Management of Confused Elderly Patients Attempting to Get Out of Bed

Non-Pharmacologic Interventions

The American College of Emergency Physicians recommends prioritizing 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
Optimize lighting with soft, natural light exposure combined with ambient and spot lighting to reduce confusion and improve visual clarity in elderly patients 2, 1
Provide clearly visible clocks and calendars for reorientation to aid navigation in confused elderly patients 3
Implement frequent reorientation by explaining location, identity of staff, and current situation to reduce confusion in elderly patients 3
The American Heart Association recommends facilitating regular family visits to promote orientation and sense of security in elderly patients 3

Remove bedrails, as they do not reduce falls and may increase fall severity in elderly patients 2, 1
Select furniture with sturdy armrests to facilitate safe transfers in elderly patients 1
The American Academy of Neurology recommends using extra thick/soft mattresses or considering reclining chairs instead of gurneys to reduce fall severity in elderly patients 2, 1
Implement bed/chair alarms and video monitoring to ensure safety in elderly patients 4

Screen for delirium using validated tools, such as the Brief Confusion Assessment Method (bCAM) or Confusion Assessment Method for ICU (CAM-ICU), to identify delirium in elderly patients 5, 6
Distinguish delirium from dementia by identifying acute onset, fluctuating course, and disordered attention/consciousness in elderly patients 5
Address common reversible causes of delirium, including infections, medications, metabolic derangements, dehydration, and electrolyte imbalances, to improve outcomes in elderly patients 5, 6, 4

The American Geriatrics Society recommends using chemical restraints only when non-pharmacologic interventions have failed and the patient poses imminent danger to themselves or others 1, 5
Antipsychotic agents may be considered for short-term use only in elderly patients with delirium 4

Never use physical restraints routinely, as they paradoxically increase unplanned extubations, device removal, agitation, and delirium in elderly patients 7
Avoid assuming confusion is "just dementia" and always assess for acute delirium with reversible causes in elderly patients 5, 6
Do not use bedrails thinking they prevent falls, as evidence shows they increase fall severity in elderly patients 2, 1
Avoid benzodiazepines as first-line sedation in elderly confused patients due to risk of respiratory depression and paradoxical agitation 4

Ensure care by a consistent team familiar with the patient to avoid disorientation from frequent staff changes in elderly patients 3
Implement early mobilization with short, frequent exercise sessions to improve outcomes in elderly patients 4
Provide physiotherapy and postural training to reduce fall risk in elderly patients 4
Regulate sleep/wake cycles and maintain day/night orientation to improve outcomes in elderly patients 4

The American College of Cardiology and other guideline societies recommend a multicomponent nonpharmacologic approach to delirium prevention, which has been proven to reduce delirium incidence by approximately one-third without the risks associated with pharmacologic interventions or physical restraints 8, 9, 10.

The NICE guidelines and Critical Care Medicine guidelines strongly recommend implementing multicomponent nonpharmacologic interventions within 24 hours of hospitalization, which improve mortality and quality of life, and reduce delirium incidence significantly (OR 0.59; 95% CI 0.39-0.88) 8, 11.
Temporal orientation with a clearly visible clock and calendar at the bedside can address cognitive impairment and disorientation, and is recommended by the American College of Internal Medicine 8, 11, 12.
Environmental optimization, including appropriate lighting and minimizing noise during sleep periods, can help reduce confusion and delirium incidence 8, 13.

The 2018 Critical Care Medicine guidelines explicitly recommend against routine use of haloperidol for treating delirium, as it does not reduce delirium duration, mechanical ventilation time, ICU length of stay, or mortality, and carries risks including extrapyramidal side effects, QTc prolongation, and increased mortality risk 14.
Atypical antipsychotics like olanzapine are not indicated for delirium prevention, and evidence shows they do not reduce delirium duration or improve outcomes when used to treat established delirium, and carry risks of sedation, metabolic effects, and paradoxical worsening of confusion in elderly patients with dementia 12, 14.

A comprehensive assessment of modifiable delirium risk factors should be conducted within the first 24 hours of admission, including infection control, hydration status, medication review, oxygenation, sleep hygiene, and bowel and bladder function 8, 11, 13.
The multicomponent approach to delirium prevention is both clinically effective and cost-effective, reducing costs while increasing quality-adjusted life-years, with an incremental net monetary benefit of £2,200 for medical patients 8.