Tips for delirium behavior management

  1. I had a patient last night postop about 2 weeks from extensive cardiac surgery. Was on a lot of pain meds on a chronic basis pre-op, so naturally is on a lot of opiates. And benzodiazepines. And antipsychotics. Precedex worked pretty well but we're trying to get this guy ready to transfer to the floor someday, so we're trying to get him on some kind of plan that will facilitate that.

    So this guy is AAOx1-2 depending on the moment, delusional, picking at his chest tubes, arterial line, central line, foley. Not tugging, but definitely too close for my comfort.

    This guy keeps almost falling asleep mid sentence because he's so tired from being in ICU and constantly awake for days on end. And just as soon as he drifts off, he startles himself back awake, freaks out, and we're back to square one.

    I know if he could just get some sleep, it would do wonders for his mental status (among other things). He's already on basically every drug I can give him without killing him (including Seroquel now, but also dilaudid, oxycodone, ativan)

    I had some mild success by turning the lights out, putting my calm voice on, pulling up a chair, and very calmly and quietly answering his questions, and basically shushing him to sleep like I would to a toddler.

    My question is, what are your hacks for getting the delirious/demented/AMS patient to:
    1. stop touching/picking at lines
    2. go the EFF to sleep
    when they won't even understand that their call bell is not a hamburger or that you just gave them a sip of water 5 minutes ago.
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  2. 19 Comments

  3. by   heron
    Ditch the benzos, they are probably aggravating, if not causing, the delirium. On my AIDS unit we frequently encountered delirium. The psychiatrist always immediately d/c all benzos and treated with antipsychotcs. Consider re-evaluating the opioids. In hospice, we frequently found that rotating to a different opioid helped to limit adverse reactions.
  4. by   Meriwhen
    Agree with Heron: benzos and opioids are likely not helping. There are other options for both categories that they provider can use.

    Soft wrist restraints and mitts are also an option, though those are usually an "we tried everything else first and nothing worked" option. Still, they could help, and they could (should!) always be removed once the patient is asleep.

    Also you need to really dig for the cause of the delirium, as it's a symptom of an underlying problem. It could be the meds. But it could also be an infection (related note: my father caused a Code Green because he was delirious d/t a respiratory infection. They needed 6 staff to control him). Or it could be an electrolyte imbalance. How do his labs look?
  5. by   NutmeggeRN
    UTI? How is his fluid load?
  6. by   heron
    OP, none of the above answer your initial question. Frankly, I can't think of anything that you aren't already doing: reducing stimulation as much as possible. If it was me, I'd also consider mitts to reduce (but not eliminate) the potential for damaging his lines.

    I'd also peruse what's available by way of PRNs to control restlessness. Ignore benzos and anticholinergics (i.e. Benadryl) if at all possible. IV haldol = cardiac issues so IM, PO or rectal is better if that's what's ordered. Keep treating his pain but try to simplify it as much as possible. Medicate early rather than late: prevention is better than playing catch-up. Pain med + antipsychotic often = relief (if only temporary).

    Re-orientation is futile. He's essentially psychotic. He'll get better when the underlying cause is treated (meds, wacked-out chemistry, untreated infection etc.) and he gets out of the sensory overload of the ICU (we old fahts used to call it "ICU psychosis"). Meanwhile, he's gonna be a 1:1 handful. Good luck!
  7. by   amoLucia
    Environmental control? And you don't say how old he is.

    With my gero-psych dementia pts, I found that a soft minimal light with gentle music helped. They do need to be able to see surroundings.

    One time I found a gospel radio station and the first song was "Amazing Grace". That LOL stopped her thrashing about and fell asleep for about 30 some straight minutes. Never saw anything like it before that. And NOTHING has quite worked as immed as that time.

    Religious/gospel does seem to work best. 'Elevator music', 'easy listening', and then 'big band/1940s' all seem to work with a geri population of 70 y/o & up.
  8. by   Okami_CCRN
    On my unit we avoid giving benzo's and benadryl to the older population since it tends to aggravate the problem of psychosis/delirium.

    We try risperdal/seroquel/haldol instead, some of other things you can do to help is dim the lights, customize your alarms to prevent nuisance alarms (e.g. knowing your patient has A-fib, but monitor dings every minute telling you it's A-fib), playing music in the room via pandora or other service/device. Lastly sometimes placing the patient on a 1:1 helps.

    I try not to put mitts and/or soft wrist restraints because more often than not it makes the patient even more agitated and next thing i know they bit off a mitt, cotton is everywhere and an IV is out.
  9. by   MunoRN
    As others have said, first on the priority list would be to get rid of the benzos, while they are tempting since they give the patient (and you) an hour or so of calm, it only perpetuates and worsens the delirium (aka "pump head" in hearts, even though it's not from the pump).

    The best way to keep a delirious patient from pulling at art lines, chest tubes, and foleys is to not have them in, since the patient is two weeks post-op and still has an art line and chest tubes (and I assume a feeding tube) it would appear the patient has not had a normal post-op course, but the sooner those can come out the better.

    There's been evidence building for the use of melatonin in delirium, not just because it might help them sleep but also because the decreased melatonin production that occurs in the hospital environment might directly contribute to delirium as well.

    Tire them out as much as possible during the day and maintain a normal sleep-wake cycle as much as possible, Seroquel at night, get rid of all alarms that aren't absolutely necessary, music, etc. At some point he'll finally get some normal sleep and get over the hump, at which point he'll probably sleep for two days straight, which will freak the doctors out, give them the Ativan you aren't giving the patient.
  10. by   kalycat
    We recently had a similar situation. The patient ended up going on palliative care, and the first thing the palliative care team did was discontinue the dilaudid and Ativan in favor of fentanyl for breakthrough pain and a long acting opioid that the patient was on pre-op. The palliative MD felt for this patient's situation, small doses of fentanyl would be less likely to worsen the confusion whereas the dilaudid was much more psychoactive for this patient.

    Of course, this was in the context of stable labs, no uti, etc. We did see improvement in the patient's orientation. His confusion and agitation seemed refractory to everything including haldol and olanzapine. We ended up adding lamictal, which helped a little. The patient didn't have a huge untreated psych history, but there was a significant history of serious anxiety and episodes of major depression.

    The startling awake after brief periods of sleep and constant picking at lines, skin, gowns, and the air was very similar to what has been described in previous posts.

    The reason the patient ended up with our palliative team was that a secondary diagnosis had been being treated successfully, then cardiac issues arose. In this situation, the delirium was so bad that the patient was unable to continue treatment for his secondary diagnosis. Tough situation.

    We fixed his heart, but whether it was pump head, ICU delerium, or a progression of his disease was unclear. All I know is that the small, short acting doses of fentanyl and returning to the pre-op analgesia regimen as soon as possible *did* help his level of orientation and sleep/wake cycle. The problem is, we were still unable to transfer the patient out for several more days due to all the med changes and behaviors. Additionally, while a fentanyl pca would be okay for our step-down unit, they frowned on receiving a patient who was receiving relatively frequent IVP doses. As soon as the pain was better managed with lower/fewer fentanyl doses and the behavior improved somewhat, we were able to get a bed.
  11. by   CCU BSN RN
    First of all, thank you to every one of you! Even those who weren't answering the question itself, you provided valid suggestions and food for thought.

    To clarify some of the questions: This guy is in his mid 60's, has been on 40-60mg oxycodone IR q4h for years at home. That makes it tougher to avoid opiates because the opiate withdrawal itself could make him more confused and/or delirious, and I really don't need a miserable patient vomiting all over their sternal incision because they're basically withdrawing from heroin. There is definitely a huge case to be made for reducing use of opiates, benzos, anticholinergics when delirious. I think the rationale for the ativan was that this guy is absurdly strong and while he was a peach for me, he has been intermittently combative and come very close to injuring staff, so we have definitely been erring on the side of giving ativan when he starts to get angry or visually upset about something.

    He did have restraints at times to prevent tube/line dislodgement but once he was extubated he would just scream constantly when restrained. He did have a sitter but it was discontinued because he would constantly talk (albeit pleasantly) and ask questions and it seemed like it was causing too much stimuli to have another person in the room with him constantly. Didn't help that she kept all the lights on, kept trying to re-orient him constantly even though it was absurdly ineffective, etc. I ended up being in the room twice as much when he had a sitter because she would call me in every time he touched his chest tube tubing or raised his voice, or she would let him have his call bell which he didn't understand how to use, then I would respond thinking it was her needing me, and she'd say 'oh yeah he's just going to push that button all night'. And I literally just couldn't even. The right sitter probably would've been a useful intervention, but the kind of sitters we were getting sent...

    To address those of you who pointed at infection as a possible cause of this guy's delirium, yeah probably. He has been intermittently spiking fevers up to 101.9 for his entire postop course. We removed and replaced his lines to culture the tips, sent urine, sputum, and several sets of blood cultures over the course of several days. We sent his pleural fluid from an effusion for culture, his incisions don't look infected at all. Mild leukocytosis, WBC somewhere between 12 and 20. Infectious disease is consulted and basically want us to CT scan his chest/abdomen/pelvis to look for some other infectious source, but getting him to behave long enough to be scanned has been a tricky mistress.

    Sodium was 155 when I picked him up. Gave IVF and encouraged PO fluids and was trending down by end of shift

    ABG was normal

    Glucose was right around 180-240

    Wearing him out during the day to establish sleep/wake schedule is also an awesome suggestion, but made more difficult by the fact that this guy has basically not been out of bed in 2 weeks. Normally totally unheard of, but combo platter of hemodynamic instability, prolonged intubation and heavy sedation (every time we lightened sedation he would flip out, get agitated, breathe over the vent, not follow directions, etc. but the doses of sedation/pain meds needed to keep him calm were causing such respiratory distress that he actually got re-intubated a few times in his first few postop days). Anyway, he was already constantly moving around in bed, but now he's so deconditioned that it's going to be a long road to get him back to ambulatory. Agree he could probably be hoyered to a chair at least.

    Normally I'm all about getting to the cause of the delirium so we can fix that, but in this case the equation simply has too many variables. Infection, prolonged ICU stay, sleep deprivation, lyte imbalances, high dose narcotics...well, they certainly complicate the clinical picture.

    Now that we've discussed a bit, I have a follow up question.

    When you go in the room to provide care, give meds, etc. and the delirious patient is coming at you with some ridiculous claim/version of reality, for example "Why won't you just give me the ice cream that's inside of that red box on the wall?", how exactly is one supposed to respond to that?
    Things I've tried:
    1. "That's a sharps bin. It's full of discarded needles. There is no ice cream in it." Then he got indignant and started accusing me of lying and saying he would get OOB and get the ice cream himself.
    2. "We're all out of ice cream. Dietary will bring more in the morning" Then he started telling me which store I should go to to buy him some ice cream with the implication being that it wouldn't be out of the realm of possibility for me to stop caring for my assignment, leave the premises, find somewhere open at 3am, and buy him ice cream.
    3. "You're diabetic and on an insulin drip. Your doctor says you can't have ice cream right now." Then he got indignant and started telling me that I was lying, the doctor said he should have ice cream.
    4. Silence. Ignore the comment. He looks at me like I'm dumb and then starts accusing me of ignoring him.
    5. "I'm going to the store to get you some ice cream, but you need to stay here in bed and leave all your lines, oxygen, etc. alone while I go. Every time you take something off I have to hightail it back here, and it will take much longer to go buy ice cream if you're not behaving." This worked until his goldfish memory reset itself, so 2 minutes max.

    Basically I just feel like I can't win with patients like this. I feel like I have no idea what to say to them, reorientation doesn't work, they have no short term memory, no logic/sense. It seems like no matter what I say, I wind up exasperated, the patient winds up agitated or loud or attempting OOB. Nobody wins.

    So, let's hear it. Who has things that they say to delirious patients that buy them some time to go care for other patients?
  12. by   heron
    I think the pt would definitely benefit from a re-vamp of his meds. If he's still on oxycodone as an inpt, then it's time to rotate. There's a reason that "oxy" is called hillbilly heroin ... it crosses the blood-brain barrier very easily and is probably one of the most high-making opioids in use. Possibly the worst option for pain control in a delirious pt, in my view.

    Get rid of the Ativan and switch to haldol, geodon, seroquel ... whatever antipsychotic psych recommends for rapid control of severe agitation r/t delusional or hypomanic states. They did get a psych consult, right?

    Every psych nurse I have ever worked with has said never argue with delusional patients ... that goes for delusions due to medical issues as well as psych. I have found that it helps to keep my interactions concrete and directive and to either ignore or deflect delusional statements (i.e. "I'll see about the ice cream later, right now we have to clean you up/check your blood pressure/give you this medicine, etc.") Accept the fact that you cannot re-orient him ... continuing to try just wastes your time and aggravates him.

    And did I mention stop giving him Ativan?
    Last edit by heron on Apr 21
  13. by   amoLucia
    "The red box refrigerator failed and the ice cream melted. Bad electric socket. Nowhere to put any new ice cream. We need the electrician in the morning to fix it."

    Reality orientation is USELESS. You don't argue or contradict. Silence won't work either. Their safety filter doesn't work. And they don't recognize their physical limitations. Very short attention span. No current memory but old memories are 'current'.

    You have to gracefully figure out some 'therapeutic fibbing' approach. LTC/Alzheimer's units' staff know this well.

    The info has to be simple, like child-level. Has to have some logic that even a child could understand. Stays neutral - doesn't commit to a 'yes' or with a 'no'.

    And SHORT, SWEET, and BRIEF.
  14. by   Meriwhen
    Quote from heron
    Every psych nurse I have ever worked with has said never argue with delusional patients ... that goes for delusions due to medical issues as well as psych. I have found that it helps to keep my interactions concrete and directive and to either ignore or deflect delusional statements (i.e. "I'll see about the ice cream later, right now we have to clean you up/check your blood pressure/give you this medicine, etc.") Accept the fact that you cannot re-orient him ... continuing to try just wastes your time and aggravates him.

    And did I mention stop giving him Ativan?
    As a psych nurse, I agree with all of this. You can give the reorientation the old college try, but I wouldn't persist on trying to make the patient AO4 (or as close as you can get), every single time you enter the room. You shouldn't feed into the delusion (i.e., don't agree with the red box being full of Blue Bell) but look for the underlying message and see what you can do for it. "The red box on the wall doesn't have ice cream but I'll see if I can get you some. First I have to...". Just like Heron said.

    Also, while Ativan and other benzos are often relied upon to snow aggressive patients, they can actually be activating/stimulating to a small percentage of the patient population. They do use Ativan to treat catatonia, after all And I see benzos frequently having this paradoxical affect in older patients. When benzos do that to a patient, we'll shelf them and use antipsychotics such as Haldol or Zyprexa to calm them down.

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