To investigate if current practices by nursing and medical staff in the dementia ward (New Craigs Psychiatric Hospital), acute medical unit and geriatric ward (Raigmore General Hospital) followed the local protocol for managing distress of non-pharmalogical approach and rapid tranquilisation (RT) in older adults (aged >65years). We believe the split between the general and psychiatric hospitals and the different time pressures experienced in these 3 wards will influence the management and RT of their older adult patients.

Data were collected from 17/09/2022 to 8/10/2022 from case notes and drug charts of older adult patients that received rapid tranquilisation from 3 wards:

1. 1. Ruthven Ward, New Craigs Psychiatric Hospital

2. 2. Acute Medical Unit (AMU), Raigmore Hospital

3. 3. Ward 2C (Geriatrics), Raigmore Hospital

Focus groups and informal discussions were made with the ward nurses and junior doctors to understand their point of view on managing distressing behaviours in patients with dementia using de-escalation techniques.

A table was collated using Microsoft Excel. The parameters used were:

1. 1. Patient Diagnosis and Legal status

2. 2. Administration

3. • Date and time started

4. • If de-escalation techniques were used

5. • If discussed with a senior doctor

6. • 1st and/or 2nd line of drugs administered (route, drug and dosage)

7. • If Haloperidol given and if ECG was done

Data collection showed the following:

1. 1. Ruthven Ward- all 32 patients did not receive RT.

2. 2. AMU- only 1 out of 280 patients received 4 subsequent RT in 5 hours including 3x haloperidol (total 3mg) and 2mg of Midazolam despite an ECG showing prolonged QT interval. The latter prescribed after consultation with a senior doctor.

3. 3. Geriatric Ward – all 10 patients did not receive RT.

Focus groups and informal discussions with staff nurses from all three wards concluded that in spite of the stressful environment posed by issues of understaffing and high patient load, de-escalation techniques (recognition of early signs of agitation, distraction and calming techniques, recognising the importance of personal space) were prioritised before moving on to RT as per local protocol. Restraining was often used if patient was at risk to self or others by staff trained in violence and aggression management.

Informal discussions with junior doctors rotating in and out of AMU showed limited awareness of the RT protocol. In general, it was evident that RT was a last resort when psychological and behavioural approaches failed but that further education was required to administer RT safely.