Guidelines for the Management of Agitation/aggression in Elderly Persons with a Major Neurocognitive Disorder in District or Regional Hospitals

Pre-amble
Approach
Route of drug administration
Agents for behavioural control

Pre-amble

• 'Behaviour that challenges' includes aggression, agitation, wandering, hoarding, sexual disinhibition, apathy and disruptive vocal activity such as shouting.
• Factors that may precipitate such behaviours include: pain, sepsis, other causes of delirium, constipation, change in environment, or over-stimulation. The effects of medications like opiates cannot be under-estimated. These need to be addressed in all cases. Note that drug of alcohol withdrawal may occur in the elderly admitted to hospital.
• People with a Major Neurocognitive Disorder (“dementia”) who develop non- behaviour that challenges should be offered a pharmacological intervention in the first instance only if they are severely distressed or there is an immediate risk of harm to the person or others.
• The choice of antipsychotic should be made after an individual risk–benefit analysis. The dose should be low initially and then titrated upwards. Treatment should be time limited and regularly reviewed.
• Note that individuals KNOWN to be using drugs to manage behaviour may need to be re-started on those same agents.
• Healthcare professionals who use medication in these settings should: be trained in the correct use of drugs for behavioural control, specifically benzodiazepines and antipsychotics; be able to assess the risks associated with using these drugs; understand the cardiorespiratory effects of the acute administration of benzodiazepines and antipsychotics;  recognise the importance of nursing people who have received these drugs in the recovery position and of monitoring pulse, blood pressure and respiration; be familiar with and trained in the use of resuscitation equipment.
• People with Major Neurocognitive Disorder who have received involuntary sedation and their carers should be provided with a clear explanation of the decision to use urgent sedation. This should be documented in their notes.

Approach

• Violent behaviour should be managed without the prescription of high doses or combinations of drugs, especially if the person with dementia is elderly or frail. The lowest effective dose should be used.
• Drugs for behavioural control should be used with caution, particularly if the person with Major Neurocognitive Disorder has been restrained, because of the following risks:
  • loss of consciousness instead of sedation
  • over-sedation with loss of alertness
  • damage to the relationship between the person with dementia, their carers and the health and social care team
  • specific issues related to age and physical and mental health.

Route of drug administration

• If drugs are necessary for the control of violence, aggression and extreme agitation, oral medication should be offered before parenteral medication.
• If parenteral treatment is necessary for the control of violence, aggression and extreme agitation, the intramuscular (IM) route should be preferred because it is safer than intravenous administration. Intravenous administration should be used only in exceptional circumstances.
• Vital signs should be monitored after parenteral treatment for the control of violence, aggression and extreme agitation. Blood pressure, pulse, temperature and respiratory rate should be recorded at regular intervals. If the person appears to be or is asleep, more intensive monitoring is required.

Agents for Behavioural Control