Behavioral emergency in the elderly: a descriptive study of patients referred to an Aggression Response Team in an acute hospital

Abstract

Aim

The management of severely agitated elderly patients is not easy, and limited guidelines are available to assist practitioners. At a Sydney hospital, an Aggression Response Team (ART) comprising clinical and security staff can be alerted when a staff member has safety concerns. Our aims were to describe the patient population referred for ART calls, reasons for and interventions during ART calls, and complications following them.

Methods

Patients 65 years and older referred for ART calls in the emergency department or wards during 2014 were identified using the Incident Information Management System database and medical records were reviewed. Demographic and clinical data were collected.

Results

Of 43 elderly patients with ART calls, 30 had repeat ART calls. Thirty-one patients (72%) had underlying dementia, and 22 (51%) were agitated at the time of admission. The main reasons for ART calls were wandering and physical aggression. Pharmacological sedation was used in 88% of the ART calls, with a range of psychotropics, doses, and routes of administration, including intravenous (19%) and, most commonly, midazolam (53%). Complications were documented in 14% of cases where sedation was used.

Conclusion

We observed a high frequency of pharmacological sedation among the severely agitated elderly, with significant variance in the choice and dose of sedation and a high rate of complications arising from sedation, which may be an underestimate given the lack of post-sedation monitoring. We recommend the development of guidelines on the management of behavioral emergency in the elderly patients, including de-escalation strategies and standardized psychotropic guidelines.

Keywords:

• aged
• aggression
• delirium
• dementia
• antipsychotic agents
• benzodiazepines

Author contributions

D Simpkins designed the study, collected the data, carried out the statistical analysis, and wrote the article. C Peisah and I Boyatzis assisted with designing the study, analyzing the data, and writing the article.

Disclosure

C Peisah is a former recipient of honorarium and travel and research support from Pfizer, Janssen, Cilag, Ely Lilly, Eisai, and Lundbeck. The abstract of this paper was presented at The Australian and New Zealand Society for Geriatric Medicine Annual Scientific Meeting 2016, “The AGEnder Paradox”, 1–3 June 2016, Cairns Convention Centre, Cairns City, QLS, Australia, and the abstract has been published in Australasian Journal on Ageing Special Issue: The Australian and New Zealand Society for Geriatric Medicine Annual Scientific Meeting 2016, “The AGEnder Paradox”, Volume 35, Issue Supplement S1, pages 18–41, June 2016. The authors report no other conflicts of interest in this work.