Agitated elderly patient

[BJJVP]

What's your go to cocktail for the agitated elderly, demented patient?

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[AlmostAnMD]

My geri psych is excellent

Someone else can chime in but I have great success following advice from a geripsych rotation

I use droperidol the young and/or stupid. But for old and demented I exclusively use Zyprexa.

Start at 2.5 mg IM q 30 minutes, titrate to stfu. By 10 mg max room should be quiet but maintaining airway

 

[lymphocyte]

My geri psych is excellent

Someone else can chime in but I have great success following advice from a geripsych rotation

I use droperidol the young and/or stupid. But for old and demented I exclusively use Zyprexa.

Start at 2.5 mg IM q 30 minutes, titrate to stfu. By 10 mg max room should be quiet but maintaining airwa

This is my approach as well. Love droperidol in the young and olanzapine in older folks.

 

[RustedFox]

We're finally getting droperidol.
Finally.
Big sign posted about it.
We all breathed out.

HAIKU:

THE droperidol.
No more crazypants retching.
Silence rules the night.

 

[Rekt]

Agree with Zyprexa for the gomers. Apparently everyone used haldol before I got where I’m at. Haldol sucks. But nurses are getting used to it.

 

[BoardingDoc]

We're finally getting droperidol.
Finally.
Big sign posted about it.
We all breathed out.

HAIKU:

THE droperidol.
No more crazypants retching.
Silence rules the night.

I read this and immediately envisioned a dirtbag cannabinoid hyperemesis patient deeply slumbering on a stretcher as cherry blossoms fell softly all around them.

 

[BoardingDoc]

My geri psych is excellent

Someone else can chime in but I have great success following advice from a geripsych rotation

I use droperidol the young and/or stupid. But for old and demented I exclusively use Zyprexa.

Start at 2.5 mg IM q 30 minutes, titrate to stfu. By 10 mg max room should be quiet but maintaining airway

I also use zyprexa for this population, but for whatever reason I have a select group that proves refractory to doses > 10mg. Invariably I start adding on benzos or find that I need to switch to typicals like droperidol. I don't have a good solution for this subset.

 

[turkeyjerky]

Agree with Zyprexa for the gomers. Apparently everyone used haldol before I got where I’m at. Haldol sucks. But nurses are getting used to it.

Can you elaborate a little? Ive always used haldol…is there evidence for atypicals in this situation?

My main advice in this patient is ti avoid benzos like the plague. Makes things worse most of the time ime.

 

[bravotwozero]

20mg IM geodon all day long m.

 

[WilcoWorld]

Just please avoid the benzos in the elderly if you can. Calms them down for us, but causes prolonged delirium for the folks upstairs.

 

[DrDrummer]

Is anyone on here giving Olanzapine IV? Off label but studied. I just hate the idea of continuously giving IM meds to an agitated nonagenerian if you have a line. I know it has been studied, but just curious if anyone's department is actually doing it.

 

[Tipsy McStagger]

In addition to the above, I'll just throw out some things we find when they come upstairs:
- make sure their bladder is empty, severe urinary retention makes them crazy. Have often seen people come up from the ED with gigantic bladders that aren't caught if they didn't get a CT or the ER doc wasn't looking for it. Nurses can do quick bedside bladder scans which are somewhat adequate
- take off any medication patches if possible
- Often polypharmacy is to blame, but takes a bit to sort out

No great meds. Sometimes I use precedex but they have to be coming to the ICU already. Geodon is ok. Nothing really works well long term.

 

[Mr. Vandemar]

Is anyone on here giving Olanzapine IV? Off label but studied. I just hate the idea of continuously giving IM meds to an agitated nonagenerian if you have a line. I know it has been studied, but just curious if anyone's department is actually doing it.

Yup, did it all through residency and do it now. Nurses and pharmacy initially were uneasy, sent them some random articles I googled and now it’s no problem.

 

[Druggernaut]

I was under the impression that olanzapine was not recommended in those with dementia, though a quick Google search makes me think that's not as much as an issue as I had thought. That was our antipsychotic of choice in residency, but it works better with the local ED culture to use Haldol or droperidol, so I mostly use droperidol for younger patients, audible vomiting/gastroparesis, and Haldol for longer sedation or more elderly.

 

[TooMuchResearch]

All the time.

 

[TooMuchResearch]

All the time.

That was @DrDrummer

 

[Jabbed]

Any antipsychotic as long as it’s IV. I’m not opposed to zyprexa, but my nurses are much more comfortable giving haldol IV.

I’ll still do benzos for imaging, preferably versed.

A sage point was made above regarding screening for urinary retention.

 

[Tiger26]

We're finally getting droperidol.
Finally.
Big sign posted about it.
We all breathed out.

HAIKU:

THE droperidol.
No more crazypants retching.
Silence rules the night.

We've had it for years because our health system makes our own stock. It's one of the very few remaining good things about emergency medicine.

 

[Boatswain2PA]

, but my nurses are much more comfortable giving haldol IV.

IV Haldol? I have yet to work a hospital where nurses or pharmacy would do that. They always require IM.

 

[RustedFox]

In addition to the above, I'll just throw out some things we find when they come upstairs:
- make sure their bladder is empty, severe urinary retention makes them crazy. Have often seen people come up from the ED with gigantic bladders that aren't caught if they didn't get a CT or the ER doc wasn't looking for it. Nurses can do quick bedside bladder scans which are somewhat adequate
- take off any medication patches if possible
- Often polypharmacy is to blame, but takes a bit to sort out

No great meds. Sometimes I use precedex but they have to be coming to the ICU already. Geodon is ok. Nothing really works well long term.

I'm sympathetic to your plight, amigo.
But you think my nurses have any time to routinely bladder scan and foley-drain the stream of admits?
If I asked them to do this; I'd have something thrown at my head.

 

[Mount Asclepius]

I'm sympathetic to your plight, amigo.
But you think my nurses have any time to routinely bladder scan and foley-drain the stream of admits?
If I asked them to do this; I'd have something thrown at my head.

Upstairs often doesn’t understand downstairs, but it takes seconds to bladder scan and minutes for a Foley. ED nurses do Foleys often. Your nurses sound almost as good as your prior job’s MLPs. If they don’t follow what you ask or order, then its not a good job and the power dynamic is inappropriately inverted. And I’m a big team not power guy.

Either way, I prefer Haldol, Drop, Geodon and Zyprexa over the bladder scan. Definitely over the benzos in older adults… any adult… well aren’t they all really just big kids? I don’t do antipsychotics in kids. Well, almost never. I guess, usually not. Hmm… (upper teeth slightly biting over lower lip with contemplative face). Actually yeah, I’d definitely do it in a scromiting teenager who doesn’t smoke pot ‘often’ - meaning for sure not more than once daily.

*Probably a poor attempt at your wonderful writing style, but it should keep rubbing off on all posters.

 

[RustedFox]

Upstairs often doesn’t understand downstairs, but it takes seconds to bladder scan and minutes for a Foley. ED nurses do Foleys often. Your nurses sound almost as good as your prior job’s MLPs. If they don’t follow what you ask or order, then its not a good job and the power dynamic is inappropriately inverted. And I’m a big team not power guy.

Either way, I prefer Haldol, Drop, Geodon and Zyprexa over the bladder scan. Definitely over the benzos in older adults… any adult… well aren’t they all really just big kids? I don’t do antipsychotics in kids. Well, almost never. I guess, usually not. Hmm… (upper teeth slightly biting over lower lip with contemplative face). Actually yeah, I’d definitely do it in a scromiting teenager who doesn’t smoke pot ‘often’ - meaning for sure not more than once daily.

*Probably a poor attempt at your wonderful writing style, but it should keep rubbing off on all posters.

1. You're right.
2. My problem is: admin has this bug up their ass about "a foley-free ED" and other nonsense, because "you can't get a CAUTI if there's no foley" and that somehow matters.
3. Nursing's problem is: We are major-league shortstaffed every shift, and everyone is crispy. To ask them to do something that is seemingly as inessential as this would not be received well.

 

[Siggy]

No great meds. Sometimes I use precedex but they have to be coming to the ICU already. Geodon is ok. Nothing really works well long term.

This is the big take away from the SCCM PADIS guidelines. In general meds don’t work to decrease or prevent delirium. If you need a Med for safety in the ICU, Precedex is likely the best medication.

Granted safe for the ICU and safe for the ED are two different situations since the ICU is more controlled/staffed.

 

[BoardingDoc]

IV Haldol? I have yet to work a hospital where nurses or pharmacy would do that. They always require IM.

That sounds like some very antiquated logic. Even the FDA says to just check their QTc if giving it IV even though it isn't approved for IV use.

https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/015923s082,018701s057lbl.pdf

Is this a one off rule, or does your ER do other old-timey (nonsense) things like refuse to let you use propofol as well?

 

[WilcoWorld]

I'm sympathetic to your plight, amigo.
But you think my nurses have any time to routinely bladder scan and foley-drain the stream of admits?
If I asked them to do this; I'd have something thrown at my head.

What if you only ordered it on the agitated ones?

"Sure I can order Zyprexa, but could you just bladder scan Grandpa first? If he doesn't have retention I'll throw that order in right away." We shouldn't need Jedi mind tricks to practice good medicine, but here we are. Gotta figure out someway to make it work.

 

[WilcoWorld]

That sounds like some very antiquated logic. Even the FDA says to just check their QTc if giving it IV even though it isn't approved for IV use.

https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/015923s082,018701s057lbl.pdf

Is this a one off rule, or does your ER do other old-timey (nonsense) things like refuse to let you use propofol as well?

In the name of patient safety, we don't want you to use propofol or paralytics in the ED. Midazolam only intubations never go poorly.

 

[bravotwozero]

IV Haldol? I have yet to work a hospital where nurses or pharmacy would do that. They always require IM.

give IV haldol all day every day. I have to have a patient on a cardiac monitor if giving IV.

 

[RustedFox]

What if you only ordered it on the agitated ones?

"Sure I can order Zyprexa, but could you just bladder scan Grandpa first? If he doesn't have retention I'll throw that order in right away." We shouldn't need Jedi mind tricks to practice good medicine, but here we are. Gotta figure out someway to make it work.

I don't mean this to be argumentative:

Which of my gomers ISN'T agitated?!

 

[WilcoWorld]

I don't mean this to be argumentative:

Which of my gomers ISN'T agitated?!

Really? Ug, an ED full of aged Florida Men!

 

[RustedFox]

Really? Ug, an ED full of aged Florida Men!

Bro, most nights in my ER it's a goddamned barnyard.

"Maaaahhhhh."
"Whoaaahhhhhhhwww."
"Heeeebheeeebheeeeeee."

Close your eyes.
In your head, play barnyardnoises.wav
This is Florida.

 

[Mount Asclepius]

Name that sound.

Orgasm or pain?

Vomiting or barnyard animal?

Alarm code blue or code brown?

 

[thegenius]

Bro, most nights in my ER it's a goddamned barnyard.

"Maaaahhhhh."
"Whoaaahhhhhhhwww."
"Heeeebheeeebheeeeeee."

Close your eyes.
In your head, play barnyardnoises.wav
This is Florida.

I actually thought there was a goat in my ER the other day.
An old woman kept on saying "hhheelllllpppp" with a stutter. The sound wasn't smooth.
The nurse would dutifully go in, time after time, to reassure the demented patient.

After awhile the "hhheaeaeaealllllpp" sounds like a goat.
Give it a try. Make sure nobody else is listening because they will you are crazy.
Try stretching out "help" over 4-5 seconds with mouth somewhat agape and sending the air up around your palate. Don't move your lips either.

 

[medninja]

Bro, most nights in my ER it's a goddamned barnyard.

"Maaaahhhhh."
"Whoaaahhhhhhhwww."
"Heeeebheeeebheeeeeee."

Close your eyes.
In your head, play barnyardnoises.wav
This is Florida.

Just when you think you’re going to log a rare sighting of porphyria, you realize half those sounds are just variations of the call of the Common Long-Billed Med-Seeker.

 

[Tipsy McStagger]

I'm sympathetic to your plight, amigo.
But you think my nurses have any time to routinely bladder scan and foley-drain the stream of admits?
If I asked them to do this; I'd have something thrown at my head.

*shrug* it takes less than 10 seconds so, yeah they probably do. I'm not saying everyone needs it, but if you have delirious / agitated elderly patient it should be high on your differential if there's nothing else obvious.

 

[thegenius]

I actually thought there was a goat in my ER the other day.
An old woman kept on saying "hhheelllllpppp" with a stutter. The sound wasn't smooth.
The nurse would dutifully go in, time after time, to reassure the demented patient.

After awhile the "hhheaeaeaealllllpp" sounds like a goat.
Give it a try. Make sure nobody else is listening because they will you are crazy.
Try stretching out "help" over 4-5 seconds with mouth somewhat agape and sending the air up around your palate. Don't move your lips either.

One of those goats is having a dissection. Can you pick it out?

 

[thegenius]

*shrug* it takes less than 10 seconds so, yeah they probably do. I'm not saying everyone needs it, but if you have delirious / agitated elderly patient it should be high on your differential if there's nothing else obvious.

Sounds reasonable to me.

 

[Ceke2002]

Severe agitation in the elderly kind of fascinates me I must admit. My Mum had several code blacks* called on her during her initial ED visit for delirium with eventual dementia diagnosis. I only have a witnessed account of one incident, but we're talking frail little old lady who suddenly has the strength to attempt to smash through a wall with a chair, dodge medical staff, knock two patient visitors to the ground, start throwing punches at responding staff once they caught up to her, and then require two security guards to take her to ground before she can be properly sedated (IM Haldol and Clonazepam). Like how? Rhetorical question, I know pathological strength states, etc, etc, but it still fascinates me how someone that small and frail can suddenly turn into the human equivalent of mighty mouse.

(Code Black in South Australian hospitals at the time was imminent risk of harm to self or otherwise).

 

[TooMuchResearch]

IV Haldol? I have yet to work a hospital where nurses or pharmacy would do that. They always require IM.

We did IV Haldol all the time in residency. We also did IV Zyprexa. In my current hospital system, IV Zyprexa was just starting to get support around 5-6 years ago and then when we were about to get droperidol, we had our insider on the P&T committee help get IV approval. Of course, they still give me a hard time about using 3% saline through a good AC 18 G.

 

[TooMuchResearch]

give IV haldol all day every day. I have to have a patient on a cardiac monitor if giving IV.

I covered in a place recently that has a 3 hour cardiac monitor order attached to droperidol by default. I unchecked it the three times I used it in 8 hours and told the nurses the patients will be discharged long before the 3 hour mark. They still hooked them all up.