Night shift part 2: Confusion in patients

Check out part 1 where I talk about the general good and bad of working night shift here.

Talking about the patients at night is a whole new discussion. There are a handful of difficulties and patterns I've noted over the years, mostly just in the very sick/elderly patients. For example, if a patient passes away at night, it almost always seems to happen between 3 and 6am. I don't know if I'm the only person that thinks that or not, but most of the time in my experience, they seem to pass around the same time... Other patterns include that vitals are usually more likely to be abnormal, I often have to apply oxygen to someone who didn't need it during the day, and depression or anxiety are intensified in some patients because they are bored or lonely with family gone and staff scarce. Pain is often more severe, possibly because of the decrease in distractions. But none of this compares to the two great night shift monsters, discussed next.

At night, older patients, especially ones with certain conditions or who have been hospitalized for a while, often experience a form of confusion that is commonly referred to as sundowning and sunrising. Around the times of sunset and/or sunrise, patients can sometimes go from completely oriented and "with it" to violent and fully confused. They forget where they are, who we are, what's going on, etc. They often will hallucinate, asking about someone standing in the room who isn't there or suddenly announcing they need to finish grocery shopping and trying to leave the room. They may become intensely paranoid and anxious, believing they are being kidnapped and held against their will. There have been quite a few times where our patients have actually called 9-1-1 to report they are being held hostage... When that happens, the police department typically calls the front desk to check in, knowing it's most likely a confused patient. I've seen the sweetest, most respectful patients turn into monsters at night, including towards their own family, and then have little or no memory of it in the morning. Oftentimes, any rapport I establish with the patient may be lost, as they completely forget who I am. They will often refuse treatments or medications in this state because they don't trust us or what we're doing or giving them.

There are different levels of confusion in these cases. There's defiant or rude but calm, where they insult you or treat you rudely, but do not become physically aggressive at all. There's "pleasantly confused", where they are saying things that make no sense but are still kind and even endearing. There's impulsive or restless, where they aren't necessarily angry or rude but repeatedly try to get out of bed, pull IV lines out, remove heart monitors, etc. There are "screamers", who literally just scream about the tiniest things. And then there's violent and physically aggressive, which sometimes results in calling security, restraints, or anti-anxiety medicines. The violence in this type of confusion can range from spitting at you to pushing you away when you're nearby to literally kicking, biting, and throwing things at you. One of our patients once picked up his walker and threw it against the window in his room, hoping to break it and escape. Another patient threw his entire IV pole at staff. I've personally been spat on, bitten, scratched, and punched. Where I work, we go through annual training courses on deescalation tactics and safety measures for these cases, we have staff members and cameras specifically designated as monitors for impulsive behavior, we have panic buttons we can take into a room with us for quick back-up, and there is a dedicated response team consisting of security, behavioral health specialists, doctors, and administration that can be called on the emergency line. Still, no matter how prepared you try to be, sometimes you get caught off-guard, especially in sundowning patients because the change in behavior is often abrupt, dramatic, and unexpected.

Over the years, I've learned several strategies that can help with managing confusion. No strategy works on everyone, and sometimes you have to do some trial and error to see what they respond to. One is leaving the patient and coming back later (as long as they are safe). Delirium often waxes and wanes over time, unless it's their baseline due to, for example, advanced dementia, so sometimes coming back later does help. Another thing that has worked for me a couple times in patients with paranoid confusion who have good family relationships is asking them "Do you trust your son?" When they reply yes, I assure them "Your son brought you to us because he believed we could give you the care you need, so if you trust him, can you try to trust us?" Sometimes this works, sometimes it doesn't. Another tactic is distraction. Turning on the television, asking the patient about their loved ones, providing puzzles or coloring books to work on, and offering food have all worked as distractions in my experience. Some patients will actually respond to logic, surprisingly, like explaining the negative impacts or dangers of refusing a treatment. I've also learned to get all the meds and assessments done early and quickly for patients who are known to be sundowners. And probably one of the most effective strategies for managing confusion or agitation is getting family involved. A lot of times, family members leave their numbers or stay the night, and if the patient is at risk of harm for refusing an intervention, it can help to ask the family member to talk to them about it. Sometimes I'll call a family member, apologize for waking them up, tell them what's going on and why the intervention we are attempting is necessary, and then just hand the phone to the patient. This works surprisingly often. A lot of times, the familiar voice is grounding for patients who are confused.

One thing is for sure though. Confused patients often provide great conversation starters (as long as privacy is maintained), and they certainly help us stay awake when we're getting sleepy! For the most part, unless the patient is suffering from certain severe illnesses or advanced dementia, these episodes tend to be temporary. Sometimes it isn't until they are discharged that they return to normal, but the important thing is keeping them safe and helping them make it through the experience with as much dignity as possible (i.e. tying closed the gown of a wandering patient). It is also important to educate the family about delirium in hospitals, because oftentimes it's a completely different side of the person they've never seen, and that can be pretty scary. Remember that family members are our "patients" too.

Check out my silly story about a patient's experience with an episode of delirium here for a great example of what I'm talking about.

• Bella, RN