Interventions in the ER
From Guidelines for Managing the Client with Intellectual Disability in the Emergency Room (© 2002)
Assessing for a psychiatric disorder in persons with intellectual disabilities presents many challenges and requires obtaining detailed historical information as well as a multidisciplinary approach. This includes drawing on not only the perspective of psychiatry, but also input from other disciplines, such as psychology, communication therapy, behaviour therapy, nursing, genetics and medicine, including neurology.
This diagnostic process can start in the ER but avoid making definitive psychiatric diagnoses at this time. Instead, provide careful documentation of whatever history is available, along with observations of behaviour, and response to interventions in the ER. Ensure that this documentation is available to the team who will provide further psychiatric assessment when the client is triaged. The ER provides an important opportunity to rule out possible medical disorders underlying the behaviours of concerns and also the opportunity to observe the client in a more structured environment.
2.1 Managing the immediate situation
The first priority is to ensure the safety of the client, caregivers and hospital staff consistent with the usual ER procedures. Only then can the assessment continue. Pharmacological or physical restraint may be required as with other clients in crisis. However, the more ER staff appreciate the individual's level of functioning and unique ways of communicating, the less likely it is that excessive medication or restraint will be needed.
2.2 Ruling out medical (and dental) disorders
The first goal is to identify and, where possible, treat any physical causes of behaviour disturbance. If you are concerned about a possible medical disorder, refer the client for a medical assessment. Also inquire about when the last vision and hearing assessments were done, and about the outcome, as deterioration in sensory functioning can give rise to changes in behaviour.
Refer the client for a dental checkup where indicated or when dental care has not been provided routinely.
2.3 Changing medications
Avoid changing all the client's previous medications in this emergency situation unless it is clear that these previous medications are contributing to the referral concerns or behaviour disturbance. Resist the temptation to try the latest new medication just because it has not yet been tried for this client. Limit your activities to dealing with the emergency and leave review of regular medication to the client's usual treatment team. If you feel strongly that an alternative medication regime is more appropriate or should be tried, discuss this first with the regular treatment team.
2.4 Treating a psychiatric disorder
Treatment is generally initiated after the multidisciplinary team does a comprehensive assessment. Once the crisis has been managed and it has been determined that a psychiatric disorder underlies the behaviour disturbance resulting in ER visits, treatment should be initiated in line with the provisional diagnosis. As well, behavioural markers should be identified and these behaviours monitored to substantiate or refute the provisional diagnosis. You will need to discuss with caregivers the behaviours they should start to monitor. For instance, if the provisional diagnosis is a mood disorder, instruct caregivers on how to collect data on such variables as eating and sleep patterns, weight, behavioural equivalents of mood, anxiety and agitation. Such documentation is likely to be invaluable to the team to which the client is triaged. (See Section 3.) A behaviour therapist, available through the developmental service sector, can provide invaluable help with this monitoring.