Aggressive disruptive behaviour in adults

R45.1/R45.4-8 + code(s) for underlying/comorbid condition(s)

DESCRIPTION

Agitation may escalate to overt aggression and often manifests with restlessness, pacing, and loud or demanding speech. Aggressive behaviour includes verbally abusive language, specific verbal threats, intimidating physical behaviour, and/or actual physical violence to self, others or property. All agitation and aggression must be considered an emergency and violence prevented wherever possible.

Multiple causes for aggressive, disruptive behaviour include:

  • Physical: acute medical illness, delirium and its causes, epilepsy (pre-, intra-, and post-ictal), intracerebral lesions, traumatic brain injury. See: Delirium with perceptual disturbances.
  • Psychiatric: psychosis, mania, agitated depression, neurocognitive disorders (e.g. dementias, old traumatic brain injury), developmental disorders (e.g. intellectual disability and autistic spectrum disorder), severe anxiety.
  • Substance misuse: alcohol, cannabis, methaqualone (mandrax) intoxication or withdrawal; stimulant (cocaine, methamphetamine (tik), methcaninone (cat)) intoxication; benzodiazepine withdrawal.
  • Psychological factors: high levels of impulsivity and antagonism, hypersensitivity to rejection or insult, poor frustration tolerance, and maladaptive coping skills all contribute to aggression and rage.
  • In pregnant women: labour, obstetric complications, sepsis, organ failure as well as substances and mental disorders (See Primary Health Care STGs and EML Maternal mental health).

CAUTION

  • Do not assume that the aggression is due to the mental illness.
  • Known psychiatric and intellectually disabled patients often have medical conditions, trauma, and substance misuse.

GENERAL MEASURES

  • Prepare, anticipate and prevent:
    Be aware of high risk patients e.g. those with previous violence, substance misuse, and State Patients on leave of absence. Have:
    • A step-wise protocol to ensure safety of all patients and staff.
    • Clear roles for all staff members.
    • A triage plan for early signs of aggression.
    • Available backup – hospital security and SAPS and EMS.
    • A designated calming area – suitable for regular monitoring.
  • De-escalate and contain:
    • Be calm, confident, kind, and reassuring.
    • Maintain a submissive posture with open hands.
    • Do NOT turn your back on the patient; avoid direct eye contact.
    • Do NOT attempt to reason with the patient.
    • Do NOT argue, confront delusions, or touch the patient.
    • Set clear limits regarding behaviour.
    • Take patient to quiet, calm area – do NOT leave unobserved.
  • Examine for delirium, medical and other causes while calming the patient and after sedation.
  • Manual restraint may be necessary to administer medication – this must be respectful, controlled and kept to a minimum. It should be applied by personnel of the same sex as the patient.
  • Mechanical restraint:
    • Only if absolutely necessary to protect the patient and others for as short a time as possible.
    • Document the type, sites and duration of any restraints used.
    • 15-minute monitoring: vital signs, the mental state, restraint sites, and reasons for use.
    • A MHCA Form 48 (restraint register) must be completed and submitted to the Mental Health Review Board.
  • Pregnant women
    • Never leave unattended.
    • Use restraint sparingly, with care, if possible, with mother in a supported semi-seated position (not supine or prone).
Agressive and Disruptive Behaviour in Adults.png

For PHC & CDC Casualty, see PHC and EML Stroke

MEDICINE TREATMENT

Rapid Tranquillisation

The goal of rapid tranquilisation is to calm the patient so that risk to self or others is minimised and the underlying condition may be managed.

CAUTION

  • Rapid tranquillisation may cause cardiovascular collapse, respiratory depression, acute dystonic reactions, and neuroleptic malignant syndrome.
  • Pregnant women, elderly, intellectually disabled and those with comorbid medical conditions and/or substance use are at highest risk.
  • Late pregnancy: neonatal sedation or extra-pyramidal side effects may occur.
  • Write out single prescriptions and review between each prescription
  • Allow at least 30 – 60 minutes between prescriptions.
  • An emergency trolley, airway, bag, oxygen and intravenous line must be available.

LoEIII [1]

  • In pregnancy, the frail and elderly, or where respiratory depression is a concern, use a short-acting benzodiazepine at the lowest dose.
  • The safest route of administration of benzodiazepines is oral followed by IM with the IV route having the highest risk of respiratory depression and arrest. Use the safest route possible.
  • Monitor vital signs closely during and after administration. Use haloperidol instead of benzodiazepines in patients with respiratory insufficiency.
  • Where aggression is clearly caused by psychosis, haloperidol and promethazine may be used as 1st line treatment and not benzodiazepines.

LoEIII [2]

Offer oral benzodiazepine treatment:

  • Benzodiazepines:

LoEII [3]

  • Lorazepam, oral, 0.5–2 mg, immediately.

LoEIII [4]

OR

  • Clonazepam, oral, 0.5–2 mg, immediately.

LoEIII [5]

OR

  • Diazepam, oral, 5–10 mg, immediately.

LoEIII [6]

OR

  • Midazolam, oral or buccal, 7.5–15 mg, immediately.

LoEIII [7]

Oral treatment refused, administer parenteral benzodiazepine treatment:

LoEII [8]

  • Lorazepam, IM, 0.5–2 mg, immediately.

LoEI [9]

OR

  • Midazolam, IM, 7.5–15 mg immediately.

LoEIII [10]

OR

  • Clonazepam, IM, 0.5–2 mg, immediately.

Note:

  • To avoid inappropriate repeat dosing allow at least 30 minutes for the oral/IM medication to take effect.

LoEIII [11]

  • Repeated IM doses of benzodiazepines may result in toxicity owing to accumulation.
  • Lorazepam IM has slower onset of sedation than midazolam IM (32 vs 18 minutes) and longer duration of sedation (217 vs 82 minutes).
  • Clonazepam oral or IM may be used if longer duration of sedation is required. Onset of action may be 30-60 minutes, time to maximum concentration is 1-4 hours. Long half-life (18-50 hours) increases risk of accumulation. Allow at least 12 hours between repeat doses.

LoEIII [12]

Inadequate response to benzodiazepines (after 30-60 minutes):

  • Haloperidol, IM, 2.5–5 mg, immediately.

AND

  • Promethazine, deep IM, 25–50 mg.

LoEII [13]

Repeat after 30–60 minutes if needed.

Under specialist care in psychiatric wards:

  • Zuclopenthixol acetate, IM, 50–150 mg every 2–3 days .
    • Maximum dose is 400 mg over a two-week period.

LoEIII [14]

If alcohol use is suspected:

ADD

  • Thiamine, oral, 300 mg immediately and daily for 14 days.

LoEIII [15]

Monitor the patient:

  • Nurse in recovery position – prevent aspiration. Nurse pregnant women in supported semi-seated position if possible or left lateral position, and not supine.
  • Monitor pulse, respiratory rate, blood pressure, temperature every 5–10 minutes for the first hour, and then every 30 minutes until the patient is ambulatory. Use pulse oximeter if available.
  • Pregnant women: monitor fetal heart rate as well as mother’s vital signs.
  • Continue observation once ambulatory: for falls and further injury (especially elderly and frail), re-emergence of aggression, and to prevent abscondment.
  • If patient absconds – request assistance from SAPS with a MHCA Form 25.

Manage acute complications: