Role of pharmacological management for acute behavioural disturbance in adults

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

For advice on the approach to management of acute behavioural disturbance, see here.

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

Pharmacological management for acute behavioural disturbance in adults is often required to reduce the risk of significant harm to self and others, and to facilitate a comprehensive assessment of the patient. This is especially relevant if nonpharmacological management techniques, such as environmental management (adaption), verbal de-escalation and psychological intervention and risk mitigation, have not adequately defused or settled the situation.

If the patient has differentiated precipitating or predisposing factors for their acute behavioural disturbance, prioritise and optimise treatment of those underlying factors. If the patient has an existing behavioural support plan, use their individualised plan as a guide¹.

Note: If the patient has an existing behavioural support plan, use their individualised plan as a guide.

In an adult with communication difficulties (eg suspected cognitive impairment or developmental disability), it can be difficult to distinguish behavioural disturbance related to severe acute pain from behavioural disturbance related to another cause. If unrecognised pain is thought to be a potential precipitant of distress and behavioural disturbance, a trial of analgesia is a reasonable first-line treatment rather than a sedative drug.

A Sedation Assessment Tool (SAT) score can assist clinical decision making about whether sedation is required—Sedation Assessment Tool (SAT) provides an example of a sedation assessment tool. The SAT score can be used to assess the imminent risk of significant harm to the patient and others, and provide guidance to the clinician on whether repeat doses of sedative drugs are required. Consider the SAT score in the context of the situation, and the patient’s baseline function and communication style (eg loud outbursts may be usual for individuals with cognitive impairment or developmental disability).

Continue nonpharmacological management techniques alongside any sedation regimen, both before and after drug administration.

The oral route of sedative drug administration is preferred for an adult with acute behavioural disturbance when there is low imminent risk of significant harm to the patient or others (see Behaviours in adults with acute behavioural disturbance that suggest imminent significant harm), the patient’s level of agitation and distress is not severe (eg SAT score +1) and they are accepting of oral medication. The oral route is preferred over parenteral administration because it:

is the least invasive route
encourages engagement and rapport between the patient and staff
allows the patient to feel more in control
aids future treatment adherence.

The intramuscular route of sedative drug administration may be used for an adult with acute severe behavioural disturbance if all the following apply:

there is imminent risk of significant harm to self or others (see Behaviours in adults with acute behavioural disturbance that suggest imminent significant harm)
the patient’s level of agitation and distress is severe (eg SAT score +3, SAT score +2 when oral therapy is not accepted)
nonpharmacological management has been unsuccessful.

Intramuscular sedation should only be used in a setting in which staff are trained in the use of intramuscular sedation and its possible complications, and appropriate equipment and expertise to monitor the patient are available.

If immediate control of the situation is required and first-line intramuscular sedative drugs have failed to control the situation, intramuscular rescue sedation can be considered. Rarely, when immediate control of an immediately life-threatening situation is required, emergency intramuscular ketamine sedation can be used first line for rapid sedation. This is only applicable in extreme circumstances and under instruction from a senior clinician.

Note: The intramuscular route is preferred over the intravenous route for parenteral drug administration for management of acute behavioural disturbance.

The intramuscular route is preferred over the intravenous route for parenteral drug administration. The intravenous route of sedative drug administration should only be used for an adult with acute severe behavioural disturbance if all the following apply:

oral or intramuscular therapy is not possible
the patient already has intravenous access established, or access can safely be established
there is imminent risk of significant harm to self or others (see Behaviours in adults with acute behavioural disturbance that suggest imminent significant harm)
the patient’s level of agitation or distress is severe (eg SAT score +3, SAT score +2 when oral therapy is not accepted).

Intravenous sedation should only be used in a setting in which staff are trained in the use of intravenous sedation and its possible complications, and appropriate equipment and expertise to monitor the patient are available.

If intravenous sedation is being considered for an adult, seek advice from a senior clinician. Most emergency departments and hospitals have protocols for the safe use of parenteral sedation, especially via the intravenous route—follow local protocols or consensus state guidelines if available.

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