Why Older Adults at High Risk of Deterioration Exhibit Rule-Breaking Behavior in Hospitals
Older adults break rules in hospitals primarily because they are experiencing delirium—an acute confusional state that occurs in approximately 25% of hospitalized geriatric patients and directly causes disordered attention, altered consciousness, and behavioral disturbances including agitation, wandering, and non-adherence to safety protocols. 1
Understanding the Core Problem: Delirium vs. Dementia
The "rule-breaking" behavior you observe is almost always a manifestation of hospital-acquired delirium, not willful non-compliance. 1, 2
Key distinguishing features:
- Delirium: Acute onset, fluctuating course throughout the day, disordered attention and consciousness, often with hallucinations 1, 2
- Dementia: Insidious onset, constant course, generally preserved attention and consciousness until advanced stages 1
Critical pitfall to avoid: Never assume confusion or behavioral problems are "just dementia" or "just old age"—delirium is a sensitive sign of serious underlying physical illness requiring immediate investigation. 2
Why This Leads to Clinical Deterioration
Delirium directly causes worse outcomes:
- Increased mortality and morbidity 1
- Extended hospital length of stay 1
- Lasting functional decline requiring nursing home placement 1
- Worse cognitive and functional recovery 1
- Higher risk of falls, device removal, and self-harm 2
The behavioral manifestations (rule-breaking) include:
- Pulling out IV lines, catheters, or monitoring devices 2
- Attempting to leave the bed or unit unsupervised 1
- Refusing medications or treatments 1
- Agitation and combativeness with staff 1, 2
- Non-adherence to safety precautions 1
Underlying Causes of Delirium in Hospitalized Older Adults
Most common precipitating factors requiring immediate investigation: 1, 2
Infections (most common):
Medications (major contributor):
Metabolic derangements:
Environmental factors:
Risk Factors That Predict Which Patients Will Deteriorate
Patients at highest risk for delirium and subsequent deterioration: 1, 3
- Cognitive impairment at baseline: 66% of patients with MMSE ≤27 develop behavioral problems during hospitalization, compared to only 31% with scores >27 3
- Pre-existing dementia (often undetected) 1
- Polypharmacy (>3 medications daily) 1
- Functional dependence (requiring help with ADLs) 1
- Recent hospitalization (within 6 months) 1
- Sensory impairments (vision, hearing) 1
- History of falls 1
Immediate Management Algorithm
Step 1: Screen and Diagnose
- Apply the two-step delirium screening: Delirium Triage Screen followed by Brief Confusion Assessment Method (bCAM) 1, 2
- Reassess regularly as symptoms wax and wane throughout the day 1, 2
Step 2: Investigate Reversible Causes
Obtain immediately: 2
- Complete blood count
- Comprehensive metabolic panel
- Urinalysis with culture
- Chest X-ray
- EKG
- Blood cultures if fever or sepsis suspected
Start empiric broad-spectrum antibiotics if systemic sepsis criteria are met, even before organism identification 2
Step 3: Medication Reconciliation
Immediately discontinue or reduce: 1, 2
- Anticholinergic medications
- Sedative/hypnotics
- Antipsychotics (unless treating delirium itself)
- Vasodilators
- Diuretics
Step 4: Environmental and Non-Pharmacological Interventions (First-Line)
Implement before considering medications: 2
- Adequate lighting with visible clocks and calendars for orientation 2
- Calm tones and simple commands 2
- Regular family visits 2
- Remove bedrails, use bed/chair alarms and video monitoring instead 2
- Rubber or nonskid floor surfaces 2
- Avoid physical restraints—they paradoxically increase agitation, delirium duration, and risk of harm 1, 2
Step 5: Pharmacological Management (Only When Necessary)
Reserve for severe agitation with imminent risk of harm after behavioral interventions fail: 2
- First-line: Haloperidol 0.5-1 mg PO/IM/SC 2
- Avoid benzodiazepines except for alcohol or benzodiazepine withdrawal—they increase delirium incidence, duration, and respiratory depression risk 2
Why Physical Restraints Make Things Worse
Critical evidence: Physical restraints are strongly discouraged because they: 1, 2
- Paradoxically increase agitation and delirium severity 1, 2
- Lead to more unplanned extubations and device removal 2
- Increase risk of pressure ulcers and functional decline 1
- May require sedation to apply, which further worsens delirium 1
The American Geriatrics Society explicitly recommends avoiding physical restraints to manage behavioral symptoms in hospitalized older adults with delirium. 1
Staff Burden and System Implications
Behavioral problems create significant staff distress: 3
- The severity of behavioral problems correlates directly with staff distress levels 3
- These patients require increased staffing (sitters), restraints, or psychiatric consultation 1, 3
- They consume more healthcare resources and have longer lengths of stay 1
Screening at admission identifies high-risk patients: Using validated tools like the ISAR (Identification of Seniors at Risk) allows early intervention before deterioration occurs. 1 Patients with ≥1 positive response require case management referral and next-day follow-up. 1
Prevention Strategy
For all hospitalized older adults, implement: 1, 4
- Routine cognitive screening at admission to establish baseline 1, 4
- Medication reconciliation focusing on high-risk drugs 1, 4
- Fall risk assessment 1
- Orthostatic blood pressure measurement 1
- Assessment of functional status and ADL dependencies 1, 4
- Early mobilization and physical therapy consultation 2
Delays in identifying and treating delirium result in prolonged duration, worse cognitive and functional recovery, and higher inpatient morbidity and mortality. 1 The key is recognizing that "rule-breaking" behavior signals an acute medical emergency requiring comprehensive evaluation, not a behavioral problem requiring punishment or restraint.