Oral drug regimens 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.

The indications for oral sedation for acute behavioural disturbance in adults are detailed here.

The aim of pharmacological management is to calm the patient with a sufficient initial dose of a sedative drug. Repeated subtherapeutic doses that are inadequate to reduce the patient’s distress and calm their behaviour can prolong the risk of harm to the patient or others. This can also result in larger cumulative doses, or multiple drug administration, both of which increase the risk of adverse drug effects. Monitor the patient closely for adverse drug effects; see Principles of monitoring patients with acute behavioural disturbance for detailed advice.

The most common drugs used in adults to manage acute behavioural disturbance are benzodiazepines and antipsychotics, which are used in this setting for their sedative effects. The sedative effects of antipsychotic drugs occur much sooner than the antipsychotic effects. If the patient has had a previous paradoxical reaction to benzodiazepines, or is tolerant to benzodiazepines, avoid benzodiazepines.

When selecting a suitable dose and regimen for a sedative drug, consider patient factors, such as their level of agitation and distress (eg measured with a Sedation Assessment Tool [SAT] score), age, body size, sex, comorbidities, drug history, previous response to sedative drugs and response to treatment.

If oral sedation is indicatedfor an adult with acute behavioural disturbance, in combination with nonpharmacological techniques, use:

1 diazepam 10 to 20 mg orally; for frail or cachectic patients use 5 to 10 mg orally¹. If required, repeat every 30 minutes; if more than 60 mg in total is required (30 mg if frail or cachectic), seek expert advice acute behavioural disturbance, adult (oral) diazepam diazepam diazepam

OR

1 lorazepam 1 to 2 mg orally; for frail or cachectic patients use 1 mg orally² ³. If required, repeat every 30 minutes; if more than 6 mg in total is required (3 mg if frail or cachectic), seek expert advice acute behavioural disturbance, adult lorazepam lorazepam lorazepam

OR

1 olanzapine 5 to 10 mg orally; for frail or cachectic patients use 2.5 to 5 mg orally; preferably use liquid or an orally disintegrating formulation (eg wafer). If required, repeat every 30 minutes; if more than 30 mg in total is required (15 mg if frail or cachectic), seek expert advice⁴. acute behavioural disturbance, adult (oral) olanzapine olanzapine olanzapine

Repeating the SAT score can be useful to determine whether sedation has been effective or if a repeat dose is needed. Individualise the target SAT score based on patient factors (eg response to nonpharmacological interventions, whether the patient needs to be sedated for investigations) and the ability to maintain patient and staff safety.

Always monitor the patient closely for potential adverse effects after administering a sedative drug for an acute behavioural disturbance (especially in drug-naive patients).

¹ Diazepam is longer acting than lorazepam and has active metabolites. Avoid diazepam in people with medical comorbidities, especially kidney or liver impairment. Return

² Lorazepam tablets can be administered sublingually but are less bioavailable than when administered orally.Return

³ Lorazepam is safer than diazepam for people with medical comorbidities, especially kidney or liver impairment, as it does not have active metabolites and is shorter acting. Return

⁴ Although the usual maximum daily dose of olanzapine is 20 mg, a total daily dose of up to 30 mg may be used when managing an adult with acute behavioural disturbance.Return