Sedation of Patients with Developmental Disabilities
- Patients with developmental disabilities (DD) often present to the emergency department with psychiatric or behavioural presentations and may in some cases need to be sedated.
- Communication can pose a challenge for clinicians, but is often key to successful treatment.
- All behaviour is communication. Patients with DD often manifest pain as changes in behaviour such as agitation or self-abuse.
Before You Start
- The goal of sedation is the same as with any other patient, to reduce agitation and associated risk of harm to the patient, and to others, in the safest and least intrusive manner possible.
- Consider whether other attempts at de-escalation can be made first.
- Consider potential drug interactions. Patients with DD are likely to be on multiple medications, including psychotropic medications such as antipsychotics and benzodiazepines.
- These patients may be less able to self-report side effects.
- Be aware that some patients experience paradoxical effects from benzodiazepines including agitation and disinhibition, and this may be more common in patients with DD, particularly Autism Spectrum Disorder. If caregivers are present, it may be helpful to ask about the patient’s history with sedation and if they have previously had any such reactions.
- Sensory hypersensitivity is common. Try to find a quiet room (i.e. isolation room, psych interview room), dim fluorescent lights, and turn off non-essential monitors.
- Some patients may come with their own individual care plan or crisis plan, or with a communication tool such as a health passport.
- Sit at the level of the patient rather than standing over them.
- Address the patient directly whenever possible, even if they are non-verbal.
- Go slow, adjust the volume of your voice. Some patients with DD may respond poorly to loud voices, others may be hard of hearing and need you to speak up.
- People with DD are frequently the victims of all forms of abuse. Remember to practice trauma informed care.
- If the patient agrees, try to accommodate caregivers to be present during interviews and exams. They are useful for providing collateral information and as a source of comfort.
- Encourage the use of comforters such as toys or music during exams and procedures.
- Consider developing a kit of soothing/distracting objects (sunglasses, earphones, squishy balls, weighted blanket) that can be kept in your ED.
- Be mindful of body language. Non-verbal patients can be especially sensitive to this.
- Explain exams and procedures using the show-tell-do approach, i.e. show the stethoscope, and explain what you are going to do with it before proceeding.
- Give ongoing encouragement for even small steps successfully completed.
- Provide clear verbal discharge instructions and give written instructions for patients to take home, either for themselves or to share with any caregivers who are not present.
Approach to Concerning Behaviour
- When looking for the cause of challenging behaviours, remember to HELP.
- First consider Health related causes such as pain.
- Next consider Environmental triggers (the ED is an unfamiliar and often overstimulating environment that can contribute to these behaviours).
- Then ask about Living circumstances (i.e. recent move or change in support staff).
- Consider Psychiatric causes only after other causes have been eliminated.
- Stereotypy, repetitive movements or vocalizations colloquially known as stimming, are common among people on the autism spectrum. Traditionally, family and clinicians have interpreted these as inappropriate and have engaged in various methods to attempt to reduce them, however they are increasingly being seen as a self-regulatory mechanism that does not require treatment and allowing your patient to engage in stimming may help them to stay calm in the ED.
- It is recommended to start with a single medication, preferably a benzodiazepine, at a sufficient dose (i.e. Lorazepam 4 mg). Wait an appropriate amount of time before giving more and use the lowest dose possible to achieve the desired level of sedation.
- Antipsychotic medications are often overprescribed to patients with DD and should be avoided when possible.
- Sedation should be used in the short term only and should not be continued longer than 72 hours.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
- There are no published standard guidelines on sedation of patients with developmental disabilities.
- There have been no large-scale studies on effects of sedation in adults with developmental disabilities.
OTHER RELEVANT INFORMATION
Lunsky, Y., Lee, J., Perry, A., & Lake Johanna. (2016). Improving Emergency Care for Adults with Developmental Disabilities: A Toolkit for Providers.
de Kuijper, G., Hoekstra, P., Visser, F., Scholte, F. A., Penning, C., & Evenhuis, H. (2010). Use of antipsychotic drugs in individuals with intellectual disability (ID) in the Netherlands: prevalence and reasons for prescription. Journal of Intellectual Disability Research, 54(7), 659–667.
Hughes, K., Bellis, M. A., Bates, G., Eckley, L., Bellis, M. A., Hughes, K., … Offi, A. (2012). Prevalence and risk of violence against adults with disabilities: a systematic review and meta-analysis of observational studies. Lancet, 379, 1621–1650.
Kapp, S. K., Steward, R., Crane, L., Elliott, D., Elphick, C., Pellicano, E., & Russell, G. (2019). “People should be allowed to do what they like”: Autistic adults’ views and experiences of stimming. Autism, 23(7), 1782–1792.
Lunsky, Y., Klein-Geltink, J., & Yates, E. (2013). Atlas on the Primary Care of Adults with Develop mental Disabilities in Ontario. Institute for Clinical Evaluative Sciences and Centre for Addiction and Mental Health. Toronto, ON.
Sullivan, W. F., Diepstra, H., Heng, J., Ally, S., Bradley, E., Casson, I., … Witherbee, S. (2018). Primary care of adults with intellectual and developmental disabilities: 2018 Canadian consensus guidelines. Canadian Family Physician, 64(4).
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated May 26, 2020
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