You are the current "on call physician" for your group, when you receive a call regarding one of your nursing home patients. The nurse reports that one patient has been acting strangely for the last few hours and is agitated at times. This patient is an 82-year-old female who has been in the nursing home for the last two years, and has always been very pleasant. You know her very well from your recent nursing home visit. She has a past medical history of hypertension, diabetes mellitus, osteoporosis, and Alzheimer's dementia. Her daily medications are amlodipine, metformin, calcium - vitamin D, and donepezil. You are concerned that something is not right with the patient.
A CT scan of the patient's head is normal. Initial lab studies reveal the presence of a urinary tract infection with mild prerenal azotemia. You start the patient on empiric antibiotic therapy and intravenous fluids; however, the patient's mental status remains unchanged. You provide a bedside sitter for the patient for constant supervision. The sitter reports that the patient is very combative now. She has been trying to get out of bed and has twice attempted to pull her IV line out. She resisted the physical restraints that the nurse was trying to apply. Frequent orientation and reassurance has not improved her behavior. Which of the following is the most appropriate next step in the management of this patient?

Question

You are the current "on call physician" for your group, when you receive a call regarding one of your nursing home patients. The nurse reports that one patient has been acting strangely for the last few hours and is agitated at times.  This patient is an 82-year-old female who has been in the nursing home for the last two years, and has always been very pleasant. You know her very well from your recent nursing home visit. She has a past medical history of hypertension, diabetes mellitus, osteoporosis, and Alzheimer's dementia. Her daily medications are amlodipine, metformin, calcium - vitamin D, and donepezil. You are concerned that something is not right with the patient.
A CT scan of the patient's head is normal. Initial lab studies reveal the presence of a urinary tract infection with mild prerenal azotemia. You start the patient on empiric antibiotic therapy and intravenous fluids; however, the patient's mental status remains unchanged. You provide a bedside sitter for the patient for constant supervision. The sitter reports that the patient is very combative now. She has been trying to get out of bed and has twice attempted to pull her IV line out. She resisted the physical restraints that the nurse was trying to apply. Frequent orientation and reassurance has not improved her behavior. Which of the following is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: The patient is exhibiting behavior that could harm herself and the healthcare staff. Initial supportive measures such as reassurance, orienting her to the environment, and having constant supervision has not been successful in managing her disruptive behavior. Low-dose haloperidol may be useful in controlling her symptoms, preventing harm, and allowing for the safe continuation of her treatment. Antipsychotics are associated with a variety of side effects. These include sedation, orthostatic hypotension, anticholinergic side effects, tardive dyskinesia, and extrapyramidal symptoms. Thus, the patient should be started at lower doses and the dose is then titrated upwards to achieve the desired effects. (Choice B) Benzodiazepines have a more rapid onset of action, but these can worsen confusion and sedation. They can be used as an adjunct to antipsychotics to reduce extrapyramidal side effects. (Choice C) Physical restraints should be only used as a last resort in a combative patient. They frequently lead to worsening of confusion. They are used when medications fail to act, and the patient remains a significant threat to his/her and the healthcare staff's safety. (Choice D) Sitters are helpful in providing orientation and constant supervision for a confused patient. Once a patient becomes combative, other modalities including chemical and physical restraints are frequently necessary. (Choice E) Performing a lumbar puncture is only indicated if the patient has unexplained fever, altered mental status, and nuchal rigidity. Change in mental status alone is not an indication for lumbar puncture. Educational objective: Physical and chemical restraints should be used judiciously in a combative and disruptive patient. These help prevent injuries and falls, and allow for the continuation of medical therapy. Always give haloperidol (antipsychotics) before you apply restraints.

You Are the Current "On Call Physician" for Your Group