What to give an elderly patient in the hospital with confusion and attempting to get out of bed?

Management of Confused Elderly Patients Attempting to Get Out of Bed

Prioritize non-pharmacologic environmental and behavioral interventions over chemical or physical restraints, as physical restraints do not reduce falls and may increase fall severity and agitation, while chemical restraints should be reserved only for situations where they are absolutely necessary. 1

Immediate Non-Pharmacologic Interventions (First-Line)

Environmental Modifications

• Optimize lighting with soft, natural light exposure combined with ambient and spot lighting to reduce confusion and improve visual clarity 1
• Reduce glare using light-colored walls with matte sheen and low-glare flooring 1
• Provide clearly visible clocks (24-hour format preferred) and calendars for reorientation 1
• Use enhanced signage and color contrast to aid navigation 1
• Minimize background noise using sound-absorbing materials (carpet, curtains, ceiling tiles) 1

Cognitive and Behavioral Interventions

• Implement frequent reorientation by explaining location, identity of staff, and current situation 1
• Provide cognitively stimulating activities such as reminiscence therapy 1
• Facilitate regular family visits to promote orientation and sense of security 1
• Consider having a family member stay with the patient rather than using restraints 1
• Use portable hearing assist devices if hearing impairment is present 1

Safety Measures Without Restraints

• Remove bedrails, as they do not reduce falls and may increase fall severity 1
• Select furniture with sturdy armrests to facilitate safe transfers 1
• Use extra thick/soft mattresses or consider reclining chairs instead of gurneys 1
• Implement bed/chair alarms and video monitoring 1
• Provide direct supervision or sitters rather than physical restraints 1

Identify and Treat Underlying Delirium Causes

Systematic Assessment

• Screen for delirium using validated tools: Brief Confusion Assessment Method (bCAM) or Confusion Assessment Method for ICU (CAM-ICU) 1, 2
• Distinguish delirium (acute onset, fluctuating course, disordered attention/consciousness) from dementia (insidious onset, constant course) 1

Common Reversible Causes to Address

• Infections: particularly urinary tract infections and pneumonia 1, 2
• Medications: review and discontinue anticholinergics, sedative/hypnotics, antipsychotics, and other high-risk medications 1, 2
• Metabolic derangements: hypoglycemia, hyponatremia, hypoxia 1
• Dehydration and electrolyte imbalances 1
• Urinary retention: assess post-void residual 1
• Pain: use appropriate pain management 1
• Constipation: prophylactic stool softeners 1

Diagnostic Workup

• Orthostatic blood pressure assessment 1
• EKG, complete blood count, electrolyte panel 1, 2
• Urinalysis and blood cultures if infection suspected 2
• Medication levels for relevant drugs 1

Pharmacologic Interventions (Last Resort Only)

When Chemical Restraint is Absolutely Necessary

Chemical restraints should only be used when non-pharmacologic interventions have failed and the patient poses imminent danger to themselves or others. 1

• Antipsychotic agents may be considered for short-term use only 1
• Avoid benzodiazepines in elderly patients due to risk of paradoxical agitation, respiratory depression, and worsening confusion 3
• If benzodiazepines must be used (e.g., alcohol withdrawal), lorazepam dosing in elderly should not exceed 2 mg initially, with extreme caution in patients over 50 years 3

Critical Pitfalls to Avoid

• Never use physical restraints routinely—they paradoxically increase unplanned extubations, device removal, agitation, and delirium 1
• Do not rely on clinical impression alone; use structured delirium screening tools as delirium is frequently missed 2
• Avoid assuming confusion is "just dementia"—always assess for acute delirium with reversible causes 1, 2
• Do not use bedrails thinking they prevent falls—evidence shows they increase fall severity 1
• Avoid benzodiazepines as first-line sedation in elderly confused patients due to risk of respiratory depression, prolonged sedation (24-48 hours), and paradoxical agitation 3
• Do not overlook depression, which can present with cognitive symptoms in older adults 2

Multidisciplinary Approach

• Ensure care by a consistent team familiar with the patient to avoid disorientation from frequent staff changes 1
• Avoid moving patients between rooms or wards unless absolutely necessary 1
• Implement early mobilization with short, frequent exercise sessions 1
• Provide physiotherapy and postural training 1
• Regulate sleep/wake cycles and maintain day/night orientation 1