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?"
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?
The ABC approach leads to an action plan
*One good resource is: https://memory.ucsf.edu/caregiving-support/behavior-personality-changes
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.
In Summary:
- 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.
Warmest Aloha,
PS: I say it over and over again: There's no one more important than the caregiver in the daily life of a frail person.
This blog is very useful, Dr.Warren! My family is dealing with this as I write. It is high/high/short. Day to day now for her passing. Nothing but fluids in past 30 days. Family has morphine to dispense if needed in final days. Thank you for the post!!!
Hi Marin, I hope that you and your family are doing as well as possible. God Bless,
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