Rapid Tranquilisation in the Older Adult Inpatient Mental Health Unit (over 65 years old)/ Management of Acute Behavioural Disturbance

NHS Borders clinical guidelines
NHS Borders

This algorithm should be used in conjunction with the following prescribing advice, taking patient risks and associated clinical condition into account.

Oral Rapid Tranquilisation Therapy (65 years +) Algorithm

 

Appendix 1 - Choice of Intramuscular Antipsychotic Medication

Appendix 2 - Prescribing Advice

Non response to rapid tranquilisation:

  • Obtain consultant advice if more than 2 doses of IM Lorazepam or Haloperidol
  • Consider Zuclopenthixol Acetate (Accuphase) on CONSULTANT advice only

 

Indication for rapid tranquilisation Choice of treatment
Acute disturbance due to delirium or dementia Typical antipsychotics
Acute disturbance due to alcohol withdrawal Benzodiazepines, use alcohol withdrawal guideline for Chlordiazepoxide
Psychotic agitation (acute disturbance due to psychiatric illness) Antipsychotics preferred first line
Non psychotic agitation Benzodiazepines

 

Choice of treatment:

  • A benzodiazepine is recommended as first line (if there is limited clinical information, antipsychotic naive, prolonged QTc)
  • Oral antipsychotic choice will depend on regular antipsychotic prescription and previous response to medication.
  • A baseline ECG is required for all patients prior to administration of haloperidol (as per license) and is now contra-indicated in combination with other potentially QTc prolonging medication. If this is not possible, the risks and benefits of haloperidol treatment should be documented clearly in notes.
  • A baseline ECG is required for all patients prior to administration of zuclopenthixol

 

Risk Associated with IM rapid tranquilisation
Drug Class Risk
Benzodiazepines Loss of consciousness, respiratory depression or arrest, cardiovascular collapse in patients receiving Clozapine and paradoxical aggression.
Antipsychotics Loss of consciousness, risk of sudden death (cardiac/respiratory complications), seizures, akathisia, dystonia, dyskinesia, NMS and excessive sedation
Antihistamines Excessive sedation, painful injection, hypotension, arrhythmias, additional antimuscarinic effects

 

Post Rapid Tranquilisation Monitoring
Guideline Post - RT parameters Post - RT Monitoring Additional Recommendations
Maudsley Prescribing Guidelines 12th edition (Taylor et al. 2015) Temperature, pulse, blood pressure and respiratory rate Every 10 minutes for 1 hour then half hourly until the patient is ambulatory
  • if monitoring of vital signs is not possible observe for symptoms of pyrexia, over sedation and general physical well being
  • Resuscitation facilities must be made available

 

Management of problems resulting from the use of IM medication
Problem Remedial Measure
Acute dystonic reaction Procyclidine 5mg IM, repeat after 20 minutes if necessary, max 20mg/24 hours. Do not prescribe IM Haloperidol alone
Orthostatic hypotension Lie patient flat, raise legs, monitor closely including regular BP measurement
Reduced respiratory rate (,10/minute or O2 saturation < 90%) Give Oxygen
Give Flumazenil if Benzodiazepine induced. Initially 200 micrograms IV over 15 seconds, then 100 micrograms at 60 seconds. Maximum 1mg/24 hours
Abnormal physical observations Continue to monitor regularly. Escalate to Ward Doctor. Record on NEWS chart and follow instructions with regard seeking medical assistance. Consider risk of neuroleptic malignant syndrome and arrhythmias in patients with a raised temperature.

 

Pharmacokinetics of IM medication
Drug Time to peak concentration (Tmax) Elimination Half Life (T 1/2)
Haloperidol 20 minutes 20 hours
Lorazepam 60-90 minutes 12- 16 hours
Promethazine 2-3 hours 5-14 hours
Zuclopenthixol Acetate 36 hours At 72 hours levels are 1/3 of max

 

QTc Off license information:

Haloperidol is contra-indicated in QT-interval prolongation. Co-prescription of haloperidol with another QT interval prolonging drug should be avoided wherever possible; but if there are no appropriate clinical alternatives then the prescriber should document this use as unlicensed and

Editorial Information

Last reviewed: 31/12/2023

Next review date: 31/12/2026

Author(s): Harvey K, Calvert L.

Version: v2.0

Author email(s): kyna.harvey@borders.scot.nhs.uk, lucy.calvert@nhs.scot.

Approved By: Area Drugs & Therapeutic Committee

Reviewer name(s): Richardson-Read S.

References
  • Patel et al. Joint BAP NAPICU evidence based consensus guidelines for the clinical management of acute disturbance: de-escalation and rapid tranquilisation. Journal of Psychopharmacology. 2018 
  • Taylor et al. Maudsley Prescribing Guidelines. 12th edition. 2018.