Significant behavioural issues, such as aggressive, challenging, non-compliant, or violent behaviours

Spectrum

Aggressive, challenging, non-compliant or violent behaviour - a presentation, not a diagnosis - always assumes an underlying driver (organic, psychiatric, substance, situational)
Ranges from verbal aggression/refusal of care to physical violence requiring restraint

Common in emergency departments, aged care, and inpatient psychiatric/medical settings
Risk factors: intoxication, dementia/delirium, psychosis, personality disorder, acute pain, prior history of violence

Organic: delirium, dementia (esp. BPSD), hypoglycaemia, hypoxia, pain, urinary retention/constipation (paradoxical agitation in dementia)
Psychiatric: psychosis, mania, severe personality disorder, PTSD triggers
Substance-related: intoxication (stimulants, alcohol) or withdrawal
Situational/communication: unmet needs, fear, frustration with care, cultural/language barriers, environmental overstimulation
Non-compliance specifically - may reflect capacity issues, poor therapeutic alliance, side effects, health literacy, or cultural factors rather than "difficult" behaviour per se

Always exclude an organic/reversible cause first - glucose, oxygenation, pain, bladder/bowel, infection screen, medication review
Assess capacity where refusal of treatment is the issue - decision-specific, not global
Risk assessment for escalation to violence - environmental cues, verbal threats, pacing, clenched fists

Calm environment, non-confrontational stance, clear simple communication, offer choices, involve familiar staff/family
Address the underlying driver directly (analgesia, treat delirium cause, reorient)

2. Pharmacological (only if de-escalation fails and there is risk to self/others)

Oral options preferred over parenteral/IM where possible
Avoid benzodiazepines as first-line in dementia-related agitation (paradoxical disinhibition, falls) - low-dose antipsychotic preferred if pharmacological management needed and non-organic cause excluded
In acute behavioural disturbance from intoxication/psychosis - benzodiazepine or antipsychotic per local protocol, lowest effective dose

Physical/chemical restraint only when de-escalation has failed and there is imminent risk, least restrictive option, time-limited, requires documentation and review under restrictive practices legislation
Regular review, debrief with patient once settled

Explore reasons (understanding, side effects, beliefs, cost, capacity) before labelling "non-compliant"
Shared decision-making, simplify regimens, involve family/interpreter as needed

Staff and patient injury, moral distress, care disruption
Underlying dementia/delirium, substance use disorder, untreated psychiatric illness
Higher rates of restrictive practice use in people with cognitive impairment and from culturally/linguistically diverse backgrounds - equity concern

Resolves with treatment of the underlying driver in most organic/delirium-related cases
Chronic behavioural disturbance (e.g., BPSD, personality disorder) requires longer-term behavioural and pharmacological management plans, ideally proactive rather than purely reactive
Repeated restrictive practice use without addressing the underlying cause predicts recurrence and escalation

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