We get a TON of consults for agitation in delirium and dementia. Our treatment plan often involves prescription of one or more medications.
But an often underappreciated aspect in care is behavioral interventions.
Agitation in a delirious patient or patient with dementia often reflects an unmet need. They do not have the ability to communicate their need, so their behavior is the communication of the need.
Some common needs:
- Physiologic –***Always start here!***
- Pain
- Sleep
- Hydration
- Nutrition
- Elimination (urine, stool)
- Oxygenation
- Elimination (urine, stool)
- Temperature comfort
- Cognitive
- Orientation (time, place, situation)
- Predictability
- Simplicity
- Ability to understand what’s happening
- Sensory
- Vision (glasses)
- Hearing
- Appropriate lighting
- Reduced noise
- Emotional
- Safety
- Reduced fear/anxiety
- Social
- Familiar people/family presence
- Autonomy –***HUGE!***
- Ability to make choices
- Control over body/environment
- Identity
- Dignity
- Sense of self
- Environmental
- Reduced overstimulation
- Day-night cues
When they have agitation, they are trying to solve a problem with a brain that can’t communicate clearly. So your job becomes figuring out:
-What problem are they trying to solve?
–Ex: pulling lines: discomfort, fear
Yelling: pain, loneliness, or overstimulation
Refusing care: loss of control
Trying to leave: need to toilet
Always ask: “What Changed?” to worsen the behavior
Thinking along these lines helps you be more sophisticated in your evaluation of the patient with agitation!
Some other specific scenarios:
***Loss of control:
-Offer limited, safe choices
(Instead of you need to stay in bed –> Would you like to walk now or after lunch?)
-Replace unsafe behavior with safe version
(Want to get out of bed, have supervised walking)
-Give them a purpose to work toward
(Your job is to rest now so you can get stronger to go home)
-Use presence instead of force
(Have someone sit with them, engage them)
-Reduce the prison feeling
(Open blinds, normalize environment, sit upright)
Agitation due to:
***Discomfort with tubing (ex: NG tubing):
-Optimize the physical discomfort
(Check placement, reduce tension, lubricate nares, oral care, ice chips if allowed, treat nausea/pain)
-Offer choices
(Do you want to sit up or lie back?)
-Keep tubing out of direct line of sight
-Calm the environment
(reduce noise/clutter, have appropriate lighting)
-Use sitter to offer presence
(sit with them, coach them – try taking slow breaths through your mouth)
***Discomfort with restraints:
-Reassure that they are safe and that restraints are temporary to keep them safe
-Offer choices
(Do you want your head up or down? Do you want water now or in a few minutes? Do you want the TV on or off?)
-Calm the environment
(reduce noise, appropriate lighting for time of day)
-Frequent repositioning + Skin care
-Scheduled release trials
***When a patient can’t communicate (ie: severe TBI):
-Assume pain/discomfort until proven otherwise
-Treat “basic needs” first
(pain, urinary retention, constipation, positioning discomfort, hunger/thirst, temperature, lines/tubes irritation)
-Look for timing patterns
(after feeds – GI discomfort, during care – overstimulation or pain)
-Use trial and response approach
(test hypotheses, try addressing pain, positioning, toileting – see if agitation improves)
-Discuss observations from nursing (high yield) or family
-Calm the environment
***Need to void but not aware catheter meeting that need:
-Rule out physiologic causes
(ensure catheter not kinked, assess for urinary retention or stool burden which can cause urinary urgency, check for UTI/irritation)
-Offer bedpan or commode trial
(Sit them upright to mimic normal voiding posture, tell them “we’ll give you a moment” to provide privacy cue)
-Show them the tubing
(point to urine bag)
-Recheck unmet needs (pain, stool, position)
-Increase supervision
(family, sitter)
Gator Psychiatry 