Managing acute behavioural problems in medicine

Abstract

Behavioural disturbances are very common in general hospitals; they can cause immense patient suffering and staff distress. Various studies have shown that more than 95% of health professionals have experienced several episodes of verbal aggression in the workplace. 1 Behavioural disturbances can present in various ways, for example refusal of proposed medical intervention, wandering, self harm, depression, anxiety, agitation, threatening behaviour, aggression and violence.The most frequent causes of behavioural problems in hospitals are confusion, alcohol misuse, substance withdrawal, drugs, fear, physical disorder, mental disorder, traumatic brain injury, cerebral vascular accidents, Huntington's disease, dementia, unmet demands and receiving bad news.Non-pharmacological interventions should be the mainstay of managing behavioural disturbances. Indeed many can be prevented by avoiding inappropriate medications. The success of pharmacologic interventions depends on accurate identification of specific problems, for example comorbid medical or mental illnesses. The November 2006 conference focused on the management of behavioural disturbances including managing delirium, self harm, capacity, alcohol misuse and delirium tremens. DeliriumDelirium is a common presentation for a wide variety of physical dysfunctions, 2 it accounts for the majority of patients with behavioural disturbances in general hospitals. In one study disturbing behaviour accounted for more than 50% of the reasons for referring patients to liaison services. 3 Of patients admitted to a general hospital, 10-15% are in a state of delirium. 4 Delirium occurs in 14-56% of elderly hospitalised patients, with associated mortality rates ranging from 10-65%. 5 There are three subtypes of delirium: hyperactive-hyperalert, hypoactive-hypoalert and the mixed type. Hyperactive-hyperalert delirium usually presents in 70% of the challenging behaviour cases encountered on the wards.Clinical management depends on good diagnostic skills. Crucially, it is important to differentiate between delirium and dementia. In delirium, the attention and working memory are impaired where as in dementia they are normal. Thinking is impoverished in dementia but disorganised in delirium. Patients in delirium usually present acutely and often have illusions, hallucinations and thought disorder.Primary prevention and non-pharmacological approaches should be the mainstay of management. In a trial of 852 general medical patients over the age of 70, strategies for primary prevention of delirium resulted in a 40% reduction in the odds of developing delirium. The protocol focused on optimisation of risk factors via the following methods: repeated reorientation by trained nurses, provision of cognitively stimulating activities, a non-pharmacological sleep protocol, early mobilisation activities, a range of motion exercises and timely removal of catheters and physical restraints. 6 Medication should only be used following adequate attention to the correction of modifiable contribution fa...