Welcome to Unit 4 – Responding to Delirium: approaches and interventions

Section 1 – Introduction

If you apply the knowledge you have gained from unit’s 1-3 to your clinical practice, you should be in a position to identify anyone who is at risk of delirium and do what you can to reduce this risk wherever possible.  You should also be in a position to recognise anyone who has delirium at an early stage and this Unit is about how to respond to those cases where the predisposing or unavoidable precipitating factors were so great that delirium was unavoidable, or where a person comes in to hospital with a delirium.

It is important to remember that delirium is usually not caused by one thing, but is a combination of a few factors so there isn’t one response to delirium.  The article gives a clear practice protocol about how to proceed in a case of delirium.

Section 2

The standard practice protocol deals mainly with the physical / environmental parts of delirium and how to address these, however the reality is that delirium takes a certain amount of time to reverse and while it is reversing we nurses have to deal with the patient in what can be very challenging circumstances. The nursing strategies you can use during this time can be broken into 2 broad areas:

  1. Understanding behaviour
  2. Responding to behaviour

Section 3

Understanding Behaviour

Behaviour that is misunderstood and managed inappropriately may escalate.

Think A B C

A = Activating Event (what was the trigger)
B = Behaviour (what behaviour resulted)
C = Consequence (what was the consequence)

If we consider Ted again, it is much easier to respond to his behaviour in a therapeutic way when we understand that he tips water on himself in an attempt to communicate about the pain he is having in his knees. In fact this was not clear at the time and it took some time for the staff to realise that a response to this behaviour should be to reinstate his anti-inflammatory medication. Having nursed Ted, it was also very easy to feel quite annoyed as he was a big man and having to change his pajamas for the 3rd time in one day was becoming quite a chore!

The behaviour should not just be considered as “confusion” or “agitation”.

  1. Behaviour is usually a form of communication and often represents an unmet need.
  2. Care givers cannot change the behaviour of the person; BUT they can change their own behaviour and the working environment.
  3. Responding to behaviour

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Understanding Aggression:

  1. Defensive behaviourreaction to a perceived threat or invasion of personal space.

INTIMATE CARE CAN BE A FRIGHTENING EXPERIENCE

  1. Reality Confrontation – exposing a confused person to the upsetting reality that they are unwell and in hospital can distress them, explaining that a loved one has passed away will just make them relive the painful memory over again.
  2. Alarm – abrupt or sudden approaches to a person who is poorly sighted/hard of hearing as well as confused, especially if from behind or involving unexpected physical contact.
  3. Goal Frustration – staff attempting to restrict or control the wishes and choices of the person. Giving instructions to STOP IT or act differently may provoke an aggressive response
  4. Psychosis – aggression may be linked to delusions – fixed false beliefs which cannot be reasoned with eg) that the neighbours are trying to kill them or poison them:

However it is important to remember that delusions may also be misperceptions of their environment or the situation in hand… Which can lead to an aggressive incident.

Ask yourself:
WHAT MIGHT BE THE MEANING BEHIND THE AGGRESSIVE BEHAVIOUR THE PATIENT IS EXHIBITING?

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Understanding Agitation:

AGITATION can be further defined:

  1. Physical Aggressive behaviour – this includes: hitting, kicking, pushing, spitting, biting, scratching, grabbing or clinging onto people, hurting themselves or others, or throwing things.
  2. Verbal Aggressive Behaviour – shouting at others, cursing at others.
  3. Physical non – aggressive behaviour – pacing, restlessness, wandering, repetitious mannerisms, inappropriate disrobing or undressing, hoarding or hiding.
  4. Verbal agitated behaviour – screaming, repeated requests for attention, strange noises and negativism.

(Cohen – Mansfield & Billig 1986)

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Understanding Wandering:

WANDERING can be further categorised into:

  1. Exit seeking behaviour – repeatedly attempting to leave the ward or unit
  2. Modellers – shadowing or following other patients or staff members
  3. Self stimulators – these patients are bored or under stimulated and may pace or wander around the ward or unit
  4. Akathisiacs – these patients are restless as a side effect of certain medications

(Lawlor 1995) 

Ask yourself:
WHAT TYPE OF SPECIFIC AGITATION OR WANDERING IS THE PATIENT EXHIBITING?

Section 4 – Responding to Behaviour

General Communication Approaches

Pie Chart of communication approaches

Communication:

  • What people remember most in our communications is body language and tone of voice, not the words that you are saying.
  • Positive communications usually receive a positive response.
  • Remember, people with dementia will reflect the mood behaviour of others.
  • When caring for a person with dementia who is having difficulty communicating, remember they will pick up on negative body language such as sighs & raised eyebrows.

Make sure that you can be seen & heard:

  • Make sure the hearing aid is on (if applicable)
  • Stand in front of the person where they can see you
  • Face the person directly so they can see your facial expression and mouth
  • Place yourself at eye level when talking or listening
  • Identify yourself by name
  • Use the person’s name
  • Try to keep calm & relaxed

Make the communication simpler & easier to understand:

  • Use gestures, pictures and/or signs to explain or express things
  • Avoid talking over/across/about the person with dementia or delirium
  • Speak gently & clearly at an even pace – avoid shouting
  • Ask one question at a time
  • Use names of people and places instead of pronouns: e.g; Jack, our neighbour,    or Major, our dog.
  • Use a statements rather than a question
  • Wait for a response before continuing
  • Explain what you are going to do & what you are doing
  • Repeat or rephrase your message if there is no response
  • Talk normally: they will understand how you are feeling, even if they are not aware of what you say.
  • Use hand gestures & facial expressions such as smiles to reinforce your words
  • Allow for the time a damaged brain takes to process messages
  • Show your concern with reassurance & acceptance
  • Give praise when it’s appropriate
  • Respond to the feelings expressed by the person
  • When talking in a group, place the person so that the conversation is around them and they won’t feel ‘left out’
  • Make it easy to join in conversation by asking questions that only need a ‘yes’ or ‘no’ answer
  • Arguments over mistaken ideas should be avoided: e.g.; If the person insists they have seen a TV program a million times before even though it is a first run say: “Oh well, I don’t think I’ve seen it before. It’s interesting isn’t it?”
  • Touching enhances feeling of security: especially if the person is upset.

Section 5 – Top Ten Tips for dealing with people who are confused

  1. STOP!!
    Think about what you are about to do and consider the best way to do it. PLAN AND EXPLAIN – Who you are; What you want to do; Why you want to do it etc
  2. SMILE!!
    The person who takes their cue from you will mirror your relaxed and positive body language and tone of voice.
  3. GO SLOW!!
    You have a lot to do and you are in a hurry but the person isn’t. How would you feel if someone came into your bedroom, pulled back your blankets and started pulling you out of bed without even giving you time to wake up properly.
  4. GO AWAY!!
    If the person is resistive or aggressivebut is NOT causing harm to themselves or others, leave them alone. Give them time to settle down and approach later.
  5. GIVE THEM SPACE!!
    Any activity that involves invasion of personal space INCREASES THE RISK OF ASSAULT AND/OR AGGRESSION. Every time you provide care for a person you are invading their space.
  6. STAND ASIDE!!
    Always provide care from the side not the front of the person, where you may be a target to hit, kick etc
  7. DISTRACT THEM!!
    Talk to the person about things they enjoyed in the past and let them hold a towel etc whilst you are providing care.
  8. KEEP IT QUIET!!
    Check noise level and reduce it when and where possible. Turn off the radio and TV etc.
  9. DON’T ARGUE!!
    They are RIGHT and you are WRONG! The brain tells the person they can’t be wrong.
  10. KNOW THE PERSON!!
    Orientate to their surroundings as necessary. If they become upset by this reality validate their feelings instead continuing to cause upset by this truth.

Adapted from the Regional Dementia Management Strategy (Australia 2001)

Section 6 – DOs & DONTs of Communication

DO

DON’T

Talk to the person in a tone of voice that conveys respect and dignity.

Talk to the person in ‘baby talk’ or as if you are talking to a child.

Keep your explanations short. Use clear and flexible language.

Use complicated words or phrases and long sentences.

Maintain eye contact by positioning yourself at the person’s eye level.

Glare at, or “eyeball” the person you are talking too.

Look directly at the person and ensure that you have their attention before you speak. Always begin by identifying yourself and explain what it is you propose to do.

Begin a task without explaining who you are or what you are about to do. Talk to the person without eye contact, such as while rummaging in a drawer to select clothing.

Use visual cues whenever possible.

Try and compete with a distracting environment.

Be realistic in expectations.

Provoke a catastrophic reaction through unrealistic expectations or by asking the person to do more than one task at a time.

Observe and attempt to interpret the person’s non-verbal communication.

Disregard your own non verbal communication.

Paraphrase and use a calm and reassuring tone of voice.

Disregard talk that may seem to be “rambling”.

Speak slowly and say individual words clearly. Use strategies to reduce the effects of hearing impairment.

Do not shout or talk too fast.

Encourage talk about things that they are familiar with.

Interrupt unless it cannot be helped.

Use touch if appropriate.

Attempt to touch or invade their personal space if they are showing signs of fear or aggression.

Adapted from the Regional Dementia Management Strategy (Australia 2001)

Section 7

Content to this Section will be added soon

Section 8

By now you should have a very clear idea of what went wrong with Ted and how this could have been avoided.

Write a reflection on this for your portfolio.