Hi, Kathleen! To me it seems that you already have a suggestion for an intervention, that is "using different devices... " What I find a bit confusing is your combination of the terms agitation and delirium. Do you specificially want to address delirium in dementia, or is your focus more on agitation in general (that is, a part of the dementia syndrome)?

If you want to address agitation as part of the neuropsychiatric symptoms in dementia, you will probably find several studies that have used the same approach. On the other hand - this approach in delirium is probably a novel approach, although probably not advisable; there are numerous other strategies that should be used before devices or toys in delirium.

As you may be aware of there is an ongoing debate on the understanding of the concept "agitation", and International Psychogeriatric Association's attempt to define the syndrome of agitation may be of interest to you. In this definition agitation is clearly a symptom of dementia, whereas delirium may or may not be co-existant:

Cummings et al. Agitation in cognitive disorders: International Psychogeriatric

Association provisional consensus clinical and research

definition Int Psychogeraitrica January 2015.

Good luck!

I would suggest to explore non pharmacological approches (NPA) to pshycological and behavioral symptoms of dementia (Gitlin, Algase); also NPA for the prevention of Delirium (Inouye). 

Best.

Jean

Agitation is often a subtle matter.  It manifests as pacing, increase in restless leg syndrome, circular questions (eg. "where are we?" several times over a brief period).  Unaddressed this often leads to the more combatitive obvious forms of agitation.  

For decades I give propranolol on a routine basis (10-80mg bid - tid) to control baseline anxiety/agitation in demented patients.  To this I add a prn 20-40mg when the soft forms of Agitation appear.   I note that the staff or family have to be trained to look for the early signs of agitation.

Propranolol is the only CNS penitrating Beta Blocker.  Thus, other beta blockers are in my hands ineffective.  The dose range is quite variable, but typically 40mg bid to tid.  The highest required to control agitation in an elderly demented patient was 880 mg per day !  It is a remarkably safe agent. 

Incidentally, do not try to mix minor tranqulizers or major neuroleptics with the propranolol.  It does not work.  The tranqulizers lead to confusion and often gait disturbance,  while propranolol leaves clear sensorium and calmness.

I suggest Summers, WK. Use of propranolol in management of agitated demented

patients: safety and effectiveness. Journal of Alzheimer’s Disease. 2006; 9:69 -75.  

Hope this helps

I'm currently doing a project on music intervention and dementia.  Research studies showed preferred music helps decrease agitation and anxiety.  I created a brochure as a guide for caregivers using music intervention as a tool in caring for older adults with dementia.  I hope  you'll give this a try.  Music intervention has little or no side effect compared to pharmacological intervention.  Always check for the reaction to the music.

In terms of environmental ques, the music is a good idea.  To this you might add an aquarium

I'd suggest screening carefully for pain, as those with untreated pain can become agitated. 

The management of cognitive issues in the acute hospital can be very difficult for the bed side nurse. The constant noise, change of staff and clinical interventions will all esclate any behaviours. My experience has been to try to assign the same staff to the patient across the shifts, discuss medical mangement with the medical officers and reduce all clinical interventions especially IV (and especially all IV alarms) and IDC. Analgesia before all interventions including showering, mobility. Have the staff maintain the same daily routine, including, sitting out of bed for ALL meals especially breakfast, only washing the patient as and when they desire (ask family for patient norms) and a rest period after lunch is essential but ensure the patient is sat up off the bed for afternoon tea. Do not put the patient to bed too early and always when the noise and activity in the area has reduced as all stimulation in the area will re-activate agitation. The playing of  the patients favourite background music is helpful (ask family) but again must be done with attention to the patient as some of the recommended interventions for the management of the confused older patient, can esclate the situation if not done by trained staff who are monitoring for the patient reactions.

    The idea that I can add are from observation from my parents who had agitation and hallucination at periods later in life from various causes.  Mother had multi infarct dementia with "normal" pressure hydrocephalus which was corrected with a shunt.  Father had a stroke, but the hallucination was a bad reaction to a drug given to him.

    What worked: gently get "into" the hallucination or agitated behavior and try to walk them to a different place.  Example: Dad saw his late father sitting in the corner of the room crying.  I went over to that corner, and bent over then returned to his bedside and said it's okay now Dad, he feels better and went to get a coffee.  He settled down with a sigh.  To have told him that his father was not there would have increased his distress and not worked.  There will be a point where this distraction technique will not work and you might go from one thing to another but for a while it can help.

Kathleen-

There is an evidenced based practice called "Simple Pleasures" developed by Linda L. Buettner, CTRS, Ph.D. while at the Decker School of Nursing, Binghamton University and Doreen B. Greenstein, Ph.D.  while at the Agricultural Engineering program at Cornell University. "Simple Pleasures" consists of 23 researched activities (e.g., activity aprons, wave machine, sensory stimulation box, etc.) that have been proved to positively impact those with Alzheimer's dementia.  These activities are low cost and community volunteers can make these items (e.g., scout troops, 4-H groups, etc.). Directions are included regarding how to make each activity.  The work was funded by the New York State Department of Health & you can access this program @ .

Hope this is helpful.

-Susan

Encourage family members to stay with patient 24/7 while in hospital.to provide comfort, prevent falls, and to avoid unnecessary/harmful pharmacologic restraints (sedatives/hypnotics to control behavior and "agitation").

Get patient out of hospital as quickly as feasible.

Avoid hospitalization in the first place if possible.

NICHE (Nurses Improving Care for Healthsystem Elders) program

http://www.nicheprogram.org/