Project Summary
The Cost Effectiveness of Alternate
Pharmacologic Interventions for Severe Agitation
The treatment of agitation during acute hospitalization is challenging.
Behavior must be controlled sufficiently to ensure safety and physiologic
stability, while side effects of the pharmacologic regimen need to be
minimized. Neuroleptics (e.g. haloperidol) are commonly chosen due to
their relatively quick therapeutic onset, but in addition to a multitude
of potential side effects, there is some concern about potential long-term
effects on recovery. Other choices available, such as benzodiazepines
(e.g. lorazepam, alprazolam) and narcotics (e.g. morphine, oxycodone),
also have the potential for significant side effects.
This naturalistic study has been designed to provide preliminary indications
of the costs and benefits of alternate pharmacologic approaches, including
relationships between medication choice and functional status and cognitive
recovery. The use of agents to manage agitation were monitored. The three
most commonly used classes of medications, neuroleptics, benzodiazepines,
and narcotics, were then further investigated. Since patients were frequently
administered medications from a combination of these classes, analysis
were conducted based on the most common combinations (a) without considering
whether an individual had received a benzodiazepine during the acute care
stay, the group of individuals who had received both narcotics and neuroleptics
were compared to those who had received narcotics but not neuroleptics;
b) for those who were given benzodiazepines, the group of individuals
who had received both narcotics and neuroleptics were compared to those
who had received narcotics but not neuroleptics; and c) for those who
were not given benzodiazepines, the group of individuals who had received
both narcotics and neuroleptics were compared to those who had received
narcotics but not neuroleptics).
First, the association between the use of these medications and injury
severity (lowest GCS, initial pupillary response, and intracranial hypertension)
was analyzed. It was found that there was no association, suggesting that
medication choice was not associated with injury severity.
The association between use of medications from these three classes and
outcomes (functional independence as measured by FIM, and length of PTA
as measured by the GOAT) was then assessed. In each of the analyses, individuals
who were given neuroleptics and narcotics (with or without benzodiazepines)
tended to have a longer length of PTA than those who were not given neuroleptics.
In some of the analyses the association was significant, in other analyses
the relationship was weaker. No consistent associations with functional
independence were found.
Interpretation of these results must be made with caution, as the associations
found do not prove causality. Controlled experimental designs can assist
with isolating the cause-effect relationship.