A nurse working at night in the hospital calls the doctor asking for help:
“I have a patient, Mrs Jones. She’s very agitated. Can you order some Haldol?"
In the situation described, another class of medications is also used at times. Sedative hypnotics such as lorazepam (Ativan) may also cause confusion and over sedation.
Imagine being the doctor in the above situation. The request can have multiple outcomes. The night doctor does not know the patient well. In addition, the doctor is busy and does not want more phone calls about the patient. In the worst-case scenario, a high dose of the medicine is ordered. The patient subsequently becomes over sedated and the next day she chokes on her food leading to pneumonia. Or she becomes more confused and clumsy and falls down with a hip fracture. The patient suffers and hospitalization is prolonged.
These are not just scary scenarios. They are realistic stories. In a stressful hospital setting, a nurse is too busy to be spending a lot of time with one patient. The request to calm a patient down with a medicine seems reasonable. Or is it? Would it seem as reasonable if the patient were not Mrs. Jones but instead Baby Jones?
Agitation doesn’t just happen in the hospital. It usually happens at home. In a previous post, I talked about patients with dementia who experience apathy. Here, I will discuss agitation.
Agitation: Start with ABC
When I don’t understand a problem well, I am unlikely to provide a proper solution. The first step in managing agitation is getting a thorough description of what’s happening. As a geriatrician, these are the questions I ask:
A. Is it an emergency? Is there immediate risk of injury to the patient or harm to others?
B. Describe the behavior. A person can be crying and yelling. Or a person may be wanting to go to the bathroom over and over again. These are very different, and both can be called agitation.
C. How severe is the behavior? Is it a crisis or not?
How Severe is the Problem?
A caregiver states: “My father yells at me all the time.” It’s my job to find out what “yelling” and “all the time” mean. The severity of the problem is determined by a combination of intensity, frequency and duration. For instance:
INTENSITY: How intense is the yelling?
- High: The person yells so loudly that you can hear them from another room.
- Medium: The person swears and belittles in an angry voice. “You’re a terrible daughter, get out of here!”
- Low: Grumbling and criticizing but not in a very loud voice. “You never cook a good meal.”
FREQUENCY: How often does the behavior occur?
- High: Multiple times in a day
- Medium: Most days
- Low: Some days, but not most days.
DURATION: How long does each episode of yelling last?
- High: For hours
- Medium: For up to an hour
- Short: Minutes but not close to an hour
The ABC approach leads to an action plan
Emergency situations require an immediate response. Urgent situations require expert one-on-one assistance as soon as possible.
Problems that aren’t urgent or emergencies still need answers. Start by finding out information online or from community resources. Many behaviors have common features and recommended approaches. Particularly important are recommendations about the wrong direction, what NOT to do. Support groups are useful for hearing what other people have experienced and tried. In addition, they are very helpful for emotional support.
In my next post, I will explain why answers need to be custom tailored. An approach that works for one patient and caregiver may not work for another. The next step is to get an in-depth understanding of the background and specific circumstances.
- Agitation can mean many things. A detailed description of the issue leads to the best action plan.
- Agitation can be an emergency, urgent or nonurgent. The action plan is different for each.
- Preventing and managing difficult behavior is different for every patient. We've started by determining an initial action plan. The next step is to understand the circumstances and background. This will be discussed more in a future post.