acute behavioural disturbance

Question 1

Behaviours in adults with acute behavioural disturbance that suggest imminent significant harm

Answer 1

anxiety
agitation
command hallucinations to harm self or others
demeaning or hostile language
excessive, apparently purposeless motor activity not influenced by external stimuli
intentional property damage
intense staring
irritability
labile affect
motor restlessness and pacing
mumbling
physically threatening or intimidating behaviour
signs of imminent self-harm
verbally threatening, shouting, demanding

Question 2

Sedation Assessment Tool

Answer 2

A Sedation Assessment Tool (SAT) score can be used to assess the imminent risk of significant harm to self and others, and guide whether repeat doses of sedation are required—consider the SAT score in the context of the situation and the individual.
Not validated for use in children or older people.

In adults, a SAT score of +2 or +3, may indicate an imminent risk of significant harm and immediate intervention is indicated.

Question 3

Environmental adaptation and verbal de-escalation for acute behavioural disturbance

Answer 3

Privacy, non judgemental, non coercive, quiet space/low stimulus, esure at least 2 exits and duress alarm and no items used as weapons

Descaltion- Use a calm, confident, empathic, nonthreatening and respectful approach to the patient.
Avoid sudden movements, intrusion into the patient’s personal space, prolonged eye contact, provocation, or confronting or intimidating behaviour.
Introduce yourself—use both your own name and the patient’s name to personalise the interaction.
Involve carers and/or family members if available.
Explain your role and wishes to help them; be clear and concise.
Offer the patient time to state their concerns and needs in a nonjudgemental and empathic atmosphere. Listen closely—this may encourage them to engage in calmer discussion.
If possible, identify the trigger for their behaviour (eg unmet needs, pain, communication difficulties).
Offer support, such as food, drink (eg a cup of lukewarm tea or coffee), toileting, nicotine replacement therapy, access to a telephone, or analgesia if indicated.
Offer options and optimism, but set clear limits.
If indicated and in consultation with the patient and their carer, consider an oral sedative drug—see oral drug regimens for acute behavioural disturbance in adults, older people and children.
Negotiate with, and debrief, the patient when it is appropriate to do so.

Enviro- orient the patient to the environment and to staff
use healthcare interpreters when required (eg for patients from non-English speaking backgrounds, and culturally and linguistically diverse patients)
reduce environmental noise and avoid overstimulation
ensure the patient’s unmet needs are identified and addressed (eg pain, toileting, hunger, thirst)
identify and remove specific triggers for behaviours, if feasible
actively engage and promote contact with a friend or family member, if they are available
address comfort (eg offer a recliner and additional pillows)
optimise communication (eg ensure hearing aids, voice amplifier and visual aids are used, if indicated)
provide diversional activities
use soothing generation-appropriate music.

Question 4

Precipitating factors for acute behavioural disturbance

Answer 4

Unmet needs: bladder distenstion, contipation, hunger, thirst, w/d- nicotine, ETOH
Acute medical conditions - pain, hypoglycemia, encephalopathy (hyoxic, metabolic, hypotensive), delirium, head trauma, hyperthermia, seizures, postictal state, nonconvulsive seizures, sepsis

Acute pscyhological trauma/abuse
Intox, poisoning, adverse drug effects - ETOH, stimulatns, pscyhoactives, opiods, anticholinergics

Question 5

Predisposing factors for acute behavioural disturbance

Answer 5

Developmental disabilities- ASD, cerebral palsy, genetics
Psych-behavioural and psychological symptoms of dementia
generalised anxiety disorder
acute mania
psychotic depression
panic attack
personality disorder
postpartum psychosis
posttraumatic stress disorder
other psychoses
Substance withdrawls states

Question 6

Medication management for acute behavioral distubance

Answer 6

PO: Diazepam 10-20mg -max: 60mg - longer acting. Avoid in pts with medical comorbids esp kidney or liver
Lorazepam 1-2mg max:6mg - safer if comorbids
Olanzapine 5-10mg, max: 30mg

IM: Droperidol 10mg , max20mg
Olanzapine 10mg max 30mg
Midazolam 5-10mg - max:20mg
If resuce sedation needed: ketamine 4-5mg -max: 200-400mg

IV: Droperidol 10mg IV, max:20mg
Midazolam 5mg - max:20mg
Diazepam 5-10mg max:60mg