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Assignment 3 Tutor comments are at bottom.
Arciniegas, D. B., Yudofsky, S. C., & Hales, R. E. (Eds.). (2018). The American Psychiatric Publishing Textbook of Neuropsychiatry and Behavioral Neuroscience. American Psychiatric Pub. Retrieved from: https://doi.org/10.1176/appi.books.9781615372423.sy08.

Proposed Changes

Current Sentence:

Delirium Wikipedia page under Treatment; Non-Pharmacologic Interventions:

“Of note, severe agitation that endangers self or others may require physical restraints and professional supervision, but only as a last resort.”

Updated Sentence:

''Restraints should rarely be used as an intervention for delirium. The use of restraints has been recognized as a risk factor for injury and aggravating symptoms, especially in elderly inpatients. The only cases where restraints should sparingly be used during delirium is in the protection of life-sustaining interventions, such as endotracheal tubes.''

Rationale for Proposed Change

The current sentence from the Delirium page discussing restraints indicates that they are used as an intervention for delirium. This contradicts current literature and guidelines which state that restraints have been identified as a risk factor for injury and aggravation of delirium (confirmed by our tutor and external sources). The current sentence says that restraints should be used “as a last resort” but does not clarify what constitutes as a last resort situation. It also does not mention the limitations or dangers of restraints. My proposed change highlights that the use of restraints is not recommended, briefly outlines the risks of their use, and mentions that they should only even be considered if there is a risk of damage of life-sustaining equipment.

Controversy or varied opinion: The topic of restraints was historically controversial as their use was previously popular in helping manage outbursts in patients experiencing conditions like delirium. Although, it is now common knowledge that the use of restraints only further aggravates symptoms of delirium and puts the patient at risk of being injured. The main grey area of this topic is what special situations restraints should still be used in as there is subjectivity in making such a decision. There may be variation between healthcare practitioners interpretation of what constitutes as “risk of damage of life-sustaining equipment” for a patient experiencing delirium.

Critique of Source

The source had relevant, current references (last 10 years), was published in the past 5 years (2018), complies with Wikipedia’s MEDRS criteria, and is published by the American Psychiatric Association (the largest psychiatric organization in the world). The benefit of using a textbook chapter published by a national association (American Psychiatric Association) is that it is written and reviewed by multiple experts in the field. One possible source of bias is that Americian Psychiatric Association relies on the pharmaceutical industry for approximately a quarter of its funding. The variety of authors and reviewers of the textbook chapter makes bias from the pharmaceutical industry less likely and the funding source should have little to no impact on a discussion on the use of restraints, although it is important to be aware of. The textbook chapter was written by experts, but the sources were not chosen through a systematic review protocol. There is subjectivity in the source selection based on the preferences of the writers/editors of the textbook and chapter. They may choose sources that resonate with their own prior knowledge and academic backgrounds and may miss important sources such as unpublished abstracts or articles not in English. There were also no tests done for clinical or statistical heterogeneity in the articles considered for or used as sources. Ultimately, the reader of this textbook must trust that the authors/editors chosen reviewed all of the relevant sources before selecting their final references and writing their respective chapters.

Assignment 2
Arciniegas, D. B., Yudofsky, S. C., & Hales, R. E. (Eds.). (2018). The American Psychiatric Publishing Textbook of Neuropsychiatry and Behavioral Neuroscience. American Psychiatric Pub. https://doi.org/10.1176/appi.books.9781615372423.sy08.

How did I search for the source?

I searched in PubMed for:

(Delirium[Title] AND (“psychiatry"[MeSH Terms] OR "psychiatry"[All Fields])) AND ("2015"[PDAT] : "3000"[PDAT])

I found an article that I liked ( https://doi.org/10.1176/appi.ajp.2018.18070893 ) but it was based on a case study and did not match MEDRS criteria. The article was in The American Journal of Psychiatry which has a search function. I look for “delirium” articles published 2015 onwards in their database, specifying for textbook chapters and review articles. I reviewed a few different textbook chapters published by the American Psychiatric Association and selected my source (see more under “Why was the source chosen” below).

Which sources were considered?

Arciniegas, D. B., Yudofsky, S. C., & Hales, R. E. (Eds.). (2018). The American Psychiatric Publishing Textbook of Neuropsychiatry and Behavioral Neuroscience. American Psychiatric Pub. https://doi.org/10.1176/appi.books.9781615372423.sy08.

Thakur, M. E. (Ed.). (2015). The American psychiatric publishing textbook of geriatric psychiatry. American Psychiatric Pub. https://doi.org/10.1176/appi.books.9781615370054.ds07.

Thom, R. P., Levy-Carrick, N. C., Bui, M., & Silbersweig, D. (2019). Delirium. American Journal of Psychiatry, 176(10), 785-793. https://doi.org/10.1176/appi.ajp.2018.18070893.

Why was the source chosen?

The source utilized discusses risk factors for injury during delirium as well as proper management and treatment of delirium. Specifically, it discusses why the use of restraints for delirium patients is inappropriate and can result in injury. The source had relevant, current references, complied with Wikipedia’s MEDRS criteria (see below), and is published by the American Psychiatric Association (the largest psychiatric organization in the world).

List at least three reasons why the source that was selected meets Wikipedia’s reliable medical sources (MEDRS) criteria?


 * 1) MERDS criteria lists “standard textbooks by experts in a field” as reliable sources. The chosen source is a chapter from The American Psychiatric Association Publishing Textbook of Neuropsychiatry and Clinical Neurosciences. The MERDS page says that “medical textbooks published by academic publishers are often excellent secondary sources.”
 * 2) MERDS criteria recommends the use of “up-to-date evidence” and the source being used was published in 2018 (within the past 5 years).
 * 3) MERDS criteria recommends that sources with minimum bias are used. The benefit of using a textbook chapter published by a national associated (American Psychiatric Association) is that it is written and reviewed by multiple experts in the field.

How do I plan to use the source for improving the article?

Delirium Wikipedia page under Treatment; Non-Pharmacologic Interventions:

“Of note, severe agitation that endangers self or others may require physical restraints and professional supervision, but only as a last resort.”

The above sentence from the Delirium Wikipedia page indicates that restraints are used as an intervention for delirium. This contradicts current literature and guidelines which state that restraints have been identified as a risk factor for injury and aggravation of delirium (confirmed by our tutor). I plan to use the chosen source as part of my justification for removing the sentence above and identifying that:

“Restraints should not be used as an intervention for delirium. Their use has been recognized as a risk factor for injury, especially in elderly inpatients.”

Assignment 3
COMMENT- I agree that it is a grey area and perspectives likely depend on the field of health care you work in. For example, a geriatrician may state they should never be used while an ICU doc may feel strongly that limb restraints should be considered to protect the patients ET tube. I think your wording is reasonable and highlights the fact that they are not recommended.

I think it was good you mentioned financial support as potential bias but minimized it for this section. Your other arguments about the source were very fair too.

The sentence does help with your aim of making it clear that restraints should not be considered part of treatment. The actual sentence used differs from the one you use in the "How do I plan to sue the source.." section and you may consider using the more forceful one, as you do highlight that it is not a NEVER EVER type of situation. You might consider changing wording to ".. older hospitalized people with delirium."