Weaning dementia patients

[Sugarcoma, RN]

Does anyone have any ideas or tips/tricks to use while attempting to wean patient's who are suffering from severe dementia? How is this done where you work? Are you able to give them medication before weaning? Are you usually successful?

We have seen a rash of severe dementia (A&Ox0-1) patients and cannot wean them from the vent. Usually they progress like this: We wean sedation, attempt to let them breath on their own, they panic, fight, HR and RR jumps sky high and we end up bolusing sedation and turning the vent back.

Eventually we wean them off sedation entirely, keep them restrained, trach them and they end up in a LTAC still on a vent.

I suggest Morphine/Ativan/Xanax/Seroquel/anything at all but they just won't budge. Usually I get a lecture about over sedation and impaired oxygenation for my trouble.

What exactly is the difference between bolusing them back under when they freak out and giving them something to help them relax before we wean? It just doesn't make sense to me. They are still on the vent if they become too sedated we can just turn it back which is what we end up doing anyway!

I have tried sitting and holding the patient's hand, singing to them, leaving soothing music on, encouraging family to come in when we wean, etc. Occasionally one of these measures may prove successful but more often than not nothing works.

I just recently had a pt. like this who still had an active order for Morphine 2mg which I gave and that pt. weaned for 2 hours before they had to turn the vent back. The order was d/c when I came back the next night and he is back to only weaning for a few minutes at a time.

[MunoRN, RN]

I'd avoid benzos in dementia patients, you'll often just worsen their symptoms after the initial sedation wears off. Precedex is the preferred med what you're describing in my facility, although most of the time it doesn't seem to make any difference.

If it was up to me, I'd prefer the patient be on a scheduled atypical antipsychotic and then give haldol prior to the weaning trial.

[Sugarcoma, RN]

We are not allowed to use Haldol under any circumstances for the heart patients. Occasionally the general sx docs will order it or seroquel. We do not have Precedex yet, we were supposed to get it a few months ago but it has not happened.

I guess my real frustration is with the families who insist we do everything including open heart surgery on patients like this.

[MunoRN, RN]

There is an argument to be made against haldol and atypical antipsychotics, but there's a much, much stronger argument to be made for treating delirium aggressively. With proper QTc monitoring, haldol can be used safely, whereas untreated delirium (either chronic, acute, or acute on chronic) causes significantly worse outcomes, both short and long term. I'd make the case to your CV surgeons that they are missing the forest for the trees.

Or you could do what we did, which was to get the CV surgeons to allow the intensivists to handle the delirium, they are much more up to date on delirium treatment and don't leave us to treat wildly out of control delirium with 0.5mg haldol q 6. (Our standard protocol is for scheduled zyprexa and 2-8mg haldol prn, adjusted per QTc).