Sitting time and physical activity after stroke: physical ability is only part of the story

Background: Understanding factors that influence the amount of time people with stroke spend sitting and being active is important to inform the development of targeted interventions.

Objective: To explore the physical, cognitive, and psychosocial factors associated with daily sitting time and physical activity in people with stroke.

Method: Secondary analysis of an observational study (n?=?50, mean age 67.2?±?11.6 years, 33 men) of adults at least 6 months post-stroke. Activity monitor data were collected via a 7-day, continuous wear (24 hours/day) protocol. Sitting time [total, and prolonged (time in bouts of ≥?30 minutes)] was measured with an activPAL3 activity monitor. A hip-worn Actigraph GT3X+ accelerometer was used to measure moderate-to-vigorous-intensity physical activity (MVPA) time. Univariate analyses examined relationships of stroke severity (National Institutes of Health Stroke Scale), physical [walking speed, Stroke Impact Scale (SIS) physical domain score], cognitive (Montreal Cognitive Assessment), and psychosocial factors (living arrangement, SIS emotional domain score) with sitting time, prolonged sitting time, and MVPA.

Results: Self-reported physical function and walking speed were negatively associated with total sitting time (r?=???0.354, P?=?0.022 and r?=???0.361, P?=?0.011, respectively) and prolonged sitting time (r?=???0.5, P?=?0.001 and ??0.45, P?=?0.001, respectively), and positively associated with MVPA (r?=?0.469, P?=?0.002 and 0.431, P?=?0.003, respectively).

Conclusions: Physical factors, such as walking ability, may influence sitting and activity time in people with stroke, yet much of the variance in daily sitting time remains unexplained. Large prospective studies are required to understand the drivers of activity and sitting time.     

A STUDY OF AGGRESSION AMONG REFERRALS TO A COMMUNITY-BASED PSYCHIATRY OF OLD AGE SERVICE

Objective. The aims of the study were to examine the prevalence of aggressive behaviour in a non-selected community-based population, to identify clinical and sociodemographic variables associated with aggression and to examine the relationship between aggression and outcome at 2-year follow-up. Design. Case series, using the Ryden Aggression Scale as a retrospective measure of aggression. Setting. A community-based specialist psychiatry of old age service. Participants. All referrals to the service over a 3-month period. Results. Of the 42 subjects included in the study, 25 patients had a diagnosis of dementia. Aggressive behaviour was reported in 18 patients, this being verbal only in nine cases and both verbal and physical in nine cases. Sexual aggression and self-injurious behaviour were each reported in one case only. Aggression was found to be positively associated with a diagnosis of dementia and high physical dependency but was not found to be associated with age, sex, physical illness or the use of psychotropic medication. At 2-year follow-up, aggressive patients were found to have a higher rate of admission to psychiatric inpatient or residential care and tended to have a higher use of neuroleptic drugs. Conclusions. These findings suggest that aggression is a significant problem for community-based elderly people and their carers, may increase the likelihood of admission into long-term care and that a reliable instrument to measure aggression would be useful in the clinical assessment of this population. © 1997 by John Wiley & Sons, Ltd.     

Informal Carers of Former Long-stay Hospital Residents With Learning Disabilities

This study set out to describe and analyse the nature and consequences of care for a small number of informal carers (n = 9) providing full-time care for people with learning disabilities discharged from long-stay hospitals between 1987 and 1992. The findings showed that these carers, whilst not adversely affected by their caring roles, did experience restrictions on their personal and social lives as well as increased anxiety and physical fatigue. In contrast with findings from other studies of carers of people with learning disabilities, they had more difficulty with practical caring tasks/activities (e.g. providing help with social activities) than with problem behaviour. Although generally satisfied with the professional support received, carers indicated that they would benefit from more support, especially holiday and weekend respite care.     

PREVALENCE AND CORRELATES OF AGGRESSIVE BEHAVIOURS OCCURRING IN PATIENTS WITH ALZHEIMER'S DISEASE

Objectives. To determine the prevalence and clinical correlates of verbal and physical aggression occurring in Alzheimer's disease sufferers. Design. A retrospective note review was performed to classify the subjects according to whether they were verbally or physically aggressive (assaultive) or non-aggressive. The characteristics of the three groups were compared. Subjects. The subjects were 262 patients who were living in non-institutional settings and had been diagnosed as suffering from dementia of Alzheimer's type. Results. Fifty-two per cent exhibited some aggressive behaviour. Ninety-one (35%) patients were reported to be verbally aggressive and a further 46 (18%) were assaultive to their carers. Male gender (relative risk 2.17, 95% confidence interval 1.11–4.17) and the presence of dyspraxia (relative risk 2.89, 95% confidence interval 1.43–5.88) both increased the likelihood of assaultive behaviour. Verbal aggression was not associated with any of the clinical features measured. Conclusion. Aggressive behaviour is a common phenomenon in AD and approximately one in five sufferers is assaultive. Assaultive behaviour is associated with male gender and dyspraxia. © 1997 by John Wiley & Sons, Ltd.     

Natural history of aggressive behaviour in dementia.

OBJECTIVE: This article analyses changes in aggressive behaviour throughout the course of dementia. DESIGN: Prospective, 10 year, longitudinal study of aggressive behaviour in dementia, with autopsy follow-up. SETTING: Subjects with dementia, living at home with a carer, Oxfordshire, UK. PARTICIPANTS: Ninety-nine people with dementia (Alzheimer's disease and/or vascular dementia) who were living at home with a carer. MEASURES: At 4-monthly intervals, the carers were interviewed about the subjects and the subjects were assessed cognitively. Subjects' behaviour was assessed using the Present Behavioural Examination. This is an investigator-based, semi-structured interview consisting of eight main sections monitoring behavioural and psychological change. Eight different aspects of aggressive behaviour were assessed in detail and comparison made with other relevant factors. RESULTS: Verbal aggression is the most common and longest lasting form of aggressive behaviour. Aggressive resistance and physical aggression are most likely to persist until death. Intimate care is the main factor precipitating aggressive behaviour. There are no correlations between any type of aggressive behaviour and age, gender or time since onset of dementia. CONCLUSIONS: Aggressive behaviour creates problems for carers. In general, the physical types of aggressive behaviour are most prevalent in people with more severe dementia.     

Short fused? associations between white matter connections,sex steroids,and aggression across adolescence

Functional neuroimaging studies in adults show that aggression involves reduced brain communication between subcortical and cortical areas dedicated to motivation and control, respectively. Prior research indicates that sex steroid hormone production during adolescence negatively influences the rapid development of white matter connectivity between subcortical and cortical areas during adolescence and may potentiate aggression. Here, we tested this hypothesis in 258 participants between 8 and 25 years of age by using Diffusion Weighted Imaging to examine the microstructure of white matter connections within the fronto‐temporal‐subcortical network. Trait aggression was measured using the Buss Perry Aggression Questionnaire and testosterone and estradiol levels were measured in saliva. Results indicated that higher levels of testosterone were associated with less white matter integrity within the fronto‐temporal‐subcortical network (i.e., higher mean diffusivity [MD] longitudinal [LD], and radial diffusivity [RD]). Furthermore, lower fractional anisotropy and higher MD, LD, and RD values within this network increased expressive forms of aggression and reduced inhibited forms of aggression (hostility). Our study indicates higher levels of testosterone relating to lower quality of structural cortical‐subcortical connectivity, arguably resulting in a shift from inhibited towards expressive forms of aggression. Our data adds evidence to the idea that aggressive tendencies are subcortically driven, but individuals with relatively high testosterone might have lower structural connectivity within cortical control areas, resulting in a stronger tendency to act on these aggressive tendencies. Hum Brain Mapp 36:1043–1052, 2015. © 2014 Wiley Periodicals, Inc.     

Assessing the need for reactive behaviour management strategies in children with intellectual disability and severe challenging behaviour

The need for reactive behavioural management strategies for aggressive behaviours in adults with intellectual disability has been clearly established, but equivalent information concerning children with challenging behaviour is lacking by comparison. The present study was conducted in order to assess this need. A retrospective study was conducted to ascertain the nature of aggressive behaviours amongst a cohort children referred to a specialist support service. Aggressive behaviours were found to occur at high rates within the study group. Almost 60% of the children displayed aggression that occurred at least daily, and the behaviours resulted in serious consequences for carers in almost one‐third of the group. Physical interventions were already in use in 56% of cases, but were largely improvised by carers. The need to include reactive behavioural training as part of an overall intervention package for carers of children with challenging behaviour appeared to be supported by the present results. The implications for training design are discussed.     

Carers and community mental health services

Background There is a growing appreciation of the role and needs of carers for people with mental health problems. Carers are a diverse group, including partners, relatives and friends who are seen as such by service users. Methods Sixty-four carers of people with severe mental health problems served by four different mental health care providers were interviewed using the Experiences of Care-giving Inventory. The districts were selected to differentiate services that are targeted at more severely impaired users from those that include a wider spectrum, and to contrast services that have greater integration between health and social care providers with those whose health and social care agencies operate relatively discretely. Results In the two districts where service users had more severe mental health problems, carers worried more about negative symptoms and thought less about good aspects of the caring relationship. In the two districts where health and social services worked more closely together, carers worried significantly less about the need to back up services. Conclusions These findings suggest that service organisation can affect carers, in particular that integration between health and social care for people with mental health problems may benefit carers in ways that were hitherto unproven. They highlight the needs of carers for younger people. They show that the ECI is a useful instrument in measuring the impact of caring for people with severe mental health problems. Accepted: 19 September 2001     

Carers' knowledge of dementia,their coping strategies and morbidity

Objective. The main hypothesis was that carers of dementia sufferers who have a higher level of knowledge on the subject of dementia have lower rates of physical and psychological morbidity. We also wanted to examine whether a carer's level of knowledge bears any relation to their attributional style and coping mechanisms. Design. Informal carers, caring for patients who fulfilled the CAMDEX criteria for mild or moderate dementia, were approached to participate in the study. Setting. Old age psychiatry services in the West Midlands and Bristol. Participants. Informal carers, caring for relatives with dementia. Measures. Trained researchers administered the Geriatric Mental State Schedule, the Dementia Knowledge Questionnaire, the Pennebaker Inventory of Limbic Languidness (an inventory of common physical symptoms) and the Carer Stress Scale. Results. More knowledgeable carers experienced significantly lower levels of depression but also higher rates of anxiety. Carers' level of knowledge on the subject of dementia showed no association with their physical health. More knowledgeable carers were more likely to have ‘reduced expectations’ of their dependants' abilities and make ‘positive comparisons’; they were also more likely to feel competent and confident as caregivers. Conclusion. The findings support the main hypothesis when considering carers' rates of depression but not when considering rates of anxiety or physical ill-health. © 1997 John Wiley & Sons, Ltd.     

Younger people with dementia: diagnostic issues,effects on carers and use of services

Objective. To determine difficulties experienced by carers of younger people with dementia. Design. Cross-sectional self-report questionnaire survey. Participants. 102 eligible carers of persons less than 65 years of age with dementia, recruited through support groups and clinicians' referrals. Main outcome measures. Problems with diagnostic process; professionals/services consulted; psychological, physical, occupational and financial impact of illness on carers and children; use of and satisfaction with services. Main results. Diagnostic problems were reported by 71% of carers. Mean time until diagnosis was 3.4 years (SD 2.8) after consulting 2·8 (1·4) professionals. Carers reported frustration (81%) and grief (73%). Adverse psychological effects were common, more so in female than male carers (p<0·01). The younger the carer, the more psychological and physical effects were experienced (p<0·01). Only 8% of carers considered that their children had encountered no problems because of the dementia. Of 61 working carers, 59% reduced their hours or stopped working after diagnosis, and 89% of all carers had experienced financial problems subsequent to diagnosis. Most carers (89%) had used a support service, but 25% had never used community support, 32% had never used respite. Proportions of carers rating services as ‘good’ ranged between 43 and 100%. Conclusions. Younger people with dementia, and their carers, face difficulties in obtaining a diagnosis. Carers also experience psychological problems, financial worries, loss of employment and family conflict, and their children are affected. Most carers had used services, but some dissatisfaction existed. © 1998 John Wiley & Sons, Ltd.     

Institutionalization risk amongst people with dementia supported by family carers in a Scottish city

We studied 114 community-resident demented older people living at home with the support of a family carer and a matched sample of 114 non-demented older people to determine the factors predictive of institutionalization. We interviewed elders and carers for presence and severity of dementia, characteristics of elder and carer, service use, and carers' perceptions of needs and attitudes to care. Subjects were followed up over a 2-year period. Eleven demented and 10 non-demented elders were lost to follow-up. Forty-nine of 103 demented and 7 of 104 non-demented elders were institutionalized. Demented elders were 8.21 times more likely to be institutionalized than non-demented elders, adjusting for age and sex (95% CI 3.69-18.23). Using Cox's Proportional Hazards Model, factors which predicted institutionalization amongst demented elders were: Mini Mental State Examination Score (RR 0.87, 95% CI 0.80-0.96), carers' perceived problems in relation to the elders' physical disabilities (need for 1-3 hours per week vs no need, RR 6.10, 95% CI 2.34-15.89), behavioural problem score (7-13 vs 6, RR 5.67, 95% CI 1.47-21.88) and carers' willingness to continue caring (willing vs totally willing RR 4.46, 95% CI 1.41-14.10). Our study confirms the high risk of institutionalization amongst demented older people. Early institutionalization of demented elders can be predicted and should be planned for, to help elders and carers cope with the process of adjustment. Where carers are totally committed to continuing care, intensive community support may be required for problems associated with advanced dementia.     

Seasonal patterns of melatonin alter aggressive phenotypes of female Siberian hamsters

Many animal species exhibit year‐round aggression, a behaviour that allows individuals to compete for limited resources in their environment (eg, food and mates). Interestingly, this high degree of territoriality persists during the non‐breeding season, despite low levels of circulating gonadal steroids (ie, testosterone [T] and oestradiol [E₂]). Our previous work suggests that the pineal hormone melatonin mediates a ‘seasonal switch’ from gonadal to adrenal regulation of aggression in Siberian hamsters (Phodopus sungorus); solitary, seasonally breeding mammals that display increased aggression during the short, ‘winter‐like’ days (SDs) of the non‐breeding season. To test the hypothesis that melatonin elevates non‐breeding aggression by increasing circulating and neural steroid metabolism, we housed female hamsters in long days (LDs) or SDs, administered them timed or mis‐timed melatonin injections (mimic or do not mimic a SD‐like signal, respectively), and measured aggression, circulating hormone profiles and aromatase (ARO) immunoreactivity in brain regions associated with aggressive or reproductive behaviours (paraventricular hypothalamic nucleus [PVN], periaqueductal gray [PAG] and ventral tegmental area [VTA]). Females that were responsive to SD photoperiods (SD‐R) and LD females given timed melatonin injections (Mel‐T) exhibited gonadal regression and reduced circulating E₂, but increased aggression and circulating dehydroepiandrosterone (DHEA). Furthermore, aggressive challenges differentially altered circulating hormone profiles across seasonal phenotypes; reproductively inactive females (ie, SD‐R and Mel‐T females) reduced circulating DHEA and T, but increased E₂ after an aggressive interaction, whereas reproductively active females (ie, LD females, SD non‐responder females and LD females given mis‐timed melatonin injections) solely increased circulating E₂. Although no differences in neural ARO abundance were observed, LD and SD‐R females showed distinct associations between ARO cell density and aggressive behaviour in the PVN, PAG and VTA. Taken together, these results suggest that melatonin increases non‐breeding aggression by elevating circulating steroid metabolism after an aggressive encounter and by regulating behaviourally relevant neural circuits in a region‐specific manner.     

Verbal and physical aggression against demented elderly by informal caregivers in the Netherlands

This study describes the extent of verbal and/or physical aggression as reported by caregivers and correlates of each type of aggression against the demented care recipient. The extent of verbal aggression alone was 30.2% and of physical aggression, 10.7%. Verbal and physical aggression were associated with sharing the same household with the care recipient, caring for a male and caring for an elderly person more severely impaired in cognitive functioning and more dependent in Instrumental Activities of Daily Living. Verbal aggression was also associated with proving more care, and physical aggression with caring for a spouse and more psychological complaints of the caregiver. Accordingly, physical aggression does not seem to be a mere extension of verbal aggression, and different intervention strategies may be required for verbally and physically aggressive caregivers.     

Psychosocial factors associated with the use/non-use of mental health services by primary carers of individuals with dementia

The study investigated psychosocial factors associated with the use/non-use of services by primary carers of people with dementia (caring for relative/friend with dementia). The factors considered were individual differences, health, stress, family/social support, years of caring, age of carers/person with dementia, gender and level of behavioural disturbance presented by the person with dementia. The participants were referred to the study by health services, social services representatives and GPs. The carers (N=50) were divided into two groups (service user/non-user). The findings indicated that primary carers in the non-user service group scored significantly higher on a measure (sense of coherence; SOC) estimating an individual's ability to deal with stressful situations. The individual's ability to deal with caring responsibilities was associated with a reduction in the level of diagnosable psychiatric disorder or ‘caseness’ and the non-use of services. None of the other factors considered were found to be significantly different between the two carer groups. However, a significant inverse association between health, stress and individual ability to deal with stressful situations was found when the two carer groups were combined. © 1998 John Wiley & Sons, Ltd.     

Abuse of vulnerable people with dementia by their carers: can we identify those most at risk?

OBJECTIVE: We wanted to explore possible associations between characteristics of carers, dementia sufferers and the caring situation and the presence of abuse that was acknowledged by carers. METHODS: Eighty-two carers of dementia sufferers were interviewed in their homes about three types of abuse (verbal abuse, physical abuse and neglect) using a structured questionnaire. RESULTS: Fifty-two percent (n = 43) carers admitted to having carried out some form of abuse. Verbal abuse was the most common form (n = 42, 51%), while 20% (n = 16) of carers admitted to physical abuse and 4% (n = 3) to neglect abuse. Significant associations were found between verbal abuse and psychological ill health in the carer and behavioural problems in the dementia sufferer. Physical abuse was significantly associated with higher levels of self-reported good health by the carer. High expressed emotion measured in carers was highly correlated with all types of abuse. CONCLUSION: It is possible to identify situations where people with dementia may be at high risk of abuse from their carers. Any effective intervention strategy should address psychological health problems in the carer, behavioural problems in the dementia sufferer and a strategy to manage high levels of expressed emotion in these situations.     

Quantifying the size of the informal care sector for Australian adults with mental illness: caring hours and replacement cost

Purpose

To quantify and value the total informal support provided by family and friends to Australian adults with mental illness in 2018.

Methods

The number of mental health carers was drawn from the 2015 Survey of Disability, Ageing and Carers (SDAC), adjusted to the 2018 population. Annual caring hours by type of assistance were estimated using the SDAC, 2007 National Survey of Mental Health and Wellbeing and an online carer survey. Caring hours for each task were assigned an hourly replacement cost from the National Disability Insurance Scheme. Informal caring was valued as the sum of these costs minus expenditure on carer income support payments, estimating how much it would hypothetically cost governments to replace this care with formal support services.

Results

An estimated 354,000 (95% uncertainty interval (UI): 327,000–383,000) Australian mental health carers provided 186 million (95% UI: 159–215) hours of support in 2018. The estimated replacement cost was AU$8.4 billion (95% UI: 7.0–10.0), excluding AU$1.3 billion in income support. Univariate sensitivity analyses demonstrated that results were robust to variation in model inputs, with total caring hours the most influential parameter. Using an alternative estimate of mean caring hours, the replacement cost could be as high as AU$13.2 billion (95% UI: 11.2–15.4).

Conclusion

Informal carers provide substantial support to people with mental illness, highlighting their important contribution to the mental health system and reinforcing the need for carer support services. Future valuation studies would benefit from refinement of available data collections, particularly on hours and types of care provided.

     

EUROCARE: a cross-national study of co-resident spouse carers for people with Alzheimer's disease: I--Factors associated with carer burden.

BACKGROUND: The challenges presented by the increasing public health and social impact of caring for people with dementia have become clear in recent years. Previous research has identified that, while there are positive as well as negative elements to the caring role, carers are at high risk of mental health problems and that the comprehensive burden of caring has social, economic and health based elements. Co-resident carers, especially spouses, are of primary importance in maintaining people with dementia in their own homes in the community rather than in institutional settings which may be both more costly and have greater environmental poverty. There have, however, been few studies which have sought to investigate factors associated with carer burden and differences and similarities between countries. In this study we aimed to produce a cross-national profile of co-resident spouse carers across the European Community, with particular attention to: living arrangements; formal and informal support; service satisfaction; perceived burden; and psychological well-being. METHOD: Twenty co-resident spouse carers of people with NINCDS-ADRDA probable dementia, who had been diagnosed as such within the past 12-36 months, were recruited from service contacts in each of 14 out of the 15 countries of the EU. All completed a semi-structured interview which included: sociodemographic data; data on health and social service use; the Carer Burden Inventory (CBI); the General Health Questionnaire-12 (GHQ-12); and open-ended qualitative questions about the experience of caring. RESULTS: Two hundred and eighty couples were recruited. There was marked variation in all variables of interest between countries, but there were consistently high ratings of carer burden (mean CBI scores between 28 and 52) and psychological distress (between 40% and 75% scoring 4 or more on the GHQ-12). Using multivariate analyses (generalized linear modelling) to estimate the individual associations of variables of interest with carer burden, controlling for the effects of all other variables in the model, the following results were obtained: 11.4% (p = 0.003) of the variance was accounted for by between-country variation; 4.9% (p < 0.001) by expressed financial dissatisfaction; 4.5% (p = 0.001) by lower carer age; 3.2% (p = 0.004) by difficulties with spouse behavioural deficits; and 2.0% (p = 0.024) by perceived negative social reactions. There was a low level of contact with support groups and Alzheimer's disease societies despite the samples having been of service contacts. CONCLUSIONS: This study confirms the high level of burden and mental distress in spouse carers for people with Alzheimer's disease in the European Community. It suggests that there are elements of burden which may vary by country but also elements which have a common effect in all. These data suggest avenues for the primary and secondary prevention of burden by addressing clinical issues (e.g. behavioural disturbance); public attitudes and education (e.g. negative social reactions); economic support for carers (e.g. financial dissatisfaction); and higher risk groups (e.g. younger spouse carers).     

An Exploratory Factor Analysis and Construct Validity of the Resident Choice Assessment Scale With Paid Carers of Adults With Intellectual Disabilities and Challenging Behavior in Community Settings

Introduction: The Resident Choice Assessment Scale (RCAS) is used to assess choice availability for adults with intellectual disabilities (ID). The aim of the study was to explore the factor structure, construct validity, and internal consistency of the measure in community settings to further validate this tool. Method: 108 paid carers of adults with ID living in supported accommodation and residential care facilities in urban, rural, and semirural areas in England completed the RCAS. Exploratory factor analyses were performed and the construct validity and internal consistency of the emerging factors were assessed. Results: Principal axis factoring with oblique rotations suggested a scale with two factors (Everyday Choices and Participation in Household Activities) which explained 45% of the variance; the factors showed favorable construct validity as they identified significant differences between those living in residential care homes compared with supported living; the factors also differentiated between people with different levels of intellectual impairment with less choice and participation in domestic activities for those with more severe ID compared to their counterparts with moderate and mild impairment. Five items did not load onto any factor, suggesting that these could be dropped from the scale when administered in community settings, thus resulting in an 18-item measure (RCAS-18). Conclusion: The RCAS-18 may provide a useful measure to assess choice availability for people with ID supported by paid carers in the community. The revised measure may be more suitable in capturing choice than the original version for use in community samples.     

Effectiveness of quetiapine for the management of aggressive psychosis in the emergency psychiatric setting: a naturalistic uncontrolled trial

Objective

Traditionally, conventional antipsychotics, often administered intramuscularly, are used to reduce hostility and aggression in the emergency setting. This study investigated the efficacy of quetiapine, an oral atypical antipsychotic, in managing aggressive psychosis.

Methods

Adult hospitalized patients (n=36) with an Overt Aggression Scale (OAS) total score ≥1 and a Brief Psychiatric Rating Scale-derived Psychosis Index score ≥6 received 100–800 mg/day flexibly dosed quetiapine and were monitored daily for a maximum of 5 days. The OAS total score and Physical Aggression Against Others subscale score were primary efficacy assessments. Tolerability was assessed with the Udvalg for Kliniske Undersogelser Side Effects Rating Scale.

Results

An 83% decrease in the OAS Physical Aggression Against Others subscale score occurred from Day 1 (baseline) to Day 2, which was generally maintained to Day 5; a 39% reduction in OAS total score was observed by Day 2. The OAS total score decreased from a mean baseline of 3.3 to 1.5 at Day 5, a significant decrease for Days 2–4 (P?<?0.01) and of borderline significance on Day 5 (P=0.059). Adverse events were mostly mild to moderate with concentration difficulties and somnolence the most common.

Conclusion

These results from an uncontrolled trial suggest that quetiapine may be helpful for some aggressive patients in the emergency setting.