Assessing a patient with acute behavioural disturbance

Managing a patient with acute behavioural disturbance is a detailed flowchart for managing a patient with acute behavioural disturbance.

Only perform a comprehensive assessment when it is safe to do so; see Determining the safety of intervening in acute behavioural disturbance.

Note: Only perform a comprehensive assessment of the patient when it is safe to do so.

As a priority, assess and manage any life-threatening conditions—in children, life-threatening medical conditions rarely cause acute behavioural disturbance. In older people, acute behavioural disturbance is often due to delirium, which may be the only warning sign of significant deterioration and ought to be treated as a medical emergency.

The approach to assessing a patient with acute behavioural disturbance will depend on whether the behavioural disturbance is differentiated (ie there are known predisposing or precipitating factors contributing, such as a medical or psychiatric disorder) or undifferentiated. In children, a history can often be obtained from their accompanying parent or carer. In people with developmental disability, detailed guidance on assessing challenging behaviour is included here. An older patient may have delirium or a history of dementia that will help to guide management. If the patient has an existing behavioural support plan¹, use it to guide management and try to involve usual carers or family if available.

Note: If the patient has an existing behavioural support plan, use it to guide management and try to involve usual carers or family in the management of the behavioural disturbance.

Assessing a patient with an undifferentiated acute behavioural disturbance involves:

determining the patient’s capacity to consent to treatment decisions
gathering history, including collateral history from others (eg family, paramedics, past clinical notes), medical and psychiatric history, history of medications and use of alcohol and drugs
measurement of vital signs
examining the patient (eg for signs of acute illness, intoxication, toxidromes, trauma, dehydration).

If it is safe to perform a comprehensive assessment, establish any potential precipitating and predisposing factors that may be contributing to the disturbance. Often multiple factors can precipitate an acute behavioural disturbance, all of which need to be managed. The principles of comprehensive assessment of behavioural disturbance in a person with developmental disability are described here and can be used as a framework for comprehensive assessment in other groups.

Precipitating factors for development of acute behavioural disturbance and Predisposing factors for development of acute behavioural disturbance include potential precipitating and predisposing factors for development of acute behavioural disturbance—they are not exhaustive. In young people, psychiatric disorders and substance use are common contributors to acute behavioural disturbance.

Table 1. Precipitating factors for development of acute behavioural disturbance
[NB1]
Unmet needs of the patient [NB2]
bladder distension constipation hunger, thirst nicotine withdrawal alcohol withdrawal
Acute medical conditions
unrecognised pain—use an appropriate pain assessment tool hypoglycaemia encephalopathy—hypoxic, hypotensive, metabolic delirium head trauma hyperthermia seizures, postictal state, nonconvulsive seizures sepsis
Acute psychological trauma or abuse
Intoxication, poisoning and adverse drug effects [NB3]
alcohol intoxication stimulant drugs novel psychoactive substances, including novel stimulants (eg cathinones), hallucinogens and synthetic cannabinoid receptor agonists gamma-hydroxybutyrate opioid drugs drugs commonly implicated in delirium drugs with significant anticholinergic effects
Note: NB1: This list is not exhaustive—these are examples of precipitating factors that may contribute to acute behavioural disturbance. Patients with these conditions may have communication difficulties that may contribute to acute behavioural disturbance. NB2: Unmet needs of the patient are more likely to contribute in people with cognitive impairment, acquired brain injury, acute confusion, delirium and acute intoxication. NB3: This list is not exhaustive; for comprehensive toxicological advice on a range of poisonings, see Toxicology and Toxinology.

Table 2. Predisposing factors for development of acute behavioural disturbance
[NB1]
Developmental disabilities [NB2]
autism spectrum disorder cerebral palsy genetic disorders
Psychiatric disorders
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 withdrawal states
alcohol withdrawal delirium benzodiazepine withdrawal opioid withdrawal
Note: NB1: This list is not exhaustive—these are examples of predisposing factors that may contribute to acute behavioural disturbance. Patients with these conditions may have communication difficulties that may contribute to acute behavioural disturbance. NB2: For comprehensive advice on a range of developmental disabilities, see Developmental disability.

¹ Behavioural support plans are commonly developed to assist people with developmental disability, cognitive impairment, and some psychiatric conditions (eg personality disorder); see Positive behaviour support.Return