Violence from older adults is a challenge for healthcare services. Risk factors include those common to working-age adults, namely substance misuse, active psychotic symptoms and inadequate care, and those more typical in older age, including cognitive impairment, acute confusion and pain. Aggression is a barrier to good care and a challenge to manage in older adults who are more vulnerable to medication effects and side effects. Medications must be used with caution. Prevention of violence through sensitive person-centred care and management of risk factors is recommended, as is non-pharmacological management. Here, we review management through non-pharmacological and pharmacological measures.

This chapter considers the use of medication as an emergency response in the management of violent and disturbed behaviour. It addresses the complex factors surrounding the decision to use rapid tranquillisation, followed by reviewing the risks and benefits of specific medication options. This is discussed within the context and continuum of acute patient care, in keeping with good practice principles, and with consideration to the relevant patient-related and medication-related risks. The current evidence for using medication or ECT in the management of a medium- and longer-term risk of violence in the context of mental illness is briefly reviewed. The recommendations are applicable to all inpatient mental health units in the United Kingdom.

As health care professionals we owe a duty of care to our patients. Our patients have a right to autonomy – to make their own decisions. If we impose treatment on them against their wishes, when they have capacity to make a decision to refuse treatment, then we may be committing the tort of battery; if we fail to treat them when they lack capacity to make treatment decisions we may be found to be negligent.

ECT remains one of the most controversial treatments in psychiatry. Although its efficacy and safety are acknowledged and have been confirmed (Chapter 1) there are still attempts (based on flawed reviews of the literature) to claim that its use cannot be scientifically justified (Read & Bentall, 2010). Media accounts of ECT tend to be highly emotive and vary from lauding ECT as life changing (Seelye, 2016) to damning it as abusive (Browne, 2000).

The Royal College of Psychiatrists recommends that a specially designated space for ECT treatment should be available (ECTAS, 2018). As the number of patients being referred for ECT continues to decline (Buley et al., 2017) the availability of ECT for patients who require it may be compromised. The College ECT Committee is supportive in helping clinics to find alternative treatments for depression which may be delivered in the ECT centre. A number of centres already provide additional services to ECT, for example clozapine and depot clinics. ECT clinics are also used for the delivery of rTMS (Chapter 15) and ketamine infusions (Chapter 17).

People with a wide range of physical illnesses are successfully treated with ECT (Tess & Smetana, 2009). Some medical problems may cause particular concern, especially cardiovascular and neurological problems.

Anaesthesia for electroconvulsive therapy (ECT) can be challenging for the anaesthetist with no prior experience. Most ECT facilities are located in remote, unfamiliar environments (Royal College of Anaesthetists, 2016). In the UK, the ECT Accreditation Service (ECTAS) has driven improvement in standards, addressing areas of criticism and bringing some level of uniformity (ECTAS, 2016; Bwalya et al., 2011; Simpson and Lynch, 1998). In this chapter, a brief examination of the issues relating to anaesthetic practice is made.

Before effective treatments for depression were available many people admitted to hospital died. After the introduction of ECT, the proportion of patients in psychiatric hospitals with depression who died in hospital fell from about 15% to 2% (Slater, 1951). Although ECT is a potentially hazardous treatment, the alternatives are not free from risk (Coupland et al., 2011) and untreated depression carries a high morbidity and mortality.