Improving Assessment and Management of Acute Agitation in Older Adults: A Quality Improvement Project at Royal Gwent Hospital

Introduction

Acute agitation is a common and challenging presentation among hospitalised older adults, often occurring in the context of delirium. While non-pharmacological strategies are first-line, antipsychotics or benzodiazepines may be required. However, these treatments carry significant risks, including falls, prolonged hospitalisation, and increased mortality. Guideline-concordant and legally compliant prescribing is therefore essential. At Royal Gwent Hospital, discrepancies between recommended practice and clinical care prompted a quality improvement project aimed at improving resident doctors’ confidence in assessing and managing acute agitation and adherence to local guidelines.

Methods

Resident doctor confidence was measured using a structured questionnaire. Ward documentation was examined through a retrospective case-note review of patients prescribed medication for acute agitation, assessing guideline-concordant prescribing, non-pharmacological de-escalation strategies, mental capacity assessments, application of legal safeguards, and adverse events. Interventions included the development and dissemination of a poster summarising local guidelines on the management of acute agitation in older adults and targeted teaching for Care of the Elderly resident doctors. Post-intervention practice was evaluated using identical measures.

Results

Post-intervention, resident doctors reported increased confidence in assessing older patients with acute agitation and greater awareness of local guidelines (survey: pre n=9, post n=5). Confidence in prescribing antipsychotics and benzodiazepines declined slightly; however, ward documentation (pre n=14, post n=12) showed improved guideline-concordant prescribing, including medication choice, route, and maximum dose. This reduction in prescribing confidence may thus reflect a more cautious, risk-aware approach. Documentation of non-pharmacological de-escalation strategies, mental capacity assessments, and legal safeguards also improved. One adverse outcome occurred at baseline, with none post-intervention.

Conclusion

A targeted quality improvement intervention combining guideline dissemination and focused teaching was associated with increased resident doctor confidence and improved adherence to safe prescribing and legal safeguards. This project highlights the value of structured, low-cost interventions in supporting safer, more consistent care for a vulnerable patient population.