One of the most challenging patients in health care is the “agitated delirious patient.” Just as challenging, for different reasons, is the lethargic confused patient who “just isn’t getting better.” The patient depicted by the drawing above was both.
The geriatric medicine team was consulted on day seven of this hospitalization because of his persistent confusion and inability of the primary team to “find placement.” According to his wife at the bedside, her 80 year old husband had fallen and fractured his hip four weeks ago, had hip surgery, “which went well” but had some “problems with mild confusion” after the surgery. He went to a skilled facility “for rehab” and then developed pneumonia within two weeks, requiring a second hospitalization. He returned to the skilled facility and was making some progress but then developed “shakes” and more confusion, which caused him to be admitted for this, his third hospitalization. The primary team had done a complete workup for reversible causes (including CT head, MRI head, lumbar puncture, EEG, and several urinalyses and cultures).
The patient was on a typical medical-surgical floor, not the intensive care unit (ICU). On our exam, we observed a rather “big” man (i.e. not thin or frail) in bed, occasionally opening his eyes and moving various parts of his body (his head at times, then his extremities as much as he could). Every few seconds, he seemed to get a surge of energy, would mumble something, and then try to sit up, at which time the nurse would say, “now, lie back down.” He would try again, then would wear out, and then close his eyes again. While observing in order to get non-verbal clues from the patient, we counted the number of restraints and tethers: NINE. What can one do in this situation?
The medical workup had been exhausted, and the patient was not getting any better. Although the primary team and nurses had been trying to maintain “non-pharmacological” measures, the “reactive” mode of management took over: The patient seemed to be a “danger to himself” and had been combative towards the staff during typical care so physical restraints were used. Then, various antipsychotics were tried, which only seemed to make things worse. If non-pharmacological approaches are going to be successful, they have to be proactive. The following are three examples of proactive principles in the non-pharmacological management of delirium:
The anecdotal evidence: our patient above. One by one, we removed the tethers and the restraints. We got to a point that he was free enough to allow us to sit him up. Although he was a big man, we were able to get his legs over the side of the bed. He did not have good sitting balance, but the longer he sat up, the more alert he became, and as he became more alert, he was able to sit without falling over. We almost stopped there, but I knew we couldn’t because the patient started to move, as if he wanted to get out of the bed. He couldn’t step very well, but, eventually, he made it to the chair. As he got his breath, he looked over at his wife and said “eh…that’s…better” -- his first intelligible words in a week.
During the next two days, we implemented the mainstay of our “treatment:” getting him out of bed. Our other treatments (interventions) included getting the urinary catheter out, getting the feeding tube out, sitting him in a chair to eat and drink and stopping the antipsychotics. The delirium started to clear, and he was discharged to the skilled facility on our fourth day of consultation in a better place than when he came in.
The indirect evidence: Studies of healthy young volunteers subjected to prolonged bed rest have shown changes in gray matter and white matter of the brain, negative effects on executive function and changes in certain cytokines. Although this research may seem space ages away from older frail patients in the hospital bed, it does point to the detrimental effect of bed rest on the brain.*
The indirect evidence: In a landmark trial of delirium prevention in a medical-surgical hospital population, delirium incidence was approximately one-third less in the intervention group compared to usual care. The intervention consisted of multiple components (protocol for sleep, fluid repletion, attention to hearing/vision, reorientation, decreasing unnecessary medications and early ambulation). However, probably the most important part of the intervention was the early ambulation.
The direct evidence: Early mobility among patients in the ICU is associated with a decreased number of days with delirium. In a study of ICU patients on the ventilator, early therapy (day 1-2) compared to usual care (initial therapy day 7 on average) resulted in 2 days (SD 0-6) of delirium in the ICU compared to 4 days (SD 2-7), respectively (p Value=.03).
A note of caution: although on the surface this may appear to be a low-key and passive approach, it is very proactive and takes a significant amount of training, culture change and effort.
Tolerate: Although tolerating certain behaviors may seem dangerous and even contrary to our training to keep patients safe, (e.g. when patients try to get out of bed by themselves), allowing patients to respond naturally to their situation while under close observation (which often means standing or sitting very close by), gives the patient some semblance of control in their confused state. More importantly, it also allows the healthcare professional to get clues about what might be bothering the patient. Imagine a patient so confused that he or she cannot communicate the need to empty his/her bladder. Climbing out of bed might be the first symptom of a full bladder!
Anticipate: It should be anticipated that patients with delirium will pull on anything that is not normally present. This is not a pejorative principle, but one of preparedness. If this happens, the “ready” caregiver has some options:
Don’t agitate: This is one of the most obvious yet subtle principles of delirium care. There are numerous potential “agitators” in the hospital environment, some of which will agitate certain delirious patients while calming others. Lights, visitors, television and music are just a few of these. Some agitators are predictable, many are not. Reorientation is one of the unpredictable techniques. If it helps, good; but if it’s not helping, don’t keep doing it.
The T-A-DA method is based on nearly two decades of experience in a specialized unit called the Delirium Room (DR). The DR is a 4-bed unit, within an Acute Care of the Elderly Unit. It is free of physical restraints and emphasizes the non-pharmacological approach to care of older hospitalized patients with delirium. Based on two different retrospective sets of data, negative outcomes associated with delirium, such as loss of function, longer hospital stay and increased mortality, can be decreased to levels seen in patients without delirium. Falls are also less frequent in the DR compared to typical rooms on the ACE Unit. The concept has been used in other countries (Singapore, Hong Kong and Australia) with some studies showing positive effects on delirium outcomes.
In summary, whether delirium is hyperactive, hypoactive or both, there is a role for a proactive non-pharmacological approach consisting of at least three principles:
*These studies were done related to research on how space flight affects the brain and cognition
Joseph H. Flaherty, MD
Professor and Associate Chair of Medicine
Saint Louis University School of Medicine