Questions for the specialists

[LuckiestOne]

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Hello, I am just a little medical student studying for the USMLE and I came across a question that I would like your specialist input on... Psychiatry/behavioral sciences are really hard for me.

An 84-year-old man with dementia, Alzheimer type, is admitted to the hospital for treatment of pneumonia. At night, he becomes confused, yelling, "Where am I? How do I get room service in this place?" He then slaps one of the nurses and tries to kick the doctor. He behaves in a similar manner for the next 2 nights. Which of the following actions is most appropriate to decrease this patient's agitation?

A) Request that the patient's family hire a sitter for him
B) Place familiar objects and a night-light near the patient's bed
C) Leave bright lights on and have the staff check on him hourly
D) Apply restraints to the patient during the night
E) Medicate the patient with a long-acting anxiolytic drug

What is the correct answer in your opinion and I would appreciate it if you could include why as well. Thank you so much, sirs.

 

[PikminOC]

i think it is b since elderly patients can get very disoriented in the hospital so you want to keep some consistency from home..

it seems his sleep wake cycles is disrupted as well either due to dementia or disorientation in an unfamiliar surrounding or sundowning

 

[Poetic Silence]

C). Make sure he's under proper supervision so as not to hurt himself.

 

[LuckiestOne]

i think it is b since elderly patients can get very disoriented in the hospital so you want to keep some consistency from home..

Thank you for your answer. Why wouldn't you use sitter/medication/restraints in this case? Using familiar object is considered more effective than other methods listed here?

 

[PikminOC]

I could be wrong...specialists disagree.

I have learned that frequent orientation and having items from home and family present help decrease confusion in demented/delirious patients.

u would not have the family pay for a sitter

and you have to be very careful in using chemical or physical restraints as people, esp elderly or combative patients can hurt themselves when restrained...some even dislocate joints! chemical restraints can result in falls, broken hips, etc.

this patient may need short term restraints with a sitter also..but the answer wasnt worded that way

safety safety safety...for self harm and harm to others..

 

[digitlnoize]

A) Request that the patient's family hire a sitter for him

- Nope. $$$ is never the answer on these tests...although this might help.

B) Place familiar objects and a night-light near the patient's bed

- I think this is definitely the answer they are looking for. This is the standard first line treatment for delirium. Check up to date. Usually, by the time psychiatrists get these patients, they're too far gone for this to work, but this should be tried first before meds.

C) Leave bright lights on and have the staff check on him hourly

- Nope. You want lighting to accurately follow normal sleep-wake cycles, so bright in the day, dark at night, etc. Leaving bright lights on would likely only make things worse.

D) Apply restraints to the patient during the night

- Never the answer on these tests. You may need restraints if B doesn't work...but you'd really, REALLY want to avoid them.

E) Medicate the patient with a long-acting anxiolytic drug

- Benzos can exacerbate delirium in the elderly/alzheimer's crowd. If you're going for a drug, you're looking at Haldol here. D/C-ing all benzos (which he's probably taking buckets of because the primary team doesn't know what they're doing, lol) would probably help. Some people argue for the 2nd gen antipsychotics (Seroquel) but recent studies have shown Haldol to be just as good, and way cheaper.

At least, that's my (limited) understanding. Someone more senior feel free to correct me! 😀

 

[splik]

An 84-year-old man with dementia, Alzheimer type, is admitted to the hospital for treatment of pneumonia. At night, he becomes confused, yelling, "Where am I? How do I get room service in this place?" He then slaps one of the nurses and tries to kick the doctor. He behaves in a similar manner for the next 2 nights. Which of the following actions is most appropriate to decrease this patient's agitation?

A) Request that the patient's family hire a sitter for him
B) Place familiar objects and a night-light near the patient's bed
C) Leave bright lights on and have the staff check on him hourly
D) Apply restraints to the patient during the night
E) Medicate the patient with a long-acting anxiolytic drug

What is the correct answer in your opinion and I would appreciate it if you could include why as well. Thank you so much, sirs.

The bold bit is key - A) does not decrease agitation it would prevent wandering or reduce chance he hurts himself/falls; c) would not decrease agitation; D) restraints increase agitation, we use them to stop patients hurting themselves when other measures have failed, they prevent wandering/pt leaving, lashing out at staff; E) you would use a short-acting (e.g. lorazepam), not a long acting anxiolytic to decrease agitation so this is not correct. Benzos CAN be used in delirium, I find them useful and although we say avoid benzos actually there are sometimes they may preferable - e.g. pt with parkinsonism or Dementia with Lewy Bodies (some people would advocate quetiapine here, but answer is far from clear).

That leaves B - behavioral techniques to decrease agitation include having a familiar person around (not a sitter, someone the pt recognizes), having familiar objects around including photos, having a big clock with the the time, a board to orient the patient stating the date and location. I will also tell these pts when I meet them "Today is the 21st August, you are in x Hospital for x, my name is dr splik and you are here because..."

 

[LuckiestOne]

Thank you for your insightful answers. So smart, I wouldn't have never thought about the question that way!

 

[vistaril]

- Nope. $$$ is never the answer on these tests...although this might help.


- I think this is definitely the answer they are looking for. This is the standard first line treatment for delirium. Check up to date. Usually, by the time psychiatrists get these patients, they're too far gone for this to work, but this should be tried first before meds.


- Nope. You want lighting to accurately follow normal sleep-wake cycles, so bright in the day, dark at night, etc. Leaving bright lights on would likely only make things worse.


- Never the answer on these tests. You may need restraints if B doesn't work...but you'd really, REALLY want to avoid them.


- Benzos can exacerbate delirium in the elderly/alzheimer's crowd. If you're going for a drug, you're looking at Haldol here. D/C-ing all benzos (which he's probably taking buckets of because the primary team doesn't know what they're doing, lol)

primary teams usually know how to treat delirium just fine.....

 

[digitlnoize]

primary teams usually know how to treat delirium just fine.....

Maybe at your "Top Institution", but in the real world, we get delirium calls all the time and almost always find the patient mis-managed. A few guys seem to know what they're doing, the rest...not so much.

 

[vistaril]

Maybe at your "Top Institution", but in the real world, we get delirium calls all the time and almost always find the patient mis-managed. A few guys seem to know what they're doing, the rest...not so much.

hehe....why don't you go over in the medicine forum then and post a thread giving advice on delirium recs and see what kind of reception you get.

 

[nitemagi]

hehe....why don't you go over in the medicine forum then and post a thread giving advice on delirium recs and see what kind of reception you get.

Having worked in multiple hospitals, delirium consults are extremely common. It's quite undertaught in the medical curriculum, particularly that the longer it's untreated, the less reversible it is. I've even see medicine teams try to discharge patients who are still delirious because their cursory evaluation couldn't come up with a medical cause.

Your post Vist is a continued straw man argument. No one here is talking about unsolicited recommendations for delirium mgmt. We're talking about responding to consults that every other professional here seems to get, except you. Which seems to lead to the more likely conclusion that YOU are not consulted often, which could be for various reasons, including your warm welcoming attitude 🙄

As for the OP, yes I agree B. C is incorrect as that's the commonly held cause of "ICU psychosis," which is really delirium from medical illness Plus sleep deprivation. You don't want to sleep deprive someone already delirious or demented.

 

[DOC PENGUIN]

hehe....why don't you go over in the medicine forum then and post a thread giving advice on delirium recs and see what kind of reception you get.

Why don't YOU do it. Again you have some grain of truth.

 

[billypilgrim37]

Maybe at your "Top Institution", but in the real world, we get delirium calls all the time and almost always find the patient mis-managed. A few guys seem to know what they're doing, the rest...not so much.

Medicine teams at my institution are very good at treating delirium. They just turn the lights on all night and crank up the ativan. Works like a charm.

The ICU is even better, scheduling Haldol IM 5mg q3 hours on the elderly patients until magically the patient isn't moving any more... at all. Problem solved!

 

[OldPsychDoc]

Medicine teams at my institution are very good at treating delirium. They just turn the lights on all night and crank up the ativan. Works like a charm.

The ICU is even better, scheduling Haldol IM 5mg q3 hours on the elderly patients until magically the patient isn't moving any more... at all. Problem solved!

Do they then consult you for "akinetic mutism"?
Or is it just "r/o depression--ECT eval".

 

[vistaril]

Why don't YOU do it. Again you have some grain of truth.

Im not going to do it because I already know medicine people know how to manage delirium for the most part.......the reason you guys wouldn't do it is because you know the question/advice would be met with humiliation and a flood of nasty and insulting remarks

 

[vistaril]

Having worked in multiple hospitals, delirium consults are extremely common. .

part of that, at the hospitals where it is common, is the "i'll scratch your back you scratch mine" mentality.......ie you will see inpatient psych consult medicine for an asymptomatic pt with a K of 2.9. Medicine spends 5 seconds on the consult and knocks one out/bills for it....and everyone is a winner.

that's not something to be proud of.

 

[digitlnoize]

hehe....why don't you go over in the medicine forum then and post a thread giving advice on delirium recs and see what kind of reception you get.

Well...because I don't need to? I worked in many different facilities, community and academic, in many different states, and universally, delirium was poorly managed by most (not all) medicine docs and they consulted psych often because they had tried to get the patient better and had failed.

If you're not experiencing this in your residency, then I can only conclude that delirium is either going unrecognized, or that your medicine teams are so baller that psych is not consulted on delirium. Either way, it does not speak well to the quality of training at your "top" institution.

Also, it's easy to get the right answers on SDN. Anyone can go to google and look up "how to treat delirium."

 

[Poetic Silence]

http://www.google.com/search?hl=en&safe=off&ie=ISO-8859-1&q=How+to+treat+delirium&btnG=Search

 

[digitlnoize]

Like that ^^^. Thanks!

 

[nitemagi]

part of that, at the hospitals where it is common, is the "i'll scratch your back you scratch mine" mentality.......ie you will see inpatient psych consult medicine for an asymptomatic pt with a K of 2.9. Medicine spends 5 seconds on the consult and knocks one out/bills for it....and everyone is a winner.

that's not something to be proud of.

Further straw man arguments. There is none of that occurring at any of the hospitals. And you have no evidence to speak of that that occurs at any of my hospitals.

What you should question is your ongoing generalizations from your limited experience. THAT is not something to be proud of.

 

[On Walden Pond]

It's very annoying when people give hypotheticals that denigrate and are unfounded.

Vistaril, it's clear you think psychiatrists are a bunch of dumb doctors. I happen to be a competitive med student who can go into just about any field, and I'm going into psychiatry for the interest and the challenge. If you have such a low opinion of the field you are in, then please consider switching into a field where you will respect yourself more.

 

[digitlnoize]

It's very annoying when people give hypotheticals that denigrate and are unfounded.

Vistaril, it's clear you think psychiatrists are a bunch of dumb doctors. I happen to be a competitive med student who can go into just about any field, and I'm going into psychiatry for the interest and the challenge. If you have such a low opinion of the field you are in, then please consider switching into a field where you will respect yourself more.

I went looking in the IM forum, thinking about posting exactly what he told me to, just to see what would happen. Turns out he posted something vaguely similar a couple months ago...

Scarily, he said that he was about to be Chief Resident at his program!

 

[OldPsychDoc]

I went looking in the IM forum, thinking about posting exactly what he told me to, just to see what would happen. Turns out he posted something vaguely similar a couple months ago...

Scarily, he said that he was about to be Chief Resident at his program!

Well that explains why he hasn't divulged to anyone where his "top program" is.
If I knew that one of my Chiefs was posting what he does, there'd be some intensive "woodshed supervision" going on!

 

[happyoolongtea]

What is the correct answer in your opinion and I would appreciate it if you could include why as well. Thank you so much, sirs.

I haven't seen anyone comment on this yet...*cough*...but some of us are ladies, too (granted, I'm a fourth year med student, going for psych). just sayin'

I think the answer is B. GroverPsychMD's post about the role of constant orientation in delirium & dementia seemed like a high yield concept to know for psych in general, as well as on the boards. I thought BRS psych (Step 1) and First Aid for psych clerkship (Step 2CK) were awesome quick-ish reads, if that helps the OP 🙂

 

[vistaril]

I haven't seen anyone comment on this yet...*cough*...but some of us are ladies, too (granted, I'm a fourth year med student, going for psych). just sayin'

I think the answer is B. GroverPsychMD's post about the role of constant orientation in delirium & dementia seemed like a high yield concept to know for psych in general, as well as on the boards. I thought BRS psych (Step 1) and First Aid for psych clerkship (Step 2CK) were awesome quick-ish reads, if that helps the OP 🙂

the answer is B, and this is a medical student level question.....the other answers are all ridiculous. The only way they could have made the answer debatable is if they had added some answer choice that involved giving a sedating antispychotic, likely prn, for increased agitation in addition to orientation strategies(as in choice B).....

 

[whopper]

A) Request that the patient's family hire a sitter for him

No. In a hospital you'd get a 1-to-1. To have visitors past visiting hours while performing duties that should be done by the hospital is a no-no.

B) Place familiar objects and a night-light near the patient's bed

Don't like this answer. First if this guy is agitated, putting objects in his room could be used as weapons. In psychiatry the design of the room, the objects in it, have to be considered. As much as I don't like it, it seems like the best answer.

C) Leave bright lights on and have the staff check on him hourly

Another bad answer that could be the right one. First, one of the theories behind sun-downing is lack of sunlight since sunlight allegedly stimulates the frontal cortex. That said, the patient at some time needs to sleep and keeping bright lights on all the time could screw with his circadian rhythm. In any inpatient facility, staff are supposed to check on the patient hourly anyway, further pointing out to how badly written this question is. I could see this one also being right.

D) Apply restraints to the patient during the night

Bad answer. You never do restraints unless absolutely needed. Lesser interventions are always the better answer. It's required that you try to use behavioral interventions, then medication, then restraints unless the circumstances are so extraordinary to the degree you'd likely never see on a question (e.g. the patient without warning grabs a pen and stabs a staff member in the eye with it.)

E) Medicate the patient with a long-acting anxiolytic drug

Same as above, you try behavioral interventions first.

 

[hamstergang]

Don't like this answer. First if this guy is agitated, putting objects in his room could be used as weapons. In psychiatry the design of the room, the objects in it, have to be considered. As much as I don't like it, it seems like the best answer.

I thought this was pretty well established as the correct solution. The idea would be to make him less agitated so he wouldn't use weapons. You shouldn't "not like" this answer.

Another bad answer that could be the right one. First, one of the theories behind sun-downing is lack of sunlight since sunlight allegedly stimulates the frontal cortex. That said, the patient at some time needs to sleep and keeping bright lights on all the time could screw with his circadian rhythm. In any inpatient facility, staff are supposed to check on the patient hourly anyway, further pointing out to how badly written this question is. I could see this one also being right.

This one, on the other hand, you should dislike more. Not letting the patient sleep in the dark is going to be terrible for normalizing their mental status. I don't see what's badly written here -- this answer would make things worse and the above answer would help make things better.

 

[nitemagi]

I thought this was pretty well established as the correct solution. The idea would be to make him less agitated so he wouldn't use weapons. You shouldn't "not like" this answer.


This one, on the other hand, you should dislike more. Not letting the patient sleep in the dark is going to be terrible for normalizing their mental status. I don't see what's badly written here -- this answer would make things worse and the above answer would help make things better.

Whopper's answers just reflect his extra training as a forensic psychiatrist rather than consult liaison. Forensic psychiatrists will think a bit more about weapons and dangerousness.

 

[LuckiestOne]

Thank you for all your answers, I learned a lot!

 

[whopper]

I thought this was pretty well established as the correct solution. The idea would be to make him less agitated so he wouldn't use weapons. You shouldn't "not like" this answer.

Whopper's answers just reflect his extra training as a forensic psychiatrist rather than consult liaison. Forensic psychiatrists will think a bit more about weapons and dangerousness.

Well I'm a biased person to analyze myself but I don't think so. Just like a 2 year old kid can't be given razor blades, same goes with a demented/delirious and agitated adult. To merely just say give the person familiar objects from their home isn't safe enough. This is not forensic psychiatrist Whopper but doctor-currently running the geriatric unit Whopper speaking.

Those "familiar" objects needs to be scrutinized by the treatment team before they are approved. This occurs on a geriatric unit, forensic unit, or any unit for a confused and agitated patient. That's why I don't like the answer. It makes the assumption that the familiar objects are safe for it to be the right answer. They may not be. Familiar object may be grandpa's Louisville Slugger, a glass framed picture of his dead wife, a blow dryer, or a portable radio powered by D-batteries--all of which could be extremely dangerous. I'd go as far as to say to not consider the object's safety in this patient's possession would not be the standard of care whether or not this is observed from a forensic perspective.

I'd say if this were the right answer, it's just a badly written question, but then again, I'm that guy who always did bad on multiple choice tests and this is probably a shining example as to why. As far as I'm concerned I'm right on this, and if anyone disagrees, argue to me that a confused agitated guy should be given objects from home without treatment team approval for each object is the right decision in front of any of the entities that take responsibility for safety.

But I'd bet it is the right answer because of the BS I see with so many multiple choice questions.

Medschool is about getting inhuman amounts of data and answering multiple choice tests on that data, and a lot of what is right isn't about whether or not you learned the material but simply the writing and thought style of the test author. This is a reason why USMLE World or Spiegel's question book for the psychiatry boards get it right, while other sources like the PRITE are pretty much just dung when preparing for the board exam.

 

[heyjack70]

You want a long acting anxiolytic so it lasts through the night.

 

[hamstergang]

You want a long acting anxiolytic so it lasts through the night.

Drugs aren't necessary yet as there is another answer that can help. Also, can't giving a benzo make the pt worse (less inhibited) and also contribute to falls?

I'd say if this were the right answer, it's just a badly written question, but then again, I'm that guy who always did bad on multiple choice tests and this is probably a shining example as to why.

You are overthinking the answers a lot, and I'd say this is why you did poorly on the MC tests. I mean, just as you can assume that the choice recommending an anxiolytic isn't talking about 100mg of Klonopin, and the restraints applied to the patient aren't handcuffs, and the sitter the family is hiring isn't coughing up an active TB infection, you can assume that the familiar objects from home aren't rifles and knives and a bottle of bleach.

It is the "most appropriate" answer.

 

[pingouin]

You are overthinking the answers a lot, and I'd say this is why you did poorly on the MC tests. I mean, just as you can assume that the choice recommending an anxiolytic isn't talking about 100mg of Klonopin, and the restraints applied to the patient aren't handcuffs, and the sitter the family is hiring isn't coughing up an active TB infection, you can assume that the familiar objects from home aren't rifles and knives and a bottle of bleach.

It is the "most appropriate" answer.

Agree. Also just as a reminder, the original question indicates the patient was admitted for pneumonia, so he is likely on a medical unit, not a geriatric psych unit. It is not unreasonable that he may have personal items in his room.

I vote for reorienting the patient first, moving to medications if that's ineffective.

 

[OldPsychDoc]

...
You are overthinking the answers a lot, and I'd say this is why you did poorly on the MC tests. ....

whopper's a forensic psychiatrist. He's PAID to overthink. 😀

 

[whopper]

Heheheh.

Maybe some truth in that.

 

[J ROD]

Hello, I am just a little medical student studying for the USMLE and I came across a question that I would like your specialist input on... Psychiatry/behavioral sciences are really hard for me.

An 84-year-old man with dementia, Alzheimer type, is admitted to the hospital for treatment of pneumonia. At night, he becomes confused, yelling, "Where am I? How do I get room service in this place?" He then slaps one of the nurses and tries to kick the doctor. He behaves in a similar manner for the next 2 nights. Which of the following actions is most appropriate to decrease this patient's agitation?

A) Request that the patient's family hire a sitter for him
B) Place familiar objects and a night-light near the patient's bed
C) Leave bright lights on and have the staff check on him hourly
D) Apply restraints to the patient during the night
E) Medicate the patient with a long-acting anxiolytic drug

What is the correct answer in your opinion and I would appreciate it if you could include why as well. Thank you so much, sirs.

Just use reasoning. (A) does not make sense - why would the patient's family hire a sitter; they are available at the hospital. (B) definitely something that would make a confused patient more comfortable, night light may help with confusion with the dark. (C) have staff check on him is a proper idea, but leaving bright lights makes no sense. (D) you dont want to restrain someone unless it is NECESSARY. They could hurt themselves. Dont normally want to restrain a dementia patient. (E) Not the best option....more in the line of restraints. Not what you would do first. More after trying less aggressive techniques. Plus, they are BEERs meds for elderly, dementia

 

[whopper]

but leaving bright lights makes no sense.

It does if you factor in the theory that sun-downing is caused by lack of light hitting the person's eyes that in turn activate the frontal cortex. Hence that is why demented and/or delirious people may do worse at night.

That said, I've yet to see anyone use light-therapy in clinical practice to ameliorate sun-downing related agitation, or anyone use it period in inpatient even though I've seen several patients that would benefit from it. Another problem is that if left on all the time, it'd screw with the person's circadian rhythms.

 

[nitemagi]

It does if you factor in the theory that sun-downing is caused by lack of light hitting the person's eyes that in turn activate the frontal cortex. Hence that is why demented and/or delirious people may do worse at night.

That said, I've yet to see anyone use light-therapy in clinical practice to ameliorate sun-downing related agitation, or anyone use it period in inpatient even though I've seen several patients that would benefit from it. Another problem is that if left on all the time, it'd screw with the person's circadian rhythms.

vs. an alternative theory of sun-downing being that in those already confused, putting them in an unfamiliar environment and then lowering the lights confuses them more. Therefore putting familiar objects in place helps reorient them. In this model the agitation comes from not knowing where they are, and often being tied to a bed. Reorienting them frequently and putting familiar objects thus reduces it. Light therapy is useful in the mornings, not at night, otherwise you end up with again "ICU psychosis" from sleep deprivation, essentially worsening delirium.