How to manage a patient with violent dementia in the Emergency Department (ED)?

From the Guidelines

For a violent dementia patient in the emergency department, I recommend a stepwise approach starting with non-pharmacological de-escalation techniques followed by medication if necessary, as suggested by the American Psychiatric Association practice guideline 1. This approach is crucial in balancing immediate safety concerns with the need to minimize adverse effects in vulnerable dementia patients. The guideline emphasizes the importance of considering the patient's goals and preferences, as well as the potential benefits and harms of a particular intervention.

Initial Assessment and Non-Pharmacological Interventions

First, ensure staff safety, remove potential weapons, and create a calm environment with minimal stimulation. Attempt verbal de-escalation with simple, clear communication. This initial assessment and non-pharmacological intervention are essential in reducing the risk of violence and improving patient outcomes.

Pharmacological Interventions

If medication is needed, consider haloperidol 0.5-1mg IV/IM for elderly patients, lorazepam 0.5-1mg IV/IM, or olanzapine 2.5-5mg IM, as recommended by the clinical policy for critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department 1. Risperidone 0.5-1mg orally or olanzapine 2.5-5mg orally can be used if the patient accepts oral medication. It is essential to reassess every 15-30 minutes and consider additional doses if needed, while monitoring for side effects like QT prolongation, extrapyramidal symptoms, or respiratory depression.

Underlying Causes of Agitation

Identify and treat underlying causes of agitation such as pain, urinary retention, constipation, infection, or medication side effects. This is crucial in reducing the risk of further agitation and improving patient outcomes.

Ongoing Management

Once stabilized, develop a plan for ongoing management including appropriate disposition (admission or safe discharge with follow-up) and consideration of a geriatric psychiatry consultation. This approach ensures that the patient receives comprehensive care and reduces the risk of future violent episodes.

The American Psychiatric Association practice guideline 1 emphasizes the importance of expert consensus and research evidence in guiding the treatment of psychosis or agitation in individuals with dementia. The guideline suggests that antipsychotic medications can be appropriate in individuals with dangerous agitation or psychosis, but also highlights the potential risks and adverse effects associated with these medications. Therefore, it is essential to weigh the potential benefits and harms of a particular intervention and consider the patient's goals and preferences when developing a treatment plan.

From the Research

Managing Violent Dementia Patients in the ED

• Dementia symptoms can manifest in various ways, such as anxiety, agitation, and an inability to communicate unmet needs, leading to behavior that challenges in people with dementia in the emergency department (ED) 2.
• Strategies to de-escalate and reduce the risk of behavior that challenges include making environmental modifications to the ED, providing person-centred care, excluding or evaluating pain and unmet needs, using various tools and strategies to improve communication, and using distraction techniques 2.

Aggression in Dementia Patients

• Aggression is common in elderly patients with dementia and is best understood as a product of the interaction of neurobiological, cognitive, and environmental factors 3.
• Haloperidol has been used to control agitation in dementia, but its effectiveness remains unclear, and evidence suggests it is useful in controlling aggression but is associated with increased side effects 4.

Treatment Options

• Risperidone may be a viable alternative to haloperidol for agitated dementia patients, particularly at a dose of 0.5 mg/day, and may produce favorable moods in these patients 5.
• The use of haloperidol should be individualized, and patients should be monitored for side effects of therapy 4.

Optimal ED Care Practices

• Optimal ED care practices for persons living with dementia (PLWDs) include functional dependence, behavioral and psychological symptoms of dementia, and identification of and management of pain 6.
• A comprehensive geriatric assessment and dedicated ED unit, a home hospital program, and a low-stimulation bed shade and contact-free monitor may improve patient-centered or health care use outcomes for PLWDs 6.