A fictional 79-year-old inpatient becomes acutely frightened, disorientated and verbally aggressive overnight after surgery.
Frame the danger first.
- An acute fluctuating change in attention, cognition or behaviour should prompt assessment for delirium and physical illness.
- Distress or aggression may communicate pain, fear, hypoxia, infection, retention, withdrawal or unmet need.
- Assess immediate risk to the person and others while preserving dignity and the least restrictive approach.
Act, escalate, reassess.
- Call sufficient trained help, reduce environmental stimulation and use one calm communicator.
- Assess ABCDE, glucose, pain, medicines, infection, elimination, withdrawal and other reversible causes.
- Use verbal and non-verbal de-escalation, orientation aids and familiar support where appropriate.
- If risk remains immediate, follow current local legal, restraint and rapid-tranquillisation policy with monitoring and senior oversight.
Red flags that change pace.
- Airway, breathing or circulation compromise, severe injury or reduced consciousness
- Immediate risk of serious harm that cannot be contained with de-escalation
- Possible intoxication/withdrawal, neurological emergency, sepsis or medication toxicity
What makes care less safe.
- Labelling behaviour as psychiatric before assessing physical illness
- Confrontation, crowding or multiple staff giving conflicting instructions
- Using restraint or sedation without proportionality, monitoring and review
Say the concern plainly.
This is an acute change from baseline with [attention/cognition/behaviour features]. Immediate risks are [summary]; likely reversible causes and actions are [list]. De-escalation has [worked/not worked], and I need senior review for the safest least-restrictive plan.