What is the best intervention to improve symptoms of confusion and evening agitation in a patient?

Management of Confusion and Evening Agitation

The best intervention for confusion and evening agitation is a multicomponent, nonpharmacologic approach focused on reducing modifiable risk factors, improving cognition, and optimizing sleep, mobility, hearing, and vision, with pharmacologic management reserved for refractory cases. 1

Initial Nonpharmacologic Interventions

Address Reversible Causes First

• Identify and treat underlying causes of confusion/agitation:
  • Hypoxia, urinary retention, constipation 1
  • Medication side effects (reduce or eliminate delirium-inducing medications like steroids, anticholinergics) 1
  • Pain, infection, metabolic disturbances

Environmental Modifications

1. Orientation strategies:

   • Ensure effective communication and orientation (explain where the person is, who they are, who you are) 1
   • Use clocks and calendars for temporal orientation 1
   • Provide cognitive stimulation during daytime hours 1

2. Sleep hygiene optimization:

   • Ensure adequate lighting during day and reduced lighting at night 1
   • Minimize nighttime noise and disruptions 1
   • Cluster care activities to allow uninterrupted rest periods (optimal uninterrupted periods: 2-4 AM) 1

3. Sensory interventions:

   • Ensure patients have access to hearing aids and eyeglasses if needed 1
   • Music therapy has shown the greatest efficacy among sensory interventions for reducing agitation 2
   • Consider aromatherapy and massage as additional options 2

4. Physical activity:

   • Implement early mobilization/rehabilitation when appropriate 1
   • Scheduled physical exercise during daytime hours 2

Pharmacologic Management (for Refractory Cases)

For Anxiety or Agitation (Patients Able to Swallow)

• Lorazepam 0.5-1 mg orally four times daily as needed (maximum 4 mg/24 hours)
• Reduce dose to 0.25-0.5 mg in elderly or debilitated patients (maximum 2 mg/24 hours) 1

For Delirium with Agitation (Patients Able to Swallow)

• Haloperidol 0.5-1 mg orally at night and every 2 hours as needed
• Increase dose in 0.5-1 mg increments as required (maximum 10 mg daily, or 5 mg daily in elderly patients)
• Consider higher starting oral dose (1.5-3 mg) if severely distressed or causing immediate danger 1
• Consider adding a benzodiazepine if the patient remains agitated despite antipsychotic treatment 1

For Patients Unable to Swallow

• For anxiety/agitation: Midazolam 2.5-5 mg subcutaneously every 2-4 hours as needed
• For delirium: Levomepromazine 12.5-25 mg subcutaneously (use 6.25-12.5 mg in elderly patients) 1
• Consider subcutaneous infusion if medications needed frequently (more than twice daily) 1

Special Considerations

Monitoring Requirements

• Monitor for excessive sedation, extrapyramidal symptoms, and orthostatic hypotension 3
• Reduce midazolam dose to 5 mg over 24 hours if eGFR <30 mL/minute 1
• Monitor for QT interval prolongation with antipsychotics, especially in patients with cardiac risk factors 3

Combination Therapy Considerations

• When using both benzodiazepines and antipsychotics, start with lower doses of both medications 3
• Consider midazolam alone or in combination with levomepromazine if the patient has both delirium and anxiety 1

Caregiver Support

• Educate caregivers on how they can help manage confusion and agitation 1
• Explain the importance of maintaining routine and using simple, clear communication techniques 3
• Provide support for caregivers coping with this distressing condition 1

Implementation Algorithm

1. Daytime management:

   • Ensure adequate lighting and cognitive stimulation
   • Implement scheduled physical activity
   • Maintain orientation with frequent reorientation cues
   • Ensure hearing aids and glasses are available if needed

2. Evening/nighttime management:

   • Reduce environmental stimuli (dim lights, reduce noise)
   • Establish consistent bedtime routine
   • Implement music therapy 30-60 minutes before bedtime
   • Cluster necessary care activities to minimize disruptions

3. For breakthrough agitation:

   • First attempt nonpharmacologic de-escalation techniques
   • If unsuccessful, implement appropriate pharmacologic intervention based on swallowing ability and severity of symptoms
   • Monitor response and adjust intervention as needed

By implementing this comprehensive approach, clinicians can effectively manage confusion and evening agitation while minimizing the risks associated with pharmacologic interventions.