At times as a resident doctor, you will be faced with the management of patients displaying aggression. There are many causes for aggressive behaviour, from pain to frustration at delays in medical care, and it should be thought of as a way of expressing distress. It is therefore important to try to understand the cause of the aggression to manage it. The below offers some advice for managing an aggressive patient.

Being safe
At all times, you should ensure your own safety and that of those around you. If a patient is becoming physically aggressive, you should not try to handle the situation alone. In these situations, you should escalate to a senior and it may be necessary to call security for additional support.

Identify the reason
Talk to the patient to try to establish the cause of their behaviour. Remain calm while doing so, being aware of your tone of voice and body language. Enquire as to the source of their frustration. Patients may be able to give a specific reason for their agitation, or you may have to take a more general history to rule out different causes, particularly in patients with cognitive impairment.

Some causes of aggression:

• Pain
• Unmet physical needs – hunger, thirst, needing toilet, tiredness
• Disorientation
• Drug/alcohol withdrawal
• Delirium
• Dementia
• Fear
• Poor communication from staff & Frustration e.g. about delays in medical care
• Complaints or wanting to self-discharge
• Medical – hypoglycaemia, meningitis/encephalitis
• Psychiatric conditions

Where a cause for the behaviour is identified, consider what can be done to resolve it. In some cases, the solution may be simple, for example offering analgesia. Other situations will require discussion of potential solutions with the patient to try to come to an agreement on a way forward. In cases where a patient has concerns about the care they are receiving, explore these further. It may be that they or someone close to them has previously had a bad experience e.g. a missed diagnosis. Taking the time to listen to the patient and explain the reasoning behind the decisions that have been made may be all that is required.

Monitor for concerning behaviours
Throughout the conversation, ensure that you are monitoring both your own and the patient’s body language. Behaviours that you should be wary about include patients tightening their fists, going quiet or staring directly at you.

In some cases, despite your best efforts, you may find that one or both of you are becoming increasingly irritated. In these situations, you are unlikely to help by continuing and may risk escalating the situation. Politely explain to the patient that it would be more appropriate to continue the conversation once you have reviewed things. Don’t ask the patient to calm down – usually, this builds aggression. If & when you do return to continue the conversation, strongly consider whether it is appropriate to involve a more senior member of staff if you have already tried talking to the patient and not been able to resolve the matter.

Delirium & Dementia
One group of patients who may display aggression is those with delirium or dementia. These patients are particularly vulnerable as they may be disoriented, unable to express their needs and/or unable to retain information given to them by staff. Aggression may be a way of expressing unmet needs, whether physical or psychological. Distraction, reorientation and calming measures should be tried in the first instance, as well as screening for any new physical issues such as pain or infection. Involve those close to the patient as they know the patient best and seeing a familiar face may provide reassurance to the patient.

Consider whether psychiatry involvement is needed. In cases where a mental health diagnosis is felt to be underlying the aggression, or there are signs suggestive of one such as response to hallucinations, expression of low mood or paranoid ideation, specialist input may be beneficial. Old age psychiatry teams are also available to support in cases of difficult to manage delirium/dementia.

Don’t forget physical causes in a patient with an acute change in behaviour! Signs pointing to an underlying physical problem may be unexplained pyrexia (meningitis/encephalitis) or sweating and shaking (alcohol withdrawal, hypoglycaemia).

Using security
If a patient is becoming physically aggressive it may be necessary to call security to maintain the safety of yourself and others on the ward. In some cases, the simple presence of security staff may be enough to de-escalate the situation, and they can add weight to your assertions that violent behaviour will not be tolerated. Security are excellent at supporting you and creating a barrier if need be to protect you – they usually don’t forcefully restrain someone to the floor like TV shows & movies suggest. It is safer for the patient for experts to restrain with minimal force than non-experts like doctors & nursing staff who could inadvertently harm the patient. The restraint will reduce the risk of them harming themselves/others and this will allow you to safely get close to the patient, for example, to administer sedation or to take bloods if this is in the best interest of the patient. The principles of the least restrictive option should always be used, i.e. restraint only used if other options have failed, for the shortest amount of time possible, and the degree of restraint should be proportionate to the risks of the situation.

Sedation
Occasionally you may need to prescribe a sedative for the aggressive patient. As with physical restraint, this should only be considered after all less restrictive options have failed, and where the patient is posing a risk to themselves or others. A capacity assessment should be made and sedation must be in the patient’s best interests (e.g. to allow the ongoing safe delivery of medical care), not for the convenience of staff. Usual starting doses would be haloperidol 0.5mg (avoid in Parkinson’s disease or Lewy Body Dementia) or lorazepam 0.5mg, either PO or IM. Ensure the patient’s observations and level of consciousness are monitored following sedation.

Ensure thorough documentation of events, particularly if physical restraint or sedation was required. Document the names of staff involved, details of any conversations with the patient, de-escalation methods tried and the reasons behind the decision to use restraint or sedation.

Further Reading

• Harwood, R. H. “How to deal with violent and aggressive patients in acute medical settings.” Journal of the Royal College of Physicians of Edinburgh 47.2 (2017).
• Raine, Tim, et al. Oxford handbook for the foundation programme. Oxford University Press, USA, 2018.
• https://www.themdu.com/guidance-and-advice/guides/assessing-capacity

Written by Dr Melissa Hartley FY2