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Aggression Case Study

Sample Case

Mrs J is a 65 year old lady with no significant past medical history. She was taken to her GP by her husband, concerned that she had become confused over the last 12 hours. The GP found her to be drowsy, disorientated in time, not knowing the day or date, and stating that the year was 1998. Her pulse was 90 bpm and her blood pressure was 110 / 70 mmHg. Her temperature was 38.5 C. There were no respiratory symptoms or signs.

The GP arranged for her to be admitted to hospital. Upon admission the clinical findings were as described before. A chest X-ray was normal. Her urine was negative for bedside ‘dipstick’ tests and the results of a sample sent for microscopy, culture and sensitivity were awaited.

Unfortunately, whilst the PRHO was attempting to take routine blood tests and cultures, she became very distressed. She screamed, “Get the terrorists out of my house!” and punched the PRHO in the face.

Explain the factors underlying her violent behaviour and discuss the management of such behaviour on the general medical ward.

Cause

  • Running a fever can cause delerium.
  • May have meningitis, or flu.
  • Probably not a UTI, due to the negative dipstick.

Management

  • Sort out fever, and the rest will follow.
  • Try calming and talking to the patient.
  • Get consent for treatment.
  • Pump them full of haloperidol/benzos.

Common Questions

This patient would respond well through de-escalation through distraction with a ball.

Know the common psychiatric disorders that may present with aggression

Understand the common causes of delirium (acute confusional state)

  • Alcohol & Drug withdrawal
  • Electrolyte Imbalance
  • Meningitis
  • Pneumonia
  • Endocarditis
  • Septicaemia
  • Other Infections

Understand the clinical symptoms and signs associated with delirium

  • Altered conciousness
  • Impaired cognitive function
  • Hallucinations (Abnormal perceptions)
  • Thought disturbances (Abnormal thoughts)
  • Aggression
  • Agitation
  • Retardation
  • Sleep disturbance - can lead to weird things like nocturnal awakeness
  • Mood disturbance

Understand the cognitive manifestations of delirium

  • Short term memory impaired
  • Recent memory impaired
  • Disorientated to time and place
  • Impaired speech and understanding

Understand the difference between delirium and dementia

Dementia

  • Chronic onset and progressive
  • Usually primary
  • No sleep problems
  • Relatively constant state

Delirium

  • Acute Onset
  • Secondary
  • Sleep disturbance
  • Fluctuates rapidly

Understand the management of delirium

  • Treat underlying cause.
  • Try calming and talking to the patient.
  • Sedate the patient if you really can't do anything else

Understand the basic measures in the management of the aggressive patient

  • Try calming and talking to the patient.
  • De-escalate them with time-out/seclusion
  • Offer treatment
  • If non cooperative, hold 'em down, and intramuscular haloperidol