delerium vs psychosis, plus a roomie

[StripeyDog]

A patient with dementia and CVA was admitted to our acute inpatient stroke rehab unit some weeks ago. She was transferred to a single room because the screaming was disturbing her room mate. When I first met her (01/21, I think) she was doing well: UTI resolving, 1:1 was being d/ced, restraint reduction program, AAOx2, confused but pleasant and cooperative. She got a new room mate late that evening.

I had her 7A to 11P on the 24th, and 7A to 7P on the 25th. Both days she was fine in the morning, hyper vigilant and hallucinating in the afternoon, and agitated and refusing meds by supper time. She had conversations with the roomie (who has mild dementia and major visual impairment) about people who weren't there. She did not take the last of the antibiotics. She screamed about us trying to kill her and and screamed for a knife to cut her pelvic belt and begged to be allowed to jump out the window. She got out of her pelvic belt (unclear whether she reached around, or whether one of the inexperienced folks filling in as techs forgot to buckle it correctly) and ambulated herself halfway down the hall before I caught up.

Yesterday I had her 3P - 11P; she had a psych eval, and an order for risperdone (which she refused) and a 1:1 (which she tolerated). Somehow someone drew labs on her, which were normal. She recognized me but thought I was the chef (her roommate perseverates on the chef). She was tense, oriented to self only, and hallucinating, but not screaming or trying to elope. I was not afraid to leave the butter knife on her meal tray. In short, much improved but still not the woman I met last week.

What gives here? The doc thinks it's sundowning, and maybe a return of the UTI, but I'm not so sure. What are the boundaries between sundowning, delirium, and psychosis? Should I chalk this up to snowmageddon & a full moon, or should I be pushing harder for this woman to stay in a single room?

[TheCommuter, BSN, RN]

Was a new medication introduced? At times, medications such as narcotic analgesics and muscle relaxants can alter an elder's mental status.

The return of the UTI is another thought I was having...