically ill, MV adults between January 1, 1998, and April 18, 2023. Results: A total of 643 abstracts and 29 clinical trials were included. Overall, the risk of bias, assessed using the Evidence Project tool, was moderate. MBIs were mostly delivered with headphones using music selected either by investigators or from a limited selection. MBIs were associated with reduced pain, agitation, dyspnea, distress and anxiety, and improved tolerance of MV and sedative weaning. Outcomes of delirium were mixed. No studies explored sleep disturbances, fear, or loneliness. Conclusions: Use of MBIs improved symptom experience for critically ill adults during MV. Future studies employing unrestricted patient-preferred music selections and exploring outcomes of sleep quality, psychological distress, and delirium are needed in this highly symptomatic patient population.

Background: Autism spectrum disorder (ASD) is a persistent neurodevelopmental disorder frequently co-occurring with attention-deficit/hyperactivity disorder (ADHD) and behavior-related disorders. While behavioral therapy is the first-line option to manage the core symptoms of ASD, pharmacological therapy is sometimes needed to treat acute problems, such as agitation and aggressive behaviors. Recent guidelines recommend the use of neuroleptics to reduce psychomotor agitation in patients with ASD. However, as children with ASD are often drug-resistant, alternative treatments are often justified. Reports from the literature have indicated that intravenous valproate (IV-VPA) can be effective in reducing agitation in psychiatric patients, with a lower frequency of adverse events compared to conventional treatments. However, as the related findings are occasionally inconsistent, IV-VPA is not yet an approved option in the context of clinical psychiatry. We aim to improve knowledge of the IV-VPA treatment option for emergency psychiatric treatment in pediatric patients. Methods: We report the case of an 11-year-old boy suffering from a complex neurodevelopmental condition who experienced a psychotic episode with severe aggressive and disruptive behaviors and was successfully treated with IV-VPA. Furthermore, we provide an updated literature review on this topic. Conclusion: In our case, first-line therapies proved to be ineffective. To the contrary, IV-VPA led to safe and prompt clinical success, which is in line with other reports. Based on our literature review, IV-VPA can be highly effective and reduces the risk of adverse events that frequently occur with the use of high-dose standard medications in emergency psychiatry.

OBJECTIVE: 40-60% of persons living with dementia (PLWD) experience agitation and/or aggression symptoms. There is a need to understand the best method to detect agitation and/or aggression in PLWD. We aimed to identify agitation and/or aggression tools that are validated against a reference standard within the context of PLWD.
METHODS: Our study was registered on PROSPERO (CRD42020156708). We searched MEDLINE, Embase, and PsycINFO up to April 22, 2024. There were no language or date restrictions. Studies were included if they used any tools or questionnaires for detecting either agitation or aggression compared to a reference standard among PLWD, or any studies that compared two or more agitation and/or aggression tools in the population. All screening and data extraction were done in duplicates. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Data extraction was completed in duplicates by two independent authors. We extracted demographic information, prevalence of agitation and/or aggression, and diagnostic accuracy measures. We also reported studies comparing the correlation between two or more agitation and/or aggression tools.
RESULTS: 6961 articles were screened across databases. Six articles reporting diagnostic accuracy measures compared to a reference standard and 30 articles reporting correlation measurements between tools were included. The agitation domain of the Spanish NPI demonstrated the highest sensitivity (100%) against the agitation subsection of the Spanish CAMDEX. Single-study evidence was found for the diagnostic accuracy of commonly used agitation scales (BEHAVE-AD, NPI and CMAI).
CONCLUSIONS: The agitation domain of the Spanish NPI, the NBRS, and the PAS demonstrated high sensitivities, and may be reasonable for clinical implementation. However, a limitation to this finding is that despite an extensive search, few studies with diagnostic accuracy measurements were identified. Ultimately, more research is needed to understand the diagnostic accuracy of agitation and/or aggression detection tools among PLWD.

BACKGROUND: Agitation/delirium is commonly seen in children after anesthesia, and a proper dose of dexmedetomidine can prevent this complication. This study aimed to investigate the effects of different doses of Dexmedetomidine (DEX) on agitation/delirium and other complications in anesthetized children, providing clinical evidence for dose recommendations of DEX.
METHODS: This study was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A systematic search was conducted in the Cochrane Library, PubMed, Web of Science, and EMBASE. Two independent researchers performed literature screening, data extraction, and assessed the methodological quality. Data analysis was conducted using R and STATA 16.0.
RESULTS: In the final analysis, 20 randomized controlled trials (RCTs) involving 2521 children were included. The results showed that in comparison to normal saline, 1 µg/kg, 1.5 µg/kg, and 2 µg/kg intranasal DEX significantly reduced the incidence of post-anesthetic emergence agitation in children with the most effective dose being 2 µg/kg (SUCRA = 0.91). Compared with normal saline, 1 µg/kg, 1.5 µg/kg, and 2 µg/kg intranasal DEX reduced patient\'s need for postoperative analgesia, with the most effective dose being 1.5 µg/kg (SUCRA = 0.78). However, 1 µg/kg DEX performed the best in reducing Pediatric Anaesthesia Emergence Delirium (PAED) Scale score (SUCRA = 0.88).
CONCLUSIONS: Compared with normal saline, intranasal administration of 2 µg/kg DEX and 1.5 µg/kg DEX are the optimal doses to reduce the incidence of agitation and the need for postoperative pain relief in children under general anesthesia. Given effectiveness and safety, intranasal use of 1 µg/kg DEX appears to be the most effective dosage for anesthetized children.

Introduction: At the end of life, the prevalence of delirium and pain is high. Current therapy is not satisfactory. Dexmedetomidine could be useful in the control of delirium and pain but is not approved outside of intensive care setting. Our objectives are to evaluate existing evidence in the literature that assessed the efficacy of dexmedetomidine in pain and delirium control and its safety in palliative care patients outside intensive care units. This systematic review was prospectively registered with PROSPERO and included a risk of bias assessment. Methods: PubMed and SCOPUS were examined for literature published until 2023. Experimental, cohort, cross-sectional, case-control studies, and case series/reports were included if they evaluate the use of dexmedetomidine in delirium and/or pain management in hospitalized palliative care adult patients. Studies were excluded if they were carried out in intensive care units. Results: Of the initial 529 records, 14 were included. Although only two studies were randomized trials, most were small and only one had low risk of bias. In most case reports and in the two retrospective cohort studies, dexmedetomidine appears to be a better option for these symptoms, although differences were not significant in the randomized trials. Discussion: Dexmedetomidine seems to be a promising option for refractory pain and delirium and may contribute to a reduction in opioid administration to control pain. This is the first systematic review of dexmedetomidine in palliative care. Quality evidence is limited, but clinical properties of dexmedetomidine justify the conduction of controlled trials in palliative care.

UNASSIGNED: Managing agitation and other behaviours that challenge is a significant dementia care challenge. The priority is to find effective non-pharmacological interventions as drug treatments can have significant side effects. This review evaluates the effectiveness of structured physical activity on agitation in dementia.
UNASSIGNED: Our rapid review searched four electronic databases, Cochrane CENTRAL, MEDLINE, CINAHL and Embase, for interventional studies using a structured physical activity programme in people with dementia and studied the effect of this activity on behaviours that challenge. Study quality was assessed using CASP criteria and data was narratively synthesised.
UNASSIGNED: We included 13 studies in this review (four rated as high quality), involving a total of 1546 participants. Results were analysed according to exercise type, frequency and intensity of the intervention. Exercise is effective in reducing agitation and studies with higher adherence to exercise demonstrated more positive effects on agitation and behaviours that challenge.
UNASSIGNED: Physical activity can be effective in reducing agitation in older adults with dementia. Further research is needed to clarify the type of intervention that is most beneficial. Strategies to make physical activity more acceptable and available to people with dementia need to be established.

Although uncommon, the risk of aggression and violence is greater in people with schizophrenia than in the general population. Clozapine is the \"gold standard\" pharmacologic treatment for the management of persistent agitation and aggression in people with schizophrenia and is consistently recommended by guidelines and reviews for this purpose. Although clozapine is indicated for treatment-resistant schizophrenia based on its superior efficacy, studies have proposed that clozapine may have specific properties that ameliorate aggression and hostility that are distinct from its antipsychotic effects. A literature review was conducted on June 3, 2023, using the US National Library of Medicine\'s PubMed resource to identify articles focusing on clozapine for the treatment of aggression, violence, and/or hostility in patients with schizophrenia or schizoaffective disorder. The majority of evidence, including from randomized control trials, supports the utilization of clozapine as maintenance treatment for persistent aggressive behavior in patients with schizophrenia, and supports that its anti-aggressive effects may be independent from its antipsychotic properties (e.g. - treatment of hallucinations and delusions). Future randomized control studies evaluating clozapine and clozapine serum levels with aggression as the primary outcome would be of benefit.

Clonidine is an α-adrenoceptor agonist acting on receptors in the brain and peripheral tissues, leading to a reduction in sympathetic outflow and release of certain neurotransmitters. Clonidine has multiple uses across various medical conditions. One of its uses is as adjuvant to anaesthetic and analgesic agents specially opioids, mostly administered through intravenous and epidural routes. The opioids, effective in cancer pain management, are associated with various side effects such as sedation, pruritus, constipation, nausea, respiratory depression, tolerance and dependence. Combination of clonidine with opioids seems to help to achieve better pain management and less need of opioids. Use of clonidine in palliative care has been less common, but it is gradually gaining recognition for its potential benefits in managing symptoms like cancer pain and agitation. This combination approach has been explored in palliative care settings, including cancer pain and agitation, where patients experience complex and refractory symptoms. It seems to be well tolerated and gives better symptom relief. The available literature on clonidine\'s use in cancer pain and agitation management, especially in subcutaneous form, is limited and outdated. Therefore, the optimal dosing, safety profile and overall effectiveness of subcutaneous clonidine requires further exploration through prospective research studies.

OBJECTIVE: Analyze the effectiveness of dexmedetomidine compared to midazolam for the treatment of ketamine-induced emergence delirium in noncardiac surgical patients.
METHODS: Systematic review.
METHODS: Guidelines outlined in the Preferred Reporting Items For Systematic Reviews and Meta-analyses (PRISMA)22 were used for this review. PubMed, Cumulative Index To Nursing And Allied Health Literature (CINAHL), MEDLINE, The Cochrane Library, EBSCOhost, National Institute of Health clinical trials, Google Scholar, and gray literature were searched for relevant studies. Only peer-reviewed nonexperimental studies, quasi-experimental studies, and randomized control trials with or without meta-analysis were included. The evidence was assessed using the Johns Hopkins Nursing Evidence-Based Practice guidelines for quality ratings and evidence level.
RESULTS: Five blinded randomized controlled trials, three quasi-experimental studies, and two retrospective nonexperimental studies comprised of 1,024 subjects were evaluated for this review. Dexmedetomidine was more effective at reducing ketamine-induced delirium in adult patients, although midazolam attenuated the psychomimetic effects of ketamine better in pediatric patients. Furthermore, postanesthesia care unit discharge times were similar between patients treated with dexmedetomidine and midazolam. The studies in this review were categorized as Level I, Level II, or Level III and rated Grade A, implying strong confidence in the actual effects of dexmedetomidine in all outcome measures of the review.
CONCLUSIONS: The current evidence suggests that dexmedetomidine is an effective alternative for alleviating ketamine-induced delirium in noncardiac adult surgical patients. Multiple studies in this review noted improved hemodynamics and reduced postoperative analgesic requirements after administration of dexmedetomidine in conjunction with ketamine.