Overview of acute behavioural disturbance

This topic focuses on management strategies used for people of all ages with acute behavioural disturbance; these strategies are context-dependent, and much nuance is required for every individual.

For the management of acute agitation and altered mental state in palliative care, see the specific topic here.

Note: Use the least restrictive intervention necessary to ensure the safety of the patient, staff and others. If it is safe to do so, align management with the patient's preferences.

There is variation in the management approach taken for acute behavioural disturbance across different age groups and settings (including emergency departments, general hospital wards, general practice clinics, other outpatient clinics or the person’s home) - refer to local protocols or consensus state guidelines if they are available. Use the least restrictive intervention necessary to ensure the safety of the patient, staff and others. If it is safe to do so, align management with the patient’s preferences.

Note: Threatening or aggressive behaviour is an expression of an underlying problem or unmet need that requires management.

Managing threatening or aggressive behaviour is challenging. Threatening or aggressive behaviour is an expression of an underlying problem or unmet need that requires management. This type of behaviour is a function of distress that should prompt the clinician to explore potential predisposing factors (eg physical, psychological, social, environmental factors). Often multiple factors can precipitate an acute behavioural disturbance (see Precipitating factors for development of acute behavioural disturbance) and multiple modes of intervention are necessary.

Note: If a person with acute severe behavioural disturbance poses an imminent risk of significant harm to self or others, the situation needs to be de-escalated urgently.

If a person presents with acute severe behavioural disturbance, they require urgent care and support to address the underlying issue, and the situation needs to be de-escalated immediately, particularly if there is an:

imminent risk of significant harm to self or others, such as a life-threatening medical condition or severe threat of violence - see Determining the safety of intervening in acute behavioural disturbance
inability of the clinician to perform a physical examination and investigations sufficient to exclude a life-threatening cause (eg head injury, hypoxia, hypoglycaemia, sepsis).

The management of acute behavioural disturbance is contextual, governed by:

principles of care
individual patient factors - the patient’s age, and the presence of unmet needs, medical and psychiatric disorders, intellectual and developmental disability - see precipitating and predisposing factors
the risk of significant harm to self or others (eg using a sedative in a patient with cognitive impairment increases the risk of falls; aggression towards others)
the setting, including
- available expertise (eg paramedic, general practitioner, aged-care facility clinician, emergency department clinician)
- available resources (eg other staff, security)
- capability to monitor patients, including post-sedation care
- access to resuscitation equipment and drugs
- access to local protocols within a health service, or consensus state guidelines
relevant legislation relating to the use of physical or chemical restraint. See Restrictive practices for definitions of restrictive practices.

Initial management steps are often undertaken simultaneously and cyclically, with assessment occurring throughout. Interventions vary depending on whether the patient’s presentation is differentiated (ie known medical or psychiatric history) or undifferentiated. Align interventions with the patient’s preferences, if it is safe to do so. Steps include:

determining the safety of intervening - any patient who is physically aggressive or threatening physical aggression requires immediate intervention
reducing the risk of harm
assessing and managing any life-threatening conditions that may be causing acute behavioural disturbance
initiating immediate nonpharmacological management including moving the patient to a low-stimulus environment and verbal de-escalation
considering the need for pharmacological management; the approach varies for different patient groups and is discussed in separate topics

Monitor the patient closely according to local protocols or consensus state guidelines - see Principles of monitoring patients with acute behavioural disturbance. If indicated, facilitate transport or transfer to an appropriate treatment setting and ensure they are comprehensively followed-up as soon as possible.

Principles of monitoring patients with acute behavioural disturbance is a detailed flowchart for managing a patient with an acute behavioural disturbance.