The International Psychogeriatric Association (IPA) published a provisional consensus definition of agitation in cognitive disorders in 2015. As proposed by the original work group, we summarize the use and validation of criteria in order to remove “provisional” from the definition.

This report summarizes information from the academic literature, research resources, clinical guidelines, expert surveys, and patient and family advocates on the experience of use of the IPA definition. The information was reviewed by a working group of topic experts to create a finalized definition.

We present a final definition which closely resembles the provisional definition with modifications to address special circumstances. We also summarize the development of tools for diagnosis and assessment of agitation and propose strategies for dissemination and integration into precision diagnosis and agitation interventions.

The IPA definition of agitation captures a common and important entity that is recognized by many stakeholders. Dissemination of the definition will permit broader detection and can advance research and best practices for care of patients with agitation.

To develop an agitation reduction and prevention algorithm is intended to guide implementation of the definition of agitation developed by the International Psychogeriatric Association (IPA)

Review of literature on treatment guidelines and recommended algorithms; algorithm development through reiterative integration of research information and expert opinion

IPA Agitation Workgroup

IPA panel of international experts on agitation

Integration of available information into a comprehensive algorithm

None

The IPA Agitation Work Group recommends the Investigate, Plan, and Act (IPA) approach to agitation reduction and prevention. A thorough investigation of the behavior is followed by planning and acting with an emphasis on shared decision-making; the success of the plan is evaluated and adjusted as needed. The process is repeated until agitation is reduced to an acceptable level and prevention of recurrence is optimized. Psychosocial interventions are part of every plan and are continued throughout the process. Pharmacologic interventions are organized into panels of choices for nocturnal/circadian agitation; mild-moderate agitation or agitation with prominent mood features; moderate-severe agitation; and severe agitation with threatened harm to the patient or others. Therapeutic alternatives are presented for each panel. The occurrence of agitation in a variety of venues—home, nursing home, emergency department, hospice—and adjustments to the therapeutic approach are presented.

The IPA definition of agitation is operationalized into an agitation management algorithm that emphasizes the integration of psychosocial and pharmacologic interventions, reiterative assessment of response to treatment, adjustment of therapeutic approaches to reflect the clinical situation, and shared decision-making.

An effective hospital response to mass casualty incidents (MCIs) requires rapid mobilization of personnel capable of caring for critically ill trauma patients and availability of resuscitation resources.

Hospitals facing an MCI wrestle with the challenge of immediately adjusting their overextended clinical operations to resuscitate a large number of rapidly arriving patients without compromising the care of existing patients.

Hospitalists are well positioned to add significant value by off-loading the emergency department (ED) given their broad clinical expertise. We describe our institution’s protocol to generate immediate and sustained surge capacity by integrating our hospitalist service into MCI response.

Our protocol details the safe and rapid transfer of care of existing ED patients to hospitalist teams to make ED staff and space available to care for incoming MCI patients.

To assess the variables associated with incomplete and unscheduled cardiology clinic visits among referred children with a focus on equity gaps.

We conducted a retrospective chart review for patients less than 18 years of age who were referred to cardiology clinics at a single quaternary referral centre from 2017 to 2019. We collected patient demographic data including race, an index of neighbourhood socio-economic deprivation linked to a patient’s geocoded address, referral information, and cardiology clinic information. The primary outcome was an incomplete clinic visit. The secondary outcome was an unscheduled appointment. Independent associations were identified using multivariable logistic regression.

There were 10,610 new referrals; 6954 (66%) completed new cardiology clinic visits. Black race (OR 1.41; 95% CI 1.22–1.63), public insurance (OR 1.29; 95% CI 1.14–1.46), and a higher deprivation index (OR 1.32; 95% CI 1.08–1.61) were associated with higher odds of incomplete visit compared to the respective reference groups of White race, private insurance, and a lower deprivation index. The findings for unscheduled visit were similar. A shorter time elapsed from the initial referral to when the appointment was made was associated with lower odds of incomplete visit (OR 0.62; 95% CI 0.52–0.74).

Race, insurance type, neighbourhood deprivation, and time from referral date to appointment made were each associated with incomplete referrals to paediatric cardiology. Interventions directed to understand such associations and respond accordingly could help to equitably improve referral completion.

Despite the prevalence of antidepressant-related sexual side effects, comparisons of treatments for these problematic side effects are lacking.

To address this, we performed a systematic review and Bayesian network meta-analysis to compare interventions for antidepressant-induced sexual dysfunction in adults. Using PubMed and clinicaltrials.gov, we identified published and unpublished prospective treatment trials from 1985 to September 2020 (primary outcome: the Arizona sexual experience scale [ASEX] score). The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation framework.

We identified 57 citations (27 randomized controlled trials, 66 treatment arms, 27 open-label trials, and 3 crossover trials) that evaluated 33 interventions (3108 patients). In the systematic review, 44% (25/57) of trials reported successful interventions; this was more common in open-label (70%, 19/27) compared to placebo-controlled studies (22%, 6/27). In the meta-analysis of placebo-controlled studies that used the ASEX (N = 8), pycnogenol was superior to placebo (standardized mean difference: −1.8, 95% credible interval [CrI]: [−3.7 to 0.0]) and there was evidence that, at a 6% threshold, sildenafil improved sexual dysfunction (standardized mean difference: −1.2, 95% CrI [−2.5 to 0.1]). In the meta-analysis including single-arm studies (15 studies), treatment response was more common with sildenafil, tianeptine, maca, tiagabine, and mirtazapine compared to placebo, but these differences failed to reach statistical significance.

While heterogeneity across randomized controlled trials complicates identifying the single best intervention, multiple trials suggest that sildenafil ameliorates antidepressant-induced sexual dysfunction. More randomized controlled trials are needed to examine the putative efficacy of other interventions.

Mass shootings account for a small fraction of annual worldwide murders, yet disproportionately affect society and influence policy. Evidence suggesting a link between mass shootings and severe mental illness (i.e. involving psychosis) is often misrepresented, generating stigma. Thus, the actual prevalence constitutes a key public health concern.

We examined global personal-cause mass murders from 1900 to 2019, amassed by review of 14 785 murders publicly described in English in print or online, and collected information regarding perpetrator, demographics, legal history, drug use and alcohol misuse, and history of symptoms of psychiatric or neurologic illness using standardized methods. We distinguished whether firearms were or were not used, and, if so, the type (non-automatic v. semi- or fully-automatic).

We identified 1315 mass murders, 65% of which involved firearms. Lifetime psychotic symptoms were noted among 11% of perpetrators, consistent with previous reports, including 18% of mass murderers who did not use firearms and 8% of those who did (χ2 = 28.0, p < 0.01). US-based mass shooters were more likely to have legal histories, use recreational drugs or misuse alcohol, or have histories of non-psychotic psychiatric or neurologic symptoms. US-based mass shooters with symptoms of any psychiatric or neurologic illness more frequently used semi-or fully-automatic firearms.

These results suggest that policies aimed at preventing mass shootings by focusing on serious mental illness, characterized by psychotic symptoms, may have limited impact. Policies such as those targeting firearm access, recreational drug use and alcohol misuse, legal history, and non-psychotic psychopathology might yield more substantial results.

To examine the association between long-term intake of total and the six classes of dietary flavonoids and decline in cognitive function over a follow-up period of up to 15 years.

In this longitudinal study, we evaluated change in eight cognitive domain scores (verbal and visual memory, verbal learning, attention and concentration, abstract reasoning, language, visuoperceptual organisation and the global function) based on three neuropsychological exams and characterised the annualised change between consecutive exams. Long-term intakes of total and six flavonoid classes were assessed up to four times by a validated FFQ. Repeated-measures regression models were used to examine the longitudinal association between total and six flavonoid classes and annualised change in the eight cognitive domains.

The Framingham Heart Study (FHS), a prospective cohort study.

One thousand seven hundred and seventy-nine subjects who were free of dementia, aged ≥45 years and had attended at least two of the last three FHS Offspring cohort study exams.

Over a median follow-up of 11·8 years with 1779 participants, nominally significant trends towards a slower decline in cognitive function were observed among those with higher flavanol and flavan-3-ol intakes for global function, verbal and visual memory; higher total flavonoids and flavonoid polymers for visual memory; and higher flavanols for verbal learning.

In spite of modest nominal trends, overall, our findings do not support a clear association between higher long-term flavonoid intake and slowing age-related cognitive decline.