10 Tools to Understand and Address Agitation, Delirium and Sundowning

You I'd like to welcome everybody to today's presentation on addressing agitation and delirium in older adults. I'm your host, Dr. Donnelly Snipes. Over the next hour we're going to recap cognitive impairment. Just talk about what that is in case you haven't been in the prior classes. We'll define agitation, delirium and sundowning and then explore the causes of those things in each peace of the older adult's life. Now remember, peace stands for physical, interpersonal, emotional, cognitive and environmental. There are a lot of things that can cause agitation and delirium particularly, and there are a few things that cause sundowning. A reminder for those of you taking this for continuing education, the PDF of the PowerPoint as well as handouts and worksheets are available in your CEU class at allce.com non clinical caregivers can also take the course@allce.com to help you better understand and respond to older adults you may be working with. So you don't have to be a clinician to take the class. Let's start out by just recapping what is cognitive impairment. And and remember, cognitive impairment has a range of symptoms, if you will. As we age, our thinking slows. That's not in indicative necessarily of dementia or something worse. It could just be aging. And then on the other end of the spectrum, we have people who have progressed dementias, Alzheimer's disease, etc. When we're talking about cognitive impairment, we're talking about people particularly that are having difficulty with the stuff that goes on in their prefrontal cortex, their memory, their attention, their concentration, their ability to find words and communicate effectively, their understanding of their surroundings. So all of those can be assessed. When we're talking about cognitive impairment, it's important to remember, and we're going to talk about this a lot today, that symptoms, especially in older adults, may be caused by a variety of things and misdiagnosed as cognitive impairment or delirium. Insulin resistance, even if the person is not pre diabetic, can cause confusion, difficulty concentrating, difficulty thinking clearly, B12, iron or vitamin D deficiencies Hearing loss, even if it's temporary, hearing loss from allergies. People may have really stuffy ears and they're not hearing you well, so they're giving you answers that don't quite make sense to what you ask them or they're not hearing you at all and you're thinking they forgot. Well, it's not that they forgot, they never had the information to begin with. If your person, whether it's a patient or a loved one. If your person suddenly starts evidencing cognitive impairment, one of the easy things to check for is can they hear well or are their ears stuffy? Obviously B12 iron, vitamin D and insulin resistance, those are things a doctor is going to have to check for, but they're easy enough to test. Dehydration is another thing you can kind of test for at home if your person is dehydrated because they've had diarrhea, because of their medications, because they're not drinking enough. Older adults remember, don't have a as sensitive of a thirst reflex, so they don't drink as much like likewise, if they've got urinary tract infections or if they're having difficulty with balance, they may not want to get up and go to the bathroom. So they may not drink because they don't want to have to pee. Paying attention to that, if you have them tent the skin on the back of their hands, if it snaps back, they're probably pretty well hydrated. If it kind of stays up there and doesn't snap back, that's one indication of possible dehydration. Also, look at their eyes. Do they look kind of sunken or are, do they look healthy and and flushed? It may be indicative of hypothyroid and hypothyroid can start at any point in time. But one of the symptoms of hypothyroid in anybody is potentially cognitive impairment, difficulty paying attention, staying alert, etc and then medication side effects including antihistamines. Now we're going to talk a lot about these things as we go through delirium. However, it's important to understand and really advocate for the older adult who is experiencing cognitive symptoms or symptoms of delirium and agitation to figure out what is going on. What is the actual underlying cause? In view of the multifactorial cause and the multi component approach of dementia and delirium, multicomponent approaches seem most promising for facing patients needs. Pharmacological intervention, neither for prevention nor for treatment, has been proven effective unanimously. You all know that I am not a super fan of a lot of heavy pharmacology because very often it doesn't work or it just covers up an underlying pathology. If somebody's having difficulty sleeping, for example, then okay, but what's causing that? You can. And what I've seen, unfortunately. We'll talk. I'll get on that soapbox a little while later. But short version is what I've seen is people who have agitation or sundowning are Often just prescribed increasing levels of medications to make them sleep instead of addressing what's causing these symptoms, what is the underlying issue? And it may not even be a pathology. It, A lot of times it's a disruption of circadian rhythms. So we need to be very wary of the medications that our older adults are on and the impact of those medications. Is it helping or is it just masking something else that's going on? Delirium is a serious and often acute disturbance that is characterized by impaired attention, difficulty sustaining or shifting focus, disorientation and confusion about time, place, or identity. Fluctuating symptoms throughout the day, cognitive impairment and altered consciousness ranging from hyper vigilance to lethargy. Delirium is acute and it's often caused by something. And we're going to talk about what those somethings are. It's different than sundowning, which is related to dementia. Typically occurs about the same time every day. Delirium is going to have an acute onset and think about somebody after they've been in a bad car crash or something, how they, they're, they're disoriented, they're not really kind of sure where they are. They're kind of walking around in a haze. A lot of times that may be what we're looking at or thinking about when we're talking about delirium. And, and I don't want people to misconstrue delirium as somebody acting crazy, because that's not it at all. But they do have altered consciousness, disorientation and confusion, and difficulty paying attention. Two types of delirium hyperactive delirium, which is the type that typically involves restlessness, agitation, rapid speech, and sometimes hallucinations or delusions. That's only 25% of the cases. All right, let that sink in. The other 75% of the cases of delirium that are being caused by something going on with the person go undiagnosed because the person is not causing a problem. Basically, they're not making a ruckus. So people don't pay attention. We need to pay attention to are older adults, whether they are able to communicate or not, whether they have dementia or not, we need to pay attention. If there's a sudden change in their behavior, they become super withdrawn, apathetic, tired. We want to examine what might be going on. Could they be getting sick? Is there pain? Are they not sleeping well? What is causing that change in presentation and behavior? With hypoactive delirium, the lack of diagnosis of those underlying issues causes us to fail to attend to that underlying pathology, which could include medication overdose, infections, and even stroke. And when I say medication overdose, I'm not talking about the adult intentionally trying to overdose. I'm talking about them being prescribed medications either independently or because of polypharmacy that aren't clearing their system fast enough and they're building up. My grandfather had hypoactive delirium and obviously we didn't realize it until one day he was all but unconscious. And then he went to the hospital and we learned that he probably shouldn't have been prescribed the Xanax that he was on or no, he was on Valium. My grandmother was on Xanax. Neither one really is recommended for older adults because it clears the liver more slowly and it contributes to risks of falls, et cetera. But if we're paying attention, if somebody starts taking. I'll use. My grandfather starts taking Valium. The first couple of days, it may seem like it's working, but then by day four, day five, day six, they start becoming very withdrawn and lethargic and unresponsive. That's what we call a clue. We shouldn't be. We should be seeing their quality of life and their presentation improve, not completely withdraw. And then there's mixed delirium. I know, just always throw something in there where the person is hyperactive some of the time and hypoactive. The some of the time. Mixed delirium is not nearly as common. It's generally hyper or hypoactive with 75% of the cases presenting as hypoactive. If you are working in long term care facilities, nursing care facilities, or doing home care for older adults, you may notice some of the adults that you're working with may start becoming hypoactive. And that's definitely something that needs to be looked at by their medical team, by their neurologist, by their physician, whomever. Your first line of referral is. Now, I told you, we talk about sundowning. Sundowning is not the same as delirium. They have a lot of symptoms that kind of overlap. But sundowning refers to a group of symptoms that commonly occur in people with dementia. You don't have to have dementia to have delirium. You can, you don't even have to be an older adult to have delirium. But you. In order to call it sundowning, the person needs to have dementia. And it typically happens in the late afternoon and evening. Key differences between sundowning and delirium, the timing. Sundowning occurs at specific times of day. You know that sometime after 4 o', clock, Jim Bob starts getting, becoming more agitated or more withdrawn. Generally with sundowning, it's agitated and restless. The duration, Sundowning is often a recurring pattern, while delirium is an acute condition. So sundowning happens not necessarily every day, but a lot of the time and generally about the same time of day when, whereas delirium, if you figure out what's causing that underlying issue that's contributing to those symptoms, the delirium will go away. Delirium is transient and acute. The underlying cause is different. Sundowning is associated with dementia and delirium is caused by a variety of things. Now, a lot of people with who are experiencing sundowning may become agitated. A lot of people, 25% of the people who are experiencing delirium may become agitated. And that's agitation is a lot of what we're focusing on today because that tends to be what's considered a problematic behavior. However, I will continually remind you that just because they're not agitated doesn't mean there's not a problem. If they're withdrawn, if they're hypoactive, we need to pay attention. And finally, cognitive fluctuations. Delirium tends to cause more severe and rapid fluctuations in cognitive status, whereas sundowning is about the same. And it's not rapid. It's kind of a gradual, gradual onset as the person becomes more tired, as their circadian rhythms fail to do what they're kind of supposed to do. Sundowning. This deserved its own slide. Sundowning is strongly associated with disrupted circadian rhythms in patients with dementia. Dementia itself has been thought to do some things to disrupt circadian rhythms. So that's important to recognize. However, remember that circadian rhythms are set by light levels, temperature levels and activity levels. When you're working with someone to help them stabilize their circadian rhythms, it needs to be bright during the day, warmer during the day, cooler at night, darker at night. And ideally, they have the same couple of things that they do as, as their body is supposed to be secreting melatonin to kind of trigger that release. Eating dinner, taking a bath and reading a book or watching TV or whatever it is they do. It doesn't have to be this huge production, but any sort of routine can help cue that person's biological rhythms that, hey, it's time to secrete melatonin and time to start getting ready for. Getting ready for bed. People with dementia are at risk of. Increase increased risk of experiencing delirium. Remember I said anybody can Experience delirium, people who have lost a lot of blood, people who are intoxicated. There are a variety of things that can cause delirium, but people with dementia are at increased risk, especially during times of acute illness, hospitalization, or environmental changes. People with dementia have reduced cognitive reserve and cognitive flexibility. So when things change, it's much more stressful for them, and as a result, it can trigger a stronger cortisol response and throw things out of balance. It can further disrupt those circadian rhythms because they feel stressed and they're unable to relax. There's increased sympathetic dominance, especially in people with Alzheimer's and Lewy body dementia. What that means is their stress response is a lot stronger than their relaxation response. So when they get stressed, they tend to dysregulate more and they have a harder time returning to baseline because their relaxation response is weaker and it's having a hard time competing with the stress response. Now, most older adults have some level of sympathetic dominance, but it's more pronounced in people with Alzheimer's and Lewy body dementia. Therefore, psychophysiological interventions like biofeedback to help strengthen vagal tone can be very helpful as an intervention, and we talked about that some last week. People with dementia have an increased susceptibility to infection and dehydration. As dementia progresses, their bodily signals kind of become disconnected and they don't realize they're thirsty. They don't remember to drink. They have more difficulty remembering how to maintain proper hygiene, whether that's washing their hands or toileting, which can lead to a lot of infections and an increased risk of polypharmacy. A lot of older adults are on a lot of medications, and those medications interact some. They, they interact together and they play nice. A lot of them do not play nice together. So one of the things we want to look at is if there has been a change in our person's presentation, has their medication changed? If it hasn't, that doesn't necessarily mean that polypharmacy is not the case, because like we talked about last week, in Lewy body Dementia, people who are on antipsychotics may over time become hypersensitive to those psych antipsychotic medications. And so their dose hasn't changed, but their sensitivity has. And that can contribute to symptoms of delirium. Now, I've divided this into addressable and preventable causes of delirium and agitation. The addressable ones are things that are. Could occur and we may not be able to completely prevent. The preventable ones are ones that you can look at and go, yeah, the person shouldn't have been prescribed this medication. There's a black box warning not to give it to elderly people. So let's talk about the addressable causes. And we're going to go through the peace dimensions like I always do, because I like that structure. Physically, if the person is having a stroke or transient ischemic attack, a mini stroke, that can cause symptoms of delirium. Remember the fast mnemonic face. If one side of their face is droopy and the other side is not, if they raise their arms and one side of their body doesn't seem to be able to cooperate, I'm sorry, it's fast face arms speech. If their speech becomes garbled or they don't suddenly don't seem to understand, and then T stands for time. It's time to call 91 1. You don't want to play. If somebody seems to be having a neurological dysfunction. Seizures can also cause delirium or agitation, especially after a grand mal seizure. Somebody may feel very disoriented. I've seen it after a catatonic seizure as well. The person takes a minute to kind of figure out who, where and when they're at. Depression or grief can actually contribute to delirium and agitation. As those neurotransmitters become imbalanced, as their sleep is impaired, as their stress goes up, they may start having imbalances in cortisol and they're at more greater risk of delirium, especially if the grief or depression is acute. You know, suddenly they've become very depressed or they've had a major loss that has really just hit them hard. They can start having symptoms of delirium, schizophrenia or bipolar disorder. If somebody has this, they have this. They've probably had it since before they were an older adult, and it's something that just needs to be managed. It is important to recognize that Lewy Body Dementia causes an increased sensitivity to those antipsychotics, which can be evidenced by the development of delirium. I know I already said that. But at some of these things, it's important enough to say two, three, four times. Pain can cause delirium when people are in a lot of pain or when they're on pain medications. But when they're in a lot of pain, it can make it harder for them to have good judgment. It can make it harder for them to be oriented to time and place and what's appropriate. It can cause agitation. Patient think about a time when you were in pain. I'm thinking like when I, I gave birth to my son, I, I was agitated and it was really challenging. And I remember telling the anesthesiologist, I can't breathe. He said, you're talking, you can breathe. And I wanted to turn around and clock him. Obviously I didn't. But, you know, I was agitated, I was stressed. And agitation is a behavioral manifestation of stress. When people become agitated, it's often because they're in pain, they're confused, they're fearful of something. Infections, particularly in older adults. Urinary tract infections and pneumonia, any type of infection. But these two types of infection are very common in older adults. Older adults that have catheters may get more urinary tract infections. They may have pain from the catheter itself and, and they may not realize that they're in pain and they're just, they feel grumpy or they may realize that they're in pain, but they don't want to be seeing that doctor. I know we're going through this with my husband's grandparents right now. They don't want to see doctors and they will not tell you when they're in pain. They will not tell you when there's a problem. So you have to kind of guess based on their overt behaviors if there's something particularly wrong and then try to figure out what it is. Dehydration. Dehydration can be caused due to medications they're taking and things that are medications that are designed to address blood pressure, that are designed to address fluid retention. Well, those cause fluid loss and so those can lead to dehydration if they have diarrhea. Some of the diabetes medications like metformin can cause diarrhea, or maybe they ate something that didn't agree with them and they've got diarrhea. They're probably not going to come out and announce, hey y', all, I got diarrhea, so watch out for my hydration. But we need to be kind of aware of that if they're not drinking enough fluid. Decaffeinated, preferably water, but definitely decaffeinated, non carbonated fluid. That can be something that leads to dehydration. And older adults who drink too much caffeine. I know my husband's grandparents drink a lot of tea, straight up, black, full caffeinated tea. And that's all they drink. And, and you know, they drink maybe I say they drink a lot of it. They drink like two cups a day, but that's about the only thing they drink all day long. So yes, they're dehydrated. And that can be something to work with the physician, with the nursing staff, with the client to increase motivation and provide behavioral cues in the environment to help them remember to drink, maybe even setting an alarm, making sure that they have water bottles with clean water next to their chair, in the kitchen, next to their bed, wherever they might spend time. That way they can reach out and drink again. A lot of older adults, especially those that are struggling with balance issues, may be reticent to get up and get something to drink. And if we make sure that they have it available to them, then we're going to be a lot more. They're going to be a lot more likely to at least stay a little more hydrated if they have it available and they're still not drinking. Again, we need to evaluate why not. Do they not like it? Are they not remembering? Do they have a UTI so when their bladder gets full, it really hurts? What's going on that is keeping them from drinking enough. When people are dehydrated, they have electrolyte imbalances, which can also contribute to delirium, interestingly, and this is not usually a problem with older adults, but if for some reason an older adult just got really thirsty and drank a whole lot, it is possible to actually drink too much and throw your electrolytes out of whack. Moderation is the key. Now, when I say too too much, I'm talking about gallons, not 8 additional ounces. Anemia and B12 deficiencies can cause problems. Now remember, older adults have more difficulty absorbing B12, even if they're eating foods or, or a diet that's high in B12. Anemia can also be related to lack of sufficient iron. And when there's not enough iron and B12 in the blood, you're not getting enough oxygen to the brain and you're going to start see confusion, disorientation, difficulty with attention, and problem solving. I have this under addressable because sometimes it's a change and, and we know as we age we become have a propensity for these things we can identify. Hey, that's what's going on. Easy solve. Medications are addressable. A lot of older adults have to be on certain medications, whether it's blood pressure or cholesterol or something else. They're on it for whatever reason and their doctor thinks they need to be on it. Okay, it's all good. Recognizing the side effects of medications. When this person started taking the cholesterol medication, those are called statins. Statins are actually associated in a Lot of people with depressive symptoms. If the person started taking the statins and started evidencing a lot of withdrawal and depressive symptoms, even if it doesn't meet what you would say was delirium, we want to help, help the person communicate with their doctor about that. Polypharmacy. When you have people taking multiple medications and those drugs don't play nice together. Unfortunately we still haven't in the U.S. gotten to the point where we have some centralized database where all the doct can log in and you have one central patient file and they can find out what medications other doctors are prescribing you. So the neurologist is relying on Jim Bob to remember all of the medications that his primary physician and his endocrinologist have him on, which as you get older those medications start to add up, it can be easy to forget. So polypharmacy is definitely something we want to consider. You can go to drugs.com and just google drugs.com and medication side effects and then drugs.com and medication interactions. And they have two different sites on drugs.com one that shows you the side effects of common medications and another one that shows you medication interactions. So you can put all the medications in there that your person is taking and see if there are any concerning interactions that you may need to call the doctor about. Abrupt withdrawal from anything, whether it's a antidepressant or pain meds or heaven forbid, benzodiazepines, anti anxiety meds that can cause delirium in, in people and anesthesia. I remember for me and, and remember I said you don't have to be an older adult. When I had my son, he was a micro preemie. There wasn't time for, you know, all that epidural stuff, even if I would have wanted it. So they pumped me full of Demerol and I tell you what, I woke up after I gave birth to him. I didn't know who, what or where I was. So even for a, you know, healthy younger adult, anesthesia, especially right after the surgery, can cause some level of delirium. It's important to recognize that anesthesia is basically opioids most of the time. And so if your person is taking painkillers at home, opioid based painkillers, they may also have symptoms of delta delirium. Neurological disorders can cause symptoms of delirium. The person doesn't know where they are. There's not enough blood getting to the brain. So the brain starts to sort of short circuit and that can lead to a Stroke. Same thing can happen during traumatic brain injury or dementia. If remember fast face, arm, speech and time to identify a stroke. If there's a traumatic brain injury, if they fall in the bathroom and they hit their head on the tub or what have you. We want to be highly alert to any indication that they're developing delirium because that could indicate pressure on the brain, that need, that's a medical emergency. Sleep deprivation or circadian rhythm disruption. Even in healthy people, young people, they've shown that more than two days of significant sleep deprivation starts to lead to confusion and disorientation. And I think it was like day six that people started evidencing signs of delirium. But in older adults, their circadian rhythms kind of already out of whack. They're already have a higher propensity or a higher risk of delirium. And when they start experiencing sleep deprivation, it's sort of additive interpersonal causes of delirium and, and agitation. If the person is having difficulty communicating, they're have having difficulty finding their words and they're just getting so angry because it's like right on the tip of their tongue. We've all been there occasionally and it can be maddening. But for a person who is experiencing cognitive slowing, they may have that more often and it can be frustrating. If they've, pardon me, got dementia, it can be even more maddening because they are, may slowly be losing their ability to communicate. Excuse me. Whether that be difficulty understanding what's being said or difficulty actually using words. And it just comes out as word salad. There can be misunderstandings due to hearing or memory loss depending on the person. And that can cause agitation and distress and frustration, or on the opposite end of the spectrum, withdrawal. The older adult thinks, you know, it's just not worth it. They are constantly irritable with me, I just don't want to engage. We need to pay attention if there's a change in their presentation. And again, let's look at the simplest things first. Is it hearing loss? Whether it is progressive hearing loss because of diabetes or something else, or it's temporary hearing loss because of allergies or a sinus infection, that's pretty easy to rule in or rule out. If they're starting to have confusion and memory loss, have they been evaluated for some form of dementia? Interpersonally, a lack of connection and meaning can also cause delirium as well as agitation. And, and again, both hyperactive and hypoactive delirium can be caused by alterations in interpersonal interaction. And one of the things that happens when people are either having adversarial interactions or they're withdrawing from interaction, is a reduction in their oxytocin level. Oxytocin can cross the blood brain barrier and improve cognitive, emotional, behavioral and social functioning in people with autism spectrum disorder as well as schizophrenia. They have not yet tested it in dementia and I don't know why. You know, that's ex. When you look at the, on PubMed, at the amount of research that's been done on dementia compared to other things in the past 10 years, it's, it's minuscule, it's heartbreaking. But oxytocin itself, whether you're talking about intranasally administered oxytocin, which you probably can't get for dementia or delirium right now, or just doing things to help the person increase their oxytocin levels. Oxytocin has anti inflammatory effects, so it can help reduce any pain that may be happening. Anxiolytic effects, so it can help reduce anxiety and agitation and analgesic effects. It can actually help promote endorphins and, and pain relief. All of these can support social connection and help buffer against stress, which inhibits cortisol release. Cortisol is your main stress hormone. If that's pumping through your body, then you're not going to sleep as well. You're going to be on edge, you're going to tend to be more agitated. So oxytocin, by inhibiting cortisol release, can help people relax a little bit more and dysregulate a little bit less. Emotional causes grief. Remember denial, anger, depression, acceptance. Grief has a lot of flavors to it and it's not a linear process. And as we talked about several weeks ago, people who are aging again, even if they don't have dementia, may start getting very grief stricken about some of the losses they're experiencing or worried about experiencing in the near future. And that can cause disruption in sleep, which is one of the main things that it does. It causes increases in cortisol, it causes reductions in oxytocin. All of those can kind of combine to increase the propensity for delirium. Now, we can't prevent grief, but we can acknowledge it, we can validate it, we can help people work through it if they're ready to. Not my place to take away your grief. If you want to hold on to it for right now, you know that that's. I'm going to empower you to decide when you're ready to move to the next step. But Once they're ready, we can help them. If we notice that right after a particular loss, whether it's loss of personal functioning, maybe they have a stroke and they can't move part of their body, that's a traumatic incident, or they lost a loved one after that acute incident, there may be a period where the grief is just so palpable that they have a hard time focusing on anything. And I think a lot of us have been there when we've had an extreme grief event that in the moment, whether it's five minutes, five hours, five days, we may have difficulty really even thinking about where we are. We're just kind of in this la la land, as I call it. Anxiety. Anxiety is an emotion that comes up when people feel unsafe. Well, hallelujah. If a person's showing that they're anxious or agitated, we can ask them, what is it that I can do to help you feel more comfortable or help you feel safer? I don't know. I want to empower them to try to tell me to try to communicate. And if they can't communicate, if they've got aphasia or something, it may be a little more difficult. But a lot of times, even people with aphasia, especially if they don't have problems understanding they're having problems speaking, if you ask them yes or no questions, they can nod their head or blink their eyes to give you a response and really help you kind of narrow down what's going on. But reducing anxiety reduces cortisol, reduces stress, improves sleep, reduces neurotransmitter dysregulation, and reduces agitation. If somebody's agitated, think to yourself, when have I gotten agitated? When have I just been, you know, irritable and cranky and I don't want anybody to bother me or trying to fix or find a solution for something and just trying this and then trying that and not sticking with anything, kind of being all over the place. We've all been there. And recognizing that that's a communication of a problem, and maybe one they can't articulate is important. And then people can become agitated and irritable when they're experiencing frustration over not being able to remember or do what they could remember or do 20 years ago. And it can be disempowering. They can feel like, hey, I've. I've lost a step or five. They can start dreading the inevitable at some point. Death. There's a lot of stuff that can start coming up when people are focused on what they can't do anymore instead of what they can do. I'm not going to take away that frustration and invalidate somebody's feelings by saying, well, I hear you can't do that anymore, but hey, let's look at all the things you can do that invalidates their feelings. I'm going to stay with them there for a minute. We're going to talk about that and how frustrating and it is and how it makes them angry and sad. And then at some point we'll try to turn our attention and embrace the other side as well. So yes, this sucks. And there are these other things that you still can do. What's the best way to use your energy to move toward your rich and meaningful life? If somebody has overt delirium, you're not going to be able to do much in the way of cognitive behavioral therapy. You're going to focus on those basic Mesovian needs of making sure that they're getting their biological needs met and they feel safe. And that's about all you can do. If they're having difficulty with executive functioning, once they we've figured out what's causing the delirium and we can start stabilizing that and they start being able to access their wise mind, so to speak, then we will be able to start addressing some of these other things. But you need to be realistic. If somebody's not oriented to person, place or time, using cognitive behavioral therapy doesn't make a lot of sense. We want to use empathy, we want to help them feel safe. We may even try to help them use biofeedback to down regulate a little bit. But we're probably not going to get into those thoughts until they're more stable cognitively. People can get agitated and develop irritability or withdrawal again if they can't find their words. Some people with, especially with dementia may have these light switch moments in which certain times of year, maybe somebody's birthday, or maybe at 7:30 every morning when this person used to leave for work, the switch gets flipped on and they think they're supposed to go to work or on somebody's birthday, they remember that person 363 other days of the year, they don't ever talk about them. But that one day without prompting, all of a sudden they remember that person. I call those the light switch moments. Same thing for the person who thinks that they need to go to work every morning. A lot of times that lasts for a small period of time, they don't dwell on it all day long. Once they, you know, get past that moment of I have to leave to go to work, then they can be redirected and reoriented to things. Obviously, that's much more prominent in people with dementia or. And Alzheimer's. Hallucinations and delusions can be a side effect of fevers, can be a side effect of medications, can be a symptom of dementias. We want to be aware if the person thinks they're hearing or seeing things that we're not seeing or hearing, Instead of trying to convince them that they're wrong, Acknowledging that they saw shadow or they saw something, and, okay, what does that mean to you? And how can I help you feel safe right now? Is generally, especially in the moment, the best way to go. If they're having delusions, beliefs that somebody's trying to poison them or trying to hunt them, or maybe delusions of grandeur, they think they're. They think they're God. Okay, you know, we're not going to be able to rationalize with them that that's not accurate. So we want to help them figure out what they can do in order to be safe at the moment. If they are feeling like they are all that in a bag of chips 10 foot tall and bulletproof, they can do anything they want. We have to try to figure out, okay, how can we help this person stay safe in this environment that we're in? And again, where did this delusion come from? Did it suddenly start? Is it a. Does the person have a history of schizophrenia or depression with psychotic features? A lot of times it's going to be depression with psychotic features. That. And. And we look back and we see this person's been depressed for a while. Unfortunately, it doesn't start getting noticed until they have some extreme symptoms. Environmental causes include sensory overload, Too much going on, whether it's family visitation or anything. It. It could be too much light, too much sound. Somebody comes in and they've got on a cologne that's too strong, it can cause agitation. And the person may or may not be able to communicate that to us. But if we notice that they start seeming overstimulated, as we used to say in my house, we can help them retreat to a different area and see if that helps. And a lot of times, if they retreat maybe to their room or outside or somewhere quiet, if their behavior starts to improve, then we recognize, hey, that was probably some sensory thing. Now we just have to figure out what it was. Coercive measures like restraints are often going to increase agitation. Now, they're probably not going to increase delirium, but they may Increase agitation. And a lot of times, unfortunately, poorly trained staff may use restraints on people who have delirium, which just makes it, makes them more combative and makes it worse. My husband's grandmother, when she was in the hospital a few weeks ago, didn't want to stay. And should she have stayed for another couple of days? Probably, but she was tired of being poked and prodded and she didn't want to stay. So she rips out her IVs and gets out of bed and starts demanding that her husband bring her her clothes. And then the nurses came in and injected her with some sedative that wasn't approved by the doctor. But in order to get her to settle down. Now let's look at that. What was going on? Did she need to be injected? No, she felt like she wasn't being heard. She felt disempowered, she was feeling terrified. There were at least five different ways that that could have been approached or where she wouldn't have gotten to the point of becoming combative. If the person has room or facility changes, and by facility, I mean they go from living at home to living with their child, or from living at home to being in the hospital, or if they're in a long term care facility, maybe they go from their room and then they're moved over to memory care or they're just. They change rooms or they change roommates. That can be triggering for delirium and they forget where they're at, especially if they move rooms. If they're in the ICU or hospitalized hospitals have crappy circadian rhythms. Let's just call it what it is. The lights don't change, the temperature doesn't change, it's always cold. And there's very little interaction, very little cognitive stimulation, which is so important. For older adults, there's a loss of familiar cues like pictures, their family and whatever that help them feel safe. And there's often limited sensory input, such as normal conversations, varied stimuli, and access to natural light. All of these things can disrupt circadian rhythms, can reduce cognitive stimulation, and can contribute to disorientation, delirium, depression, etc. Preventable causes, substance use or misuse, especially if they're using medications. If they're taking medications and they're still drinking, you know, that may be their choice. However, we need to make sure that they understand if they're still capable of making their own judgments, make sure that they understand the risks that they're taking. Substances interact with most medications. So generally the rule is if you're on medications, probably shouldn't be drinking alcohol, but the American Geriatric Society beers. Criteria I know, what a weird name. Are guidelines for healthcare professionals to help improve the safety of prescribing medications for older adults. We are not prescribers, but we will be working with patients who have generally multiple prescribers. Being aware of the medications that your person is on can help you potentially identify some medication interactions or problems. The criteria include five lists of medications that should be avoided, used with caution, dosed differently based on the patient's age, health conditions, and kidney function. I'm going to go through, and I know I said we're not prescribers, but let's go through some of these medications that can cause delirium and agitation. Antipsychotics like Haldol or Haloperidol block dopamine receptors, which can exacerbate Parkinson's, Parkinsonism, and other symptoms, including delirium, agitation, confusion, et cetera. Antipsychotics with strong anticholinergic properties can worsen cognitive impairment and autonomic dysfunction, which means they have more problems with hypotension. Their blood pressure drops as soon as they stand up and they get dizzy and they're at risk of falls. Some of these antipsychotics with strong anticholinergic properties include Zyprexa, Thorazine, and Clozarill. Unfortunately, these medications are often prescribed for agitation, sleep, sleeplessness, or anxiety. And there's a lot of argument, again, about whether that's more helpful or more hurtful in the long term because we're not addressing what's causing their agitation, sleeplessness, and anxiety. We're just doping them up and using chemical restraints. Atypical antipsychotics. The FDA has issued warnings regarding increased risk of strokes, transient ischemic attacks, and mortality in older patients with dementia treated with atypical antipsychotics. Seroquel's one of them. A lot of these medications are really not recommended for older adults. Dehydration can be caused by loop etics for somebody maybe who has kidney failure and ACE inhibitors, which are used for blood pressure. Sedation can be caused by benzodiazepines, barbiturates and opioids. Now, sedation's a problem because when we're sedated, you know, on a lot of those medications, they have a warning that you're not supposed to drive or operate heavy machinery, et cetera. Well, older adults, whatever the younger adult feels is generally intensified in the older adult. It can increase the risk of falls, confusion, disorientation, forgetfulness. Maybe they take their medication twice because they forgot if they took it. Now, it's interesting. Some medications are what they call lipophilic. And when you take them, they can get stored in your fat cells. And so with medications like benzodiazepines, you can see symptoms of delirium in people who take the benzos and they are feeling disoriented and loopy. As my grandmother would say, when they're withdrawing from the benzodiazepines, as the benzo is leaving their system, the system doesn't naturally keep up quite as well. So there's a period during that withdrawal period where anxiety goes up, agitation goes up, restlessness goes up. And if the person was taking benzos, we, when they were say 150 pounds and they've gotten sick recently and they've dropped 15 pounds, you may actually see some protracted withdrawal as the benzos that were stored in the fat tissue actually get released into the system. We see that with marijuana too, but that's, that's a different presentation. Therefore, if we start seeing somebody, even if they're not actively taking benzos right now, seeming to become more agitated, if they have a history of taking benzodiazepines even as prescribed, we need to consider whether their symptoms may be caused by release of some of that or an imbalance caused by either taking or withdrawing from the benzo. Medications with strong anticholinergic effects, particularly antihistamines, can cause delirium in older adults in order from least to most anti cholinergic. So when you're looking at the top four or most intense four, it's the least anticholinergic of the four, but it is, you know, way at the top of the list. Diphenhydramine, that's Benadryl. So your older adults who are taking diphenhydramine are at much greater risk of dementia and confusion and disorientation. Difficulty with balance. Loritidine, it's another very common over the counter antihistamine that a lot of people are on. And then desloridine, which is, goes by the name brand Clarinex, has even stronger anticholinergic effects. And finally Phenergan, which I've seen, but it's not nearly as popular as the other three. But your older adults who are living independently or even who are in a assisted living facility may be on antihistamines. And those antihistamines may be contributing to their cognitive issues, their agitation, their restlessness, Sleep aids typically are antihistamines. They're just relabeled and certain antidepressants, especially Paroxetine or brand name Paxil is known to have really strong anticholinergic effects. It makes people sleepy, but it also contributes to confusion and disorientation and brain fog if you will. Antidepressant Trazodone is a. Sorry, it's a serotonin antagonist reuptake inhibitor. Trazodone is a commonly used off label drug for insomnia that improves sleep quality and sleep continuity, but carries significant risk. Older adults, those over 65 may be more likely to experience side effects including drowsiness, dizziness, increased risk of falls due to low blood pressure and suicidal ideation. Unfortunately, I know at least in one facility here they hand out trazodone like candy and it's on that beers list of medications that really shouldn't be prescribed to older adults. Serotonin Syndrome oh my gosh, who would have thunk it? I didn't. This is something I learned. Serotonin syndrome occurs in association with the administration of select selective serotonin reuptake inhibitors and other medications that increase serotonin levels. But if the person is taking either multiple medications that increase serotonin or a antidepressant that's too strong that increase for their age and their liver function, they may develop Serotonin syndrome. Serotonin syndrome is a medical emergency. It's characterized by tremor, hyperreflexia, spontaneous rigidity, ocular clonus, difficulty moving their eyes, agitation and fever. Older adults are at increased risk due to polypharmacy and reduced medication clearance. Be aware of the signs of serotonin syndrome. And again, if your older adult has had a medication change recently, even just adding an over the counter medication, this is something to think about. When people have delirium, they may become either agitated or withdrawn. Delirium onset often indicates an underlying issue. Some are preventable, some are addressable, but they all can. The symptoms of delirium generally can be abated once you identify and address that underlying cause. Sundowning is similar to delirium and is associated with disrupted circadian rhythms. Paying attention to the person's presentation on a day to day basis, noting changes in behavior and exploring the causes of those behavioral changes is essential. As I said, even for people older adults who can communicate well, they may not want to tell you that they're in pain or that they're sick because they don't want to go to the doctor. Being cognizant and being curious is so important in working with older adults. Are there any questions? Thank you Shade Viking. I really appreciate you watching the channel and I'm glad the resources are helpful to you. Hello Ty hello Rupa Rajni, I really don't know much about clinical hypnotherapy. Danny, you are so right. Hypothyroid. I have it too. And my husband was just astounded and at how much better my energy and mood and stuff got and how much longer I was able to focus once we actually started addressing those issues. So I echo that. Alrighty everybody, I have got to switch over to my live Q A. Please feel free to join me over there. Otherwise I will see you next week. But it's we're going back to the Wednesday classes. So Wednesday at 12pm EST, 11aM CST. Take care and have a happy New Year.