Role of pharmacological management for acute behavioural disturbance in older people

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.

Older people are more likely than other adults to have predisposing medical conditions that contribute to, or precipitate, distress and acute behavioural disturbance. In addition, if the patient has cognitive impairment or communication difficulties, they are more likely to have unmet needs. Acute behavioural disturbance in older people can often be managed by addressing unmet needs (eg pain, hunger, thirst, toileting needs), and by using nonpharmacological management techniques, such as environmental management (adaption), verbal de-escalation and psychological intervention and risk mitigation. Pharmacological management is often not required if sufficient effort is put into these techniques first.

If the older person 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. Existing conditions or medications may influence the choice of pharmacological management (eg Lewy body dementia, Parkinson disease). Sometimes pharmacological management is part of a patient’s existing behavioural support plan.

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

Behavioural disturbance in older people is most often associated with delirium or behavioural and psychological symptoms of dementia (BPSD), for which drug therapy is rarely used to manage symptoms. Clinicians who manage acute behavioural disturbance in older people require adequate training in the diagnosis and management of delirium and BPSD, and in nonpharmacological management of acute behavioural disturbance. Only use the drug recommendations for sedation in this topic if the acute behavioural disturbance is severe and there is an imminent risk of harm to the patient or others, and the required expertise and equipment is available.

In an older person with communication difficulties (eg suspected cognitive impairment), 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 precipitant of distress and behavioural disturbance in an older adult, a trial of analgesia is a reasonable first-line treatment rather than a sedative drug.

A Sedation Assessment Tool (SAT) score may assist clinical decision making about whether sedation is required; however, the SAT score has not been validated for use in older people. In older people with cognitive impairment or communication difficulties, consider the SAT score in the context of the patient’s baseline function and communication style (eg loud outbursts may be usual for individuals with dementia). Sedation Assessment Tool (SAT) provides an example of a sedation assessment tool.

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

If nonpharmacological management techniques have not adequately defused or settled an acute behavioural disturbance in an older person, consider oral sedative drugs. The oral route of sedative drug administration is preferred to parenteral administration for older people because:

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

Consider the oral route of sedative drug administration when there is low imminent risk of significant harm to self or others (see Behaviours in adults with acute behavioural disturbance that suggest imminent significant harm), or the patient’s level of agitation and distress is not severe (eg SAT score +1) or is moderately severe (eg SAT score +2) and they are accepting of oral medication.

The intramuscular route of sedative drug administration is rarely required in older people, but may be used for an older person with acute severe behavioural disturbance if all of the following apply:

there is an 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 or 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.

The intravenous route of administration is rarely appropriate for older people. If intravenous sedation is being considered for an older person, 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. 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 resuscitation equipment and expertise to monitor the patient are available.

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