Behavioural disturbances at all stages of life

The College of Psychiatrists of Ireland Spring Conference featured a number of fascinating parallel sessions that encompassed a variety of ‘hot’ clinical topics.

These included a session on the ‘Management of acute behavioural disturbance across the lifespan: Evidence, guidelines, and best practices’. This session was chaired by Dr Jenny Bond and the talks were delivered by Dr Bond, Dr Sharon Ryan, Dr Sarah O’Dwyer, and Dr Matthew Sadlier.

The presenters explored the management of acute behavioural disturbance across different age groups right through the lifespan, from children and adolescents to adults and the elderly. The speakers discussed age-specific presentations and the development of guidelines, including the recent work on paediatric guidelines at Children’s Health Ireland. The role of physical restraint was also discussed, as well as rapid tranquilisation in a crisis. The speakers also used case studies to illustrate the challenges in implementing safe and effective interventions, as well as real-world applications.

Dr Bond pointed out the “huge variation in practice” around psychotropic medication between hospitals and different jurisdictions. She also touched on observational studies suggesting that olanzapine is often effective in behavioural disturbances and acute agitation.

She also discussed special considerations, such as using off-label medications, and reviewed more case studies from Children’s Health Ireland.

Dr Ryan discussed current guidelines and the use of rapid tranquilisation and subsequent monitoring for sedation.

“We have tried to give users of this guideline a framework to use to determine when to use rapid tranquilisation,” said Dr Ryan.

“We talk about using it for aggressive or combative behaviour, [while] also thinking about where that presentation happens and whether there is a need for that patient to remain in hospital.” Other considerations include whether the level of behaviour is causing a risk to themselves or others. “Just as important as knowing when to use it is knowing when not to use it,” said Dr Ryan.

Dr O’Dwyer provided an overview of medications to treat behavioural disturbances, as well as dosing considerations, and the first step is to offer the patient oral medications, she said. Dr O’Dwyer discussed specific medications, and circumstances where ketamine may be appropriate. Among the considerations for doctors in this scenario is respiratory depression, she pointed out.

Dr Sadlier told the conference that the majority of aggressive older adult patients in his clinic suffer with delirium.

“Hyperactive delirium is the one that leads to agitated behaviour,” he pointed out. Dr Sadlier presented data from studies and also discussed the causes of delirium and the brain’s arousal networks.

“What we are essentially trying to do is ease the patient from a hyperactive delirium to a hypoactive delirium,” said Dr Sadlier.

“Medication doesn’t solve delirium in the older adult – what solves delirium is fixing the negative reason for the systemic inflammation that is leading to a breakdown in their neural networks and neural pathway. By giving the medication, you are trying to induce a safer state for the person, which leads them to a lower risk, which leads them to have a period where they can avoid tripping over a chair, or assaulting somebody. The treatment is on that risk basis and overall, the treatment is the removal of the thing that is causing them to have the delirium in the first place.”