Elyssia Bourke, Kate Klein, Jonathan Knott, Simon S Craig, Emma Tavender, Franz E Babl
Version published: 29 May 2024
https://doi.org/10.1002/14651858.CD014826
Acute severe behavioural disturbance (ASBD) is a medical emergency driven by a range of organic and psychiatric triggers. It encompasses any behaviour (including agitation, violence, or self‐harm) that can result in a risk of harm to the patient, staff, or others and generally requires immediate medical intervention to prevent or reduce this harm, or both (Stevenson 2021).
Any individual can present with an episode of ASBD, and all age groups can be affected (Carison 2020; Lovett 2022; Oliver 2019). There are a number of known contributing factors in the development of ASBD including mental health disorders, substance intoxication and/or withdrawal, infection, metabolic derangements, and neurodevelopmental disorders. People presenting with ASBD can have one or more of these factors contributing to their agitation (Yap 2019). Due to the high acuity of ASBD and the urgent need for safe and effective management, the emergency department (ED) is a common place for these individuals to present for care (Miner 2018). Options available to patients and carers are very limited. Many are found agitated in the community, or have emergency services called due to escalating behaviours. It is probable that milder degrees of agitation are managed successfully in the community. The population reaching the ED are the most extreme, which is manifest in their use of services and resources.
Although the factors associated with ASBD are well described, emergency treatment of undifferentiated severe agitation may be required before the underlying cause has been determined. This is in contrast to other settings, such as an inpatient mental health unit, where the underlying cause is often known, allowing for more targeted treatment. A safe and effective general approach to the management of all individuals with ASBD in the ED ‐ regardless of the underlying cause ‐ is required.
Currently, a step‐wise approach is often recommended(Downes 2009; Gottlieb 2018; Richmond 2012),aiming to achieve rapid behavioural control using the least restrictive means possible. Controlling the person’s behaviour as quickly as possible ensures the physical and psychological safety of the patient and those around them. Minimising the use of restrictive interventions such as physical and mechanical restraint and the use of medications unless less restrictive means of behavioural control have failed aims to maintain the person’s dignity and autonomy.
Non‐pharmacological methods such as verbal deescalation are usually attempted first, followed by the provision of medications if required.
If medications are provided, oral sedative medications are offered to individuals willing to accept them. Intranasal or inhaled agents are also an alternative route of administration. However, some people with ASBD will be profoundly agitated and therefore require parenteral (intramuscular or intravenous injection, or both) medication to assist in behavioural control. This group are the most challenging to manage due to their intense level of agitation and are the focus of this review. These individuals are also at higher risk of adverse events from the medications provided, as there is less time to carefully titrate these medications to achieve behavioural control. They may therefore end up oversedated, which can result in respiratory depression, aspiration, or a range of other complications.
Children and adolescents (less than 18 years of age) and older persons (over 65 years of age) are of particular interest in this review. Neurodevelopmental disorders including autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) are commonly associated with ASBD in children and adolescents (Bourke 2021). The medications used to manage ASBD may have different pharmacokinetic properties in the paediatric population, leading to changes in clinical effects (Grunwald 1993). On the other hand, older persons have higher rates of dementia and acute medical illnesses as triggers for acute behavioural disturbance (Page 2020), and may be more susceptible to adverse effects of medications (Tampi 2014).