Medical assessment

Diagnosis and drug prescription are mostly specific to doctors. However, care is multi-professional, and all professionals who contribute to care should be aware of these processes in order to adopt a consistent approach.

All professionals need to be flexible and vary their approach according to the situation that presents itself. Good communication with the team and close working with others are required, especially in dangerous situations.

The medical approach recommended here for the assessment and management of clinically related challenging behaviour has been specifically designed for patients with delirium, dementia or learning disabilities, but it will also be appropriate in other conditions or settings, for example substance abuse or personality disorders.

It must be emphasised that the clinical needs of the patient should be the utmost priority, regardless of exhibited behaviour.

Immediate considerations

In situations where a patient or service user is exhibiting challenging behaviour, the following should be taken into consideration as a priority:

  • First, the situation should be rapidly assessed for resuscitation needs and physical safety.
  • If there is an immediate grave risk to the life or health of the patient, staff, visitors or others, physical restraint and rapid tranquilisation may be required, using one or both of haloperidol or lorazepam, in doses determined by the patient’s age, size, co-morbidities and state of arousal. In the case that physical or pharmacological intervention is applied, adequate aftercare must be provided.
  • In all cases, further assessment should be based on information from the patient or other person (such as a family member or support worker), examination and investigation findings, and frequent, regular review. Assess cognition and other aspects of the patient’s mental state, ability to communicate, and capacity to make decisions about treatment. Seek evidence of delirium, psychosis, pain or other causes of discomfort or distress, and treat as required, including carefully reviewing medication.
  • Drug treatment sometimes helps, but is rarely the whole answer, and drugs may have adverse as well as beneficial effects. Be especially careful, and seek expert advice, if the patient has Dementia with Lewy Bodies, as they may react very badly to drug treatment. Identify the main problem symptom, and choose a drug that targets it. Review for effects and side effects. Only continue if there is benefit. Some symptoms or related behaviours, such as wandering, cannot be treated by drugs.

Be aware of legal obligations regarding mental capacity, consent, the use of restraint and ‘best interests’ assessments. For more information, see the section on Physical intervention.

Liaison with mental health services and/or geriatricians can often help if needed.

For further information on Medical Assessment, please see the full guidance document.

You can find related treatment guidelines in the Resources section.