Delirium and Haldol

art by Bijou DeLaney

Confusion and delirium are common end-of-life occurrences, and they can be very distressing to the patient, the family, and the caregiver. I want to share a recent story that represents typical presentation and treatment for delirium. 

I cared for a woman who was 95 years old. She came to our in-patient facility bedbound, combative, and agitated. The CNA and I kept circling back to her room to help her get ready for the day. We wanted to wash her face, and she would bat us away. We wanted to change her wet brief, and she grabbed on to her brief and would not let go while screaming, “Heeeeeeelp!” She gave us the evil eye when we offered her a drink of water, assuming we were poisoning her. When we left the room, she would attempt to get out of bed and the alarms would start ringing, which only increased her agitation. She was unable to walk, but this did not prevent her from trying. Oh no, she was bound and determined to get the hell out of that bed. 

And I know how that story ends; unfortunately I have seen it too many times. So one of us hovered near her room to keep an eye on her. We would run in as soon as her leg made it to the edge of the bed. 

The family arrived a bit later, relieved to have gotten some sleep. They had been taking care of her for a few months, and this last week had brought them to their knees. Her confusion came on suddenly and intermittently throughout the week made it difficult to do anything for her. She’d already had two falls in just the last week even while everyone was on high alert and on “grandma duty.” 

Like our 95-year-old patient, delirious patients are unsafe to be alone, and it becomes extremely difficult to care for them. This is often how delirium can present. Delirium comes on suddenly and waxes and wanes. The waxing and waning delays treatment or diagnosis because the family thinks, “Oh, Grandma is fine now. That was a strange episode.” 

Delirium can also present in other ways: inattention, confusion, inability to hold a conversation, hallucinations, garbled speech, disorientation, combativeness, agitation, and restlessness. I wrote a blogpost on delirium and confusion that discusses the reversible causes of delirium, medications, as well as non-pharmaceutical interventions. 

We saw glimmers of our patient’s personality. While I was offering her some applesauce, she glared at me and then was distracted by my necklace. I told her I bought it for myself, for my 53rd birthday, and she said, “Good for you!” And she kept staring at it with a big grin on her face. I saw her, who she had been and who she wanted to become again. And then she took a few more bites of applesauce, forgetting her earlier insistence that I was trying to poison her. 

The family also helped to reorient and redirect her. We encouraged a calm, quiet room with soft music as the TV was seeping into her reality and increasing her confusion. 

At this stage, as a hospice nurse, I look for the reversible causes of delirium, which are: constipation, low blood sugar, dehydration, infection (UTI is very common and easily treatable with oral antibiotics), medications (some can lead to delirium, but this gal refused her medications or spit them out), low oxygen levels (she was at 87% and we would put oxygen on, but she often took it off), urinary retention (although she would not let us get close to her to scan or palpate her bladder, and even if she did, she was in no position to endure the insertion of a catheter).

So we placed her on oxygen, set food and drinks at her bedside, and let her go. Each time we came back we would try to establish trust with her, but we did not make much progress. She would yell, “Heeeeeeeelp! Lions!” That is probably how we appeared to her, like vicious creatures that were trying to dominate. The nugget of truth is that we were trying to get her to do things she did not want to do, even though we had her best interest at the core. Delirium is a terrifying experience for most patients.

I called the doctor, and she prescribed Haldol, 5mg every six hours. Easy for her to say. Now I had to find a clever way to give my skeptical, paranoid patient this medication. 

Haldol is an antipsychotic medication that rebalances dopamine to improve thinking, mood, and behavior. Most home hospice patients are given an emergency kit which contains a few doses of Haldol because delirium is a very common end-of-life symptom. Haldol can help clear a confused patient and bring them out of their distressed state. I love to use it because it can generally bring the patient back to their old personality. I also love to use it because I know that delirium can be a terrifying experience for the patient. They feel out of control, disoriented, and scared. Generally, if my patient is in distress and there is nothing we can do at that moment to reverse the delirium, Haldol is a great next step. 

Of course there are side effects, such as sleepiness, constipation, dry mouth, and blurred vision. I also think it can dull the patient a bit, which is sad to witness, and hopefully the patient will just need it short-term for a “reset” and then they can be tapered off the Haldol. And of course, there are contraindications, such as lowering the seizure threshold, which makes a patient more prone to seizures. Haldol should not be used if a patient has Parkinson's, and Haldol should be used judiciously with dementia. 

The CNA and I took a breath and walked into her room. I carried an oral syringe with a crushed Haldol tablet mixed with a tiny splash of water. Nichole distracted her with an entertaining story while I squirted the medication into our patient’s  mouth. She hated me and distrusted me, but she’d hated me all morning. 

An hour later she was sleeping, and one hour after that she let us change her brief. It really felt like her brain got rebooted. It took four doses of Haldol in that next 24-hour period before she was in a good space: smiling, eating, engaging, and letting us care for her. I was finally able to scan her bladder and found she was retaining urine, which was likely the reason she was so confused and delirious. She was now in a position to endure the insertion of a catheter and keep it in. 

The family was relieved to see Grandma back to being Grandma, and she returned home about a week later. 

Delirium is a distressing symptom for the patient and the family, and when you are caring for someone at home, the responsibility is overwhelming. Call the hospice team for guidance if your loved one is displaying unusual behavior, hallucinating, or is agitated and unable to be redirected. The hospice nurses will guide you over the phone and should be able to visit and assess the patient. My blogpost How to Manage Confusion and Delirium, has tips for non-pharmaceutical interventions that may be helpful. 

Blessings.