Sundowning & Delirium
Francisco Fernandez, M.D., USF Health,
Department of Psychiatry, Tampa, FL
www.thecjc.org
Sundowning: Definition
• Sundowning  a group of behaviors occurring in
some older patients with or without dementia at the
time of nightfall or sunset.
• BEHAVIORS:
•
•
•
•
•
Confusion
Anxiety, agitation, or aggressiveness
Psychomotor agitation (pacing, wandering)
Disruptive, resistance to redirection
Increased verbal activity
• Overlap with dementia, delirium, and sleep
disturbance.
Epidemiology of Sundowning
Syndrome
• Not uncommon phenomenon
• Exact prevalence unknown
• Reports have ranged between
2.4% and 25%
• In patients with Alzheimer’s disease
or dementia, the range is widened up
to 66%
Risk Factors for Sundowning:
Physiologic Factors
• Circadian abnormalities in elderly and in
patients with Alzheimer’s disease progress
concomitantly with their behavioral and
cognitive dysfunction.
• Sundowning is more common in AzD.
• Neurofibrillary tangles found in the hypothalamus of
patients with Alzheimer’s may lead to the behavioral
changes of sundowning through mechanical disruption of
brain tissue.
• Pathologic damage to the suprachiasmatic nucleus
(SCN) is believed to result in disruptive behaviors
associated with sundowning.
Risk Factors for Sundowning:
Environmental Factors
• Amount of daily light
exposure
• Activities during the
day
• Noise level
• Disruptions at night
• Medications
• Medical
comorbidities
• Nursing home residents
with sundowning were
more likely to
•
•
•
•
Recent admission
Moved to a new room
Staff shift changes
Low levels of lighting
during the day and bright
hallway lighting during
the night
• Increased naptime during
daytime hours and
reduced nighttime sleep
Etiology of Sundowning
• Dysfunction of the circadian rhythm result in
disturbed sleep and agitation
• Deterioration of the SCN seen in patients with
Alzheimer’s disease is actively investigated to be
an important factor in the disruption of the
circadian rhythms.
• Suprachiasmatic nucleus volume and cell number
are found to be decreased in those between the
ages of 80 and 100 years.
• Melatonin is found to be decreased in the
cerebrospinal fluid levels of patients with
Alzheimer’s disease.
Mrs. Flabeetz
• 84 yo female, living at
the NH for the last 8
years after a stroke; was
having problems
managing at home
• Axis III: Type II Diabetes
and hypertension
• Active in her NH, using
her walker; also a little
more forgetful and
repetitive, and this has
been getting slowly
worse over the last year
In the ER…
• Came into ER after being
found on the floor of the NH
• Unable to get up and
complaining of L hip and
abdominal pain
• In the ER, very muddled up
& disoriented
• incontinent of foul smelling
urine
• Picking at imaginary things,
scared, and very frightened
Initial work up…
• No fracture on X-ray
• Normal CBC, lytes and
troponins
• CT head shows mild atrophy
& bilateral lacunar infarcts
• Urine collected from foley
inserted shows E. coli;
started ABX
• Admitted to Medicine for
further assessment and
work up of confusion
Alas! It’s been 5 days later, and she’s still not better …
TRANSFER TO PSYCHIATRY!!!!!!!
What would you do?
Is this Delirium? Dementia??
Or something else???
Would you transfer to
Psychiatry Service?
Delirium
• Most common psychiatric disorder in the medically ill
• Point prevalence - 20% of all admissions
• 30% new onset among medical inpatients
• 50% medical and surgical patients > 60 yo
• 89% of patients with known dementia
• Higher prevalence with increasing age, CNS disease,
CABG, and THR
• NOT a benign condition - sign of impending death in
25% cases
• Etiology - multifactorial
Rothschild et al, Arch Int Med 2000; Burns et al, JNNP 2004
Diagnostic Criteria: DSM-IV
• Disturbance of consciousness (reduced
clarity of awareness of environment)
• Reduced ability to focus, sustain or shift
attention
• A change in cognition (memory,
disorientation, language disturbance) or
the development of a perceptual
disturbance that is not better accounted
by dementia
Diagnostic Criteria: DSM-IV
• The disturbance develops over a short
period of time (usually hours to days)
• All abnormalities tend to fluctuate during
the course of the day
Diagnostic Criteria: DSM-IV
•
There is evidence from the medical history,
physical examination, or laboratory findings
of:
1. A general medical condition etiologically related
•
Sepsis, seizures, tumor, hypercalcemia, hypoglycemia
2. Substance induced intoxication or withdrawal
3. More than one etiology
4. NOS
“Motoric” Subtypes
Various levels of psychomotor activity
are associated with delirium:
1. Hypoactive
2. Hyperactive
3. Mixed
Characteristics Hypoactive
Hyperactive
Age
MMSE
Digit span
54.3 (18.7)
13.6 (7.4)
4.1 (2.4)
5.7 (2.4)
59.4 (17.8)
13.2 (7.3)
4.6 (2.2)
5.6 (2.3)
5.4 (2.3)
3%
0%
3%
0%
21%
2.4 (2.0) ***
67% ***
26% ***
50% ***
20%***
72% ***
Clouding of
Consciousness
Somnolence
Hallucinations
Illusions
Delusions
Paranoia
Agitation
Adapted from Ross et al., Int Psychoger 1991
“Motoric” Subtypes
• Subtyping not fully accepted by all
disciplines
• Subtyping may have implications for
treatment
Epidemiology & Risk Factors
• Depending on the cohort, the
prevalence of delirium ranges from 8%
to 80%
• Post-surgical rates > general medical
patients
• Advancing age increases the risk (> 60
yoa)
• 15-20% of patients on a medical
surgical ward have an undetected
delirious process
Burns et al, JNNP 2004; Kales et al, JNNP 2002; vanZyl & Davidson, Can J Psych 2003
Epidemiology and Risk
Factors
• The Commonwealth-Harvard Study
(Levekoff et al., Int Psychoger, 1991)
• Patients 65 yoa or older
• Admissions to Beth Israel Hospital from
Hebrew Rehabilitation Center (n=114) and
East Boston CHC (n=211)
• CHC  24.2% were delirious
• HRC  64.9% were delirious
Epidemiology and Risk
Factors
• CNS abnormality
• Dementia, coexisting structural brain disease,
and HIV-1 infection increase the risk
• Drug dependency
• Alcohol, sedative hypnotics, stimulants, steroid
(rapid taper) increase the risk
• Low serum albumin
• Malnutrition, chronic disease, aging, nephrotic
syndrome, hepatic insufficiency
Why is Delirium important?
Delirium has a poor prognosis
•
•
•
•
•
LOS (>7d more)
 risk dementia dx (55%/2y)
ADL decline
institutionalization
mortality (2.1x/12 mos)
McCusker et al, JAGS 2003; McCusker et al, Arch Int Med 2002;
Rahkonen et al, JNNP; Inouye et al, JGIM 1998
Delirium Risk : A Predictive
model
• Independent risk factors on
admission in a prospective
cohort of elderly medical inpts
1. Vision < 20/70
2. Severe illness (APACHE > 16)
3. MMSE <24
Inouye et al, Ann Int Med 1993
Diagnosis
• Rapid recognition of either prodromal or
fully developed clinical features
• “A,B,C’s” of Neuropsychiatry (Affect, Behavior
and Cognition)
• Prodromal features
• Restlessness, anxiety, irritability, sleeplessness,
hypervigilance, distractibility, fatigue, disinterest,
hypersomnolence, inattentiveness, depressed,
disillusionment
Diagnosing Delirium
Delirium Sx Interview
1. Orientation
2. Sleep disturbance
3. Perceptual disturbance
4. Speech disturbance
5. Disturbance of consciousness
6. Psychomotor activity
7. Affect & behavior
Albert et al, J Ger Psych Neurol 1992
Diagnosis: MSE
• Mental status examination
• Cognitive history  chart review
• What changes (consciousness, restlessness,
anxiety, moodiness)
• When did changes occur (starting/stopping
drug, fever, hypotension, deteriorating renal
function, rhythm changes)
• MMSE, focused NBE
Diagnosis Testing - Standard
MMSE & CDT
-Not designed for delirium
-Useful at separating “normal” from
“abnormal”
-Not specific for distinguishing delirium
from dementia
-May be useful as change from baseline
-Overkill  add TMT-A, TMT-B
Diagnostic Testing: Tools
Sensitivity
• CAM*
•
•
•
•
.46-.92
Delirium Rating Scale .82-.94
Clock draw+
.87
MMSE (24 cutoff) .52-.87
Digit span test
.34
Specificity
.90.92
.82-.94
.93
.76-.82
.90
*validated for delirium & capable of distinguishing
delirium from dementia
+validated for delirium, correlated with deterioration of
dominant frequencies on EEG
1. [Acute Onset] Is there evidence of an acute change in mental status from the patient's
baseline?
2A. [Inattention] Did the patient have difficulty focusing attention, for example, being easily
distractible, or having difficulty keeping track of what was being said?
2B. (If present or abnormal) Did this behavior fluctuate during the interview, that is, tend to come
and go or increase and decrease in severity?
3. [Disorganized thinking] Was the patient's thinking disorganized or incoherent, such as rambling
or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from
subject to subject?
4. [Altered level of consciousness] Overall, how would you rate this patient's level of
consciousness? (Alert [normal]; Vigilant [hyperalert, overly sensitive to environmental stimuli,
startled very easily], Lethargic [drowsy, easily aroused]; Stupor [difficult to arouse]; Coma;
[unarousable]; Uncertain)
5. [Disorientation] Was the patient disoriented at any time during the interview, such as thinking
that he or she was somewhere other than the hospital, using the wrong bed, or misjudging the
time of day?
6. [Memory impairment] Did the patient demonstrate any memory problems during the interview,
such as inability to remember events in the hospital or difficulty remembering instructions?
7. [Perceptual disturbances] Did the patient have any evidence of perceptual disturbances, for
example, hallucinations, illusions or misinterpretations (such as thinking something was moving
when it was not)?
8A. [Psychomotor agitation] At any time during the interview did the patient have an unusually
increased level of motor activity such as restlessness, picking at bedclothes, tapping fingers or
making frequent sudden changes of position?
8B. [Psychomotor retardation]. At any time during the interview did the patient have an unusually
decreased level of motor activity such as sluggishness, staring into space, staying in one
position for a long time or moving very slowly?
9. [Altered sleep-wake cycle]. Did the patient have evidence of disturbance of the sleep-wake
cycle, such as excessive daytime sleepiness with insomnia at night?
Dx Delirium with CAM
http://www.hartfordign.org/publications/trythis/issue13.pdf
1. Acute onset, fluctuating course
AND
2. Inattention
AND EITHER
3. Disorganized thinking
OR
4. Altered level of consciousness
*sensitivity 94 - 100%; specificity 90 - 95%
Inouye et al, Ann Int Med 1990
Diagnostic Testing: EEG
• Diffuse slowing
• Most helpful to get a baseline
• Patients with AzD may have abnormally slowed
EEG
• Worsens from baseline with delirium
• Patients with minimal slowing may have test
read as “normal”
• Alpha (13 cps) may slow down (9 cps) and still be in
normal range
• Comparison with baseline
• Comparison with repeat EEG post delirium
What Causes Delirium?
The Importance of DDx
Differential Diagnosis: Urgent
• When in doubt, throw out the
•
•
•
•
•
•
•
•
•
Wernicke’s
Withdrawal
Hypoxia
Hypoglycemia
Hyper- hypotension
Infection
Intracranial bleed
Meningitis
Poisoning
• Failure to make these diagnoses may lead to permanent
CNS damage
I
WATCH
DEATH
• I Infection: Most
common are
pneumonias & UTI in
elderly, but sepsis,
cellulitis, SBE and
meningitis can also
occur
I
WATCH
• I Infection
• W Withdrawal:
benzodiazapines,
ETOH, opiates
DEATH
I
WATCH
DEATH
• I Infection
• W Withdrawal
• A Acute metabolic:
electrolytes, renal
failure, acid-base
disorders, abnormal
glycemic control,
pancreatitis
I
WATCH
DEATH
• I Infection
• W Withdrawal
• A Acute metabolic
• T Trauma: head injury
(SDH, SAH), pain,
vertebral or hip fracture,
concealed bleed,
urinary retention, fecal
impaction
I
WATCH
DEATH
• I Infection
•
•
•
•
W Withdrawal
A Acute metabolic
T Trauma
C CNS pathology:
tumor, dementia,
encephalitis, meningitis,
abscess
I
WATCH
DEATH
• I Infection
•
•
•
•
•
W Withdrawal
A Acute metabolic
T Trauma
C CNS pathology
H Hypoxia from
COPD exacerbation,
CHF
I
WATCH
DEATH
• I Infection
• D Deficiencies: B•
•
•
•
•
W Withdrawal
A Acute metabolic
T Trauma
C CNS pathology
H Hypoxia
12, folate, protein,
calories, water
I
WATCH
DEATH
• I Infection
•
•
•
•
•
W Withdrawal
A Acute metabolic
T Trauma
C CNS pathology
H Hypoxia
• D Deficiencies
• E Endocrine
thyroid, cortisol, cancer
I
WATCH
DEATH
• I Infection
•
•
•
•
•
W Withdrawal
A Acute metabolic
T Trauma
C CNS pathology
H Hypoxia
• D Deficiencies
• E Endocrine
• A Acute
vascular/MI : stroke,
myocardial infarction
I
WATCH
DEATH
• I Infection
•
•
•
•
•
W Withdrawal
A Acute metabolic
T Trauma
C CNS pathology
H Hypoxia
•
•
•
•
D Deficiencies
E Endocrine
A Acute vascular/MI
T Toxins-drugs
Really anything, but anticholinergics, long acting
benzodiazepines, narcotics
(meperidine) and other
psychotropics are common
bad actors, OTC, OPM
I
WATCH
DEATH
• I Infection
•
•
•
•
•
W Withdrawal
A Acute metabolic
T Trauma
C CNS pathology
H Hypoxia
•
•
•
•
•
D Deficiencies
E Endocrine
A Acute vascular/MI
T Toxins-drugs:
H Heavy
metals (lead,
mercury, platinum)
Dementia and Delirium
• Dementia is a risk factor for delirium
• Diagnosis of delirium in context of
dementia is often missed
• Of 2000 consecutive admissions:
• 9.1% of patients had diagnosis of dementia
• 41.4% of these demented patients had delirious
process on admission
Erkinjuntii et al., Arch Int Med, 1986
Delirium versus Dementia?
DELIRIUM
• Acute
• Inattention
• AbN LOC
• Fluctuations/minutes
• Reversible
• Hallucinations
common
DEMENTIA
• Gradual
• Memory disturbance
• N LOC
• None/days
• Irreversible
• Hallucinations
common only in
advanced disease
It is common for Delirium to be superimposed on Dementia!
So What? Who Cares?
Delirium is unimportant!
3 criteria:
Common, Morbidity & Costly!
•On admit? 15-20%
•Death ~20-35%
•LOS doubles
•In hospital? 7-31%
•Cognitive drop in
40%
• ++ hospital $
•Ortho - 25-65%
•ICU: 90%
•Premature
institutionalization
•Caregiver
burden
What can trigger Delirium?
ANYTHING!!!
Patient Predisposing Factors
• Age
• ↓ Physical fn/ immobility
• Dementia
• ↓ Hearing
• Male
• ↓ Vision
• Dehydration
• Severity of illness
• Malnutrition
• Comorbid psych dx
(Depression;
EtOH abuse)
Elie et al, JGIM 1998; Burns et al, JNNP 2004
Environmental Predisposing
Factors
• # of room changes
• Bladder catheter
• Absent clock/watch
• ICU or LTC
• Absent reading glasses
• Restraints
• Absence of family
McCusker et al, JAGS 2001
Delirium Precipitants
Prospective study incidence of delirium
229 elderly medical inpatients
•
•
•
•
•
•
•
•
Fluid/ electrolyte dysfunction (40%)
Infection (40%)
Drugs (30%)
Metabolic/Endo (26%)
Sensory/ Environmental (24%)
 perfusion/ (14%)
Neurological
EtOH/Drug Withdrawal
**No clear precipitant in 15 – 25%
Francis et al, JAMA 1990
Delirium Workup
History:
time course of mental status changes
association with other events (i.e.. meds, illness)
Pre-existing impairments of cognition or sensory
modalities
Physical Exam
• Vitals: normal range of BP, HR, pO2, Temp
• Good physical exam: particular emphasis on
Cardiac, pulmonary and neurological systems
• Hydration status (dry axilla = dehyd!)
• Also rule out
• fecal impaction
• urinary retention (bladder U/S, in-and-out catheter)
• Infected decubitis ulcer
Treatment and Management
• Identify and “correct
the correctibles”
• Multiple causes in
elderly
• Careful monitoring
• Place patient near
nursing station (1:1)
• VS, I & O, O2
• Reduce psychiatric
symptomatology
• Agitation
• Psychosis
• Discontinue nonessential medication
• Drug toxicity and
drug induced
delirium is most
common
• See Medical Letter Drugs that cause
psychiatric symptoms
•(Larsen et al., J Gerontol, 1985)
Treatment and Management
• ENVIRONMENTAL
• Restraints often indicated: posies, vests,
mitts, helmets, geri-chairs, locked leathers
• Provide cognitive structure, emotional
support to patient and loved ones
• Make sure behavioral monitoring is
adequate and if empathy exists
• Soft light, clock, familiar objects from home
Nonspecific Treatment of Delirium,
Mild Agitation, Lability, and Psychosis
A Case for Psychopharmacology
Pharmacology Of Atypical Antipsychotics
Clozapine
Risperidone
M1
5HT2A
5HT2A
D2
1
H1
5HT2C
H1
1
5HT2C
5HT2A
1
D2
H1
5-HT1A
Olanzapine
M1
D2
Ziprasidone
5-HT1D
5HT2A
Quetiapine
5HT2C
M1
D2
5D2 HT2A
1
H1
H1
5HT2C
Zorn SH et al. Interactive Monoaminergic Brain Disorders. 1999:377-393.
Schmidt AW et al. Eur J Pharmacol.2001;425:197-201.
1
55- HT1A
HT2C
Receptor occupancy (%)
Quetiapine 5HT2 & D2
Occupancy
100
90
80
70
60
D2 occupancy
5-HT2 occupancy
50
40
30
20
10
0
0
200
400
600
Quetiapine (mg/d)
800
IM Ziprasidone vs IM Haloperidol: QTc
Interval at Cmax
Injection 2
(4 hours after 1st injection)
Injection 1
15
10
5
6
4.6
0
change from baseline (ms)
20
Mean (95% CI) QTc interval
Mean (95% CI) QTc interval
change from baseline (ms)
20
15
14.7
12.8
10
5
0
IM ziprasidone
20 mg
(n=25)
IM ziprasidone
30 mg*
(n=25)
IM haloperidol
7.5 mg
(n=24)
*IM ziprasidone 30 mg is 50% above recommended dose.
IM haloperidol
10 mg
(n=24)
Adapted from Miceli et al. APA poster. 2002.
Preliminary data may not reflect final findings and results from the respective studies.
Risks of Using v Not Using
Atypical Antipsychotics
• Increased mortality in elderly patients
with dementia-related psychosis
• 17 placebo controlled trials
• Modal duration of 10 weeks
• Risk of death in treated patients 1.7 times
that seen in placebo treated patients
• Varied cause
• CV (HF, sudden death)
• Infectious
Final Verdict
• Atypical antipsychotics are not approved for
the treatment of patients with dementiarelated psychosis
• FDA stated “The agency is not advising
against all off-label use of atypicals, but is
reminding the public that these drugs are not
approved fro treating dementia and is
advising patients treated with these drugs to
have their treatment plans reviewed”.
If In Its Infinite Wisdom …
• The FDA were treating a patient, what
would they do with
•
•
•
•
•
•
•
Hallucinations
Delusions
Pressured motor activity
Overt aggression
Disruptive behaviors
Behaviors endangering others
Assaults
What is Best Practice?
• Assessment
• Medical risks
• Psychiatric risks
• Treatment options
• Risk v benefits for each
•
•
•
•
Coordinate care with PCP/geriatrician
Communicate with PCP and family
Establish monitoring system
Review literature in support of off-label use
Dosing Atypical Antipsychotics in
Dementia
• Start low and go slow
• Titrate quickly in
patients who are
moderately stressed or
agitated
• Switch agents if patient
unable to tolerate
• Avoid using if patient
recently had a heart
attack or stroke unless
behavior is life
threatening
• Reassess need
• Every week x 4
• Every month x 4
• Every 4 months
thereafter (if stable)
• Reduce dose and
monitor
• Use lowest effective dose
• Eliminate medication if
patient is stable
• Use prn meds to avoid
decompensation
Agent
IM Dose (mg)
Comments
Haloperidol
0.5 – 20 mg
Droperidol
1.0 – 40 mg
Lorazepam*
0.5 – 4 mg
Olanzepine
2.5 – 10 mg
Ziprasidone
10 – 20 mg
Akathisia,
dystonia
Prolongation of
QT
Respiratory
depression,
cognitive changes
Weight gain over
time, antichol
Prolongation of
QT
Nonspecific Treatment of Moderate to
Severe Delirium, Agitation, Lability,
and Psychosis
A Case for Psychopharmacology
IV-Haloperidol  drug of choice
• Virtually no anticholinergic or
hypotensive properties
• Generally does not suppress
respirations
• Minimal cardiotoxicity
• Can be given parenterally without
added toxicity
Treatment of Agitation:
Protocol
IV-HALOPERIDOL PROTOCOL
• Mild:
1-2 mg haloperidol iv
• Moderate: 5 mg haloperidol iv
• Severe:
10 mg haloperidol iv
Treatment of Agitation: Protocol
MGH Protocol
• Keep doubling the dose
of iv haloperidol until
calm
• May require “mega”
doses (2 grams/day)
• When calm, administer
2/3 total in divided
doses
• Taper by 10-20% day
MDAH Protocol
• Fix IV-H dose at 10mg & add
lorazepam
• Fix lorazepam dose at 10mg
THI Variant
• Add opiate
• Buprenorphine (0.1-0.3 mg)
to haloperidol-lorazepam
• Hydropmorphone (0.5-2 mg)
to haloperidol-lorazepam
Treatment of Severe Agitation:
Protocol
• If previous IV-H protocols fail
• Trial of continous intravenous infusion of IV-H
• 10-50 mg/hour
• 1 - 2 gms/day
• Trial of droperidol but greater propensity for
hypotension limits its use in cardiovascular
patients
• Add opiate
• Propofol (FDA approved)
• Paralysis
Non-pharmacological
Interventions
A Case For Risk Factor Reduction
Interventions To Prevent
Delirium
• 852 patients aged 70+
• Prospective matching of patients on
intervention unit with patients on 2 usual care
units
• Risk factor reduction strategy targetting:
•
•
•
•
•
cognitive impairment
sleep deprivation
immobility
visual impairment
dehydration
Treatment and Management
• Unambiguous communication
•
•
•
•
•
Glasses, hearing aids etc...
Avoid medical jargon
Communicate succinctly & clearly
Make contact while communicating
Translators if necessary
Cole et al, CMAJ 2002; Conn & Lieff, Can Fam Phys 2001;
Inouye et al, JAGS 2000
Treatment and Management
• Provide cognitive structure, emotional support to
patient and loved ones
•
•
•
•
•
•
Same staff
Quiet; avoid excess noise/stimulation
Simplify space
Maximize uninterrupted sleep
Restraints as last resort for patient safety
Make sure behavioral monitoring is adequate and if
empathy exists
Cole et al, CMAJ 2002; Conn & Lieff, Can Fam Phys 2001;
Inouye et al, JAGS 2000
Treatment and Management
• Maintain function
•
•
•
•
Fluid balance and hydration
Adequate nutrition
Encourage self-care
Walk with assistance or range of motion
• Minimum – 3 times/day
Cole et al, CMAJ 2002; Conn & Lieff, Can Fam Phys 2001;
Inouye et al, JAGS 2000
Results
Study
Control
Any episode
9.9%
15%
p=0.02
# episodes
62
90
p=0.03
161
p=0.02
Delirium days 105
Inouye NEJM 1999
If it is not delirium, and it is not
dementia, and there is no
significant agitation …
Sundowning
To Reduce Sundowning
• Provide orientation clues
• Give adequate daytime stimulation
• Evaluate for delirium
• Maintain adequate levels of light in daytime
• Establish bedtime routine and ritual
• Provide consistent caregivers
• Remove environmental factors that might
keep patient awake
• Discourage drinking stimulants or smoking
near bedtime
To Reduce Sundowning
• Give diuretics, laxatives early in day
• Provide personal care at same time each day
• Ensure patient has glasses, working hearing aid
• Place familiar objects at bedside
• Monitor amount of sensory stimulation
• Consider late afternoon bright light exposure
• Avoid prn sedative hypnotics
• Establish regular dose of drug for disturbing behavior
(if needed)
• Assist caregiver in obtaining respite help
If You Want to Run With the Texas Wild
Dogs …. You Can’t Pee Like a Puppy!