Agitation and Possible Delirium in an Older Adult
Mrs. Bianchi, 79, has mild dementia and was admitted to a psychiatric unit for depression with psychotic features. On day 3 she becomes acutely confused overnight, pulling at her IV line and calling for her deceased husband. She is disoriented to time and place, sweaty, and her hands tremble. She takes oxybutynin for urinary urgency, has a new order for hydroxyzine as needed for anxiety (given twice yesterday), and was started on an antidepressant 3 days ago. She has not had a bowel movement in 4 days and is drinking little. The aide says, 'This is just her dementia getting worse, we should give the PRN hydroxyzine and let her sleep.'
1. Assess the aide's plan and identify the most likely explanations for the change.
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The aide's plan is unsafe. Acute onset overnight, fluctuating confusion, sweating, tremor, and visual-type misperceptions in an older adult point toward delirium rather than a stepwise worsening of dementia. Dementia changes gradually; delirium develops over hours to days and is a medical emergency.
Several contributors are plausible here. Anticholinergic burden is high: oxybutynin is strongly anticholinergic, hydroxyzine adds anticholinergic and sedating effects, and the combination in a 79-year-old with dementia is a recognized delirium risk. Constipation of 4 days and poor fluid intake raise concern for impaction or dehydration, and a new antidepressant can cause hyponatremia or other disturbances. Infection, pain, and urinary retention also belong on the list. Giving more hydroxyzine would likely worsen the delirium and increase fall risk. The priority is a medical evaluation, not sedation.
2. Describe your immediate nursing actions and the information you would gather before the provider calls back.
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I would ensure safety first: stay with her or arrange continuous observation, lower the bed, use a low bed or mat if available, and remove the IV line from her reach if it is no longer essential, coordinating with the nurse. I would obtain a full set of vital signs including temperature and oxygen saturation, check a fingerstick glucose, assess for pain and urinary retention, and perform a focused review of medications and last bowel movement.
I would gather the medication administration record, the time of onset, a baseline cognitive description from family or prior notes, intake and output, and any recent laboratory results. Then I would call the provider with a structured report: what changed, when, the vital signs, the medication concerns including anticholinergic load, and the constipation and hydration issues. I would request orders for laboratory studies, a urinalysis, and medication review, and I would document the findings and the escalation. Nonpharmacologic measures such as reorientation, glasses and hearing aids, lighting, and family presence should be started now.
3. The provider orders the PRN hydroxyzine again for agitation. How do you handle this?
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I would not simply administer it. I would express my concern directly and specifically: the agitation is likely delirium, hydroxyzine is anticholinergic and sedating, and adding it risks worsening the confusion, prolonging the episode, and increasing falls. I would ask the provider to reconsider and propose alternatives such as treating the underlying cause, nonpharmacologic measures, and if medication is truly needed, a lower-risk agent at the lowest effective dose for the shortest time.
If the provider maintains the order, I would clarify the indication and parameters, administer only if the clinical situation meets them, monitor closely for worsening confusion and sedation, and document the discussion and my concerns. I would also raise the pattern with the charge nurse or pharmacy so the medication regimen is reviewed. Administering a drug I believe is harmful without raising the issue would be a failure of advocacy.