Have you or a loved one ever experienced confusion when hospitalized or sick? You or your loved one may have experienced delirium (Duh-lee-ree-um).
What is Delirium?
Delirium is not a disease; it is a sudden change in a person's baseline mental abilities. Between 10-60% of patients aged 65 and older are at risk of developing delirium in the hospital, up to 60-80% of older adults in the intensive care unit. Delirium can increase hospital stay length, increase admission risk to a nursing facility, lead to functional loss, and increase death risk.
Who is at risk?
Hospitalized patients
Older adults aged 65 years and older
Patients with a history of underlying Dementia
Patients who have had surgery
Patients on multiple medications
Patients who are sick in the intensive care unit
Patients who have an infection
Uncontrolled pain
Signs and Symptoms of Delirium
Appearing confused
Easily distracted
Hyperactive,
Fidgety, or tired and withdrawn
Unaware of the day or time
Unsure of surroundings
Mood changes that include anger, sadness, fear, irritability
Change in regular routine such as sleeping habits
Hallucinations both visual and/or hearing
Delirium is not dementia!
Often when I see a patient in the hospital due to a sudden onset of confusion, I
am asked by their loved one if they have developed dementia. But delirium is
not dementia!
Delirium is a sudden onset of changes in attention and awareness. It usually occurs during hospitalization, after a medical problem, or surgery. This change is typically reversible once the underlying problem has been addressed.
Dementia is a gradual loss of cognition. We describe cognition as the process of thinking, problem-solving, remembering, and judgment. Patients who have dementia do not have sudden changes in awareness and attention from their baseline. There is no change in the patient's awareness or attention from their baseline. Patients ultimately die from dementia due to worsening loss of function. Family members need to provide an accurate history of a patient's baseline; sometimes, those with advanced dementia may appear to have delirium. Dementia symptoms are not reversible; symptoms get worse over time.
How long does delirium last?
Every individual will experience delirium differently. Some people will recover within days; for some, it may take up to six months to return to their previous mental baseline or a new mental baseline. There is no way to know how long delirium will last. It can last from days to weeks to months. Hospitalized patients and loved ones should not get discouraged if delirium symptoms do not resolve before leaving the hospital.
Can a person be affected by delirium more than once?
Patients who develop delirium are at risk of developing delirium again.
Different Types of Delirium
Hypoactive delirium
Hypoactive delirium is the most common. The patient may seem withdrawn, tired, and "down." These patients are at high risk for complications. Hypoactive delirium is often missed in the hospital setting because patients just appear to be tired and withdrawn. Aside from poor patient outcomes, this is another reason hospitals around the country have established protocols to evaluate people for delirium.
Hyperactive delirium
Hyperactive delirium is much less common, but due to symptoms, this type of delirium that family members and health care providers don't miss. Patients have more agitation, aggression, and extreme emotional changes. The primary concern here is pulling at needed medical equipment and possible harm to the patient due to uncontrollable symptoms.
Mixed delirium includes both hypoactive and hyperactive signs and symptoms.
Delirium Treatment
The best strategy is to try and prevent delirium. There are no medications that will cure delirium. The best treatment is to reassure, reorient, and redirect. Some medicines can even worsen the symptoms of delirium. Treating the underlying cause of delirium is the best initial treatment approach. For example, an older person may develop confusion due to an infection; once the condition is treated, delirium will usually start to resolve.
Although there are no recognized medications to treat delirium, sometimes medical providers use medicines to control a patient's behaviors. These medicines are usually used for other conditions like anxiety, depression, behavioral disorders to prevent them from harming themselves or others. The main goal is to use behavioral and environmental treatment approaches.
What can you do?
A person who has had delirium in the past is at higher risk of experiencing delirium again. You can do the following to prevent delirium and to improve delirium symptoms if they have already started:
Be present, stay with your loved one as long as possible.
Reorient your loved one, explain calmly and frequently where they are, go over the day, time, and explain the situation. Remind your loved one not to pull on tubes, such as IV lines or oxygen tubing, and remind them not to get out of bed without assistance.
Bring a familiar item like a picture, a blanket, or a keepsake. This will help a hospitalized older person feel more at home.
Encourage your loved one to work with physical therapy and get out of bed during the day with hospital staff assistance.
Keep the blinds open during the day to prevent your loved one from sleeping all-day. I can not stress how important it is to preserve a patient's normal sleep-wake cycle in the hospital. If a patient sleeps through the day, they are more likely to confuse their days and nights. Confusing days and nights can increase the risk of developing delirium. Confused and sleepy patients miss out on physical therapy and other needed treatments throughout the day.
Problems with seeing and hearing can worsen delirium, so please bring glasses and hearing aids to the hospital if your loved one uses them.
Please let nursing staff/doctors know if your loved one is in pain. Untreated pain can increase the risk of developing delirium.
Summary
Delirium is a common often unrecognized condition that can be scary to witness. The most important thing you can do is inform the medical team of any risk factors discussed in this blog that you and your loved one may have. I hope you enjoyed this post; check out other posts by www.geriacademy.com
References
1. Pandharipande P, Jackson J, Ely EW. Delirium: Acute cognitive dysfunction in the critically ill.Curr Opin Crit Care. 2005; 11:360–368. [PubMed: 16015117]
2. Douglas L. Leslie, Ph.D.1 and Sharon K. Inouye, M.D., MPH2,3: The Importance of Delirium: Economic and Societal Costs J Am Geriatr Soc. 2011 November ; 59(Suppl 2): S241–S243. doi:10.1111/j.1532-5415.2011.03671.x.
3. A Profile of Older Americans: 2001. Administration on Aging, U.S. Department of Health and Human Services; Washington, DC: Mar. 2002 2001
4. Statistical abstract of the United States. Washington, D.C.: Bureau of the Census, 1996:116.
5. Inouye SK, Rushing JT, Foreman MD, Palmer RM, Pompei P. Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. J Gen Intern Med 1998;13:234-42.
6. Cole MG, Primeau FJ. Prognosis of delirium in elderly hospital patients. CMAJ 1993;149:41-6.
7. One-year health care costs associated with delirium in the elderly population. Leslie DL, Marcantonio ER, Zhang Y, Leo-Summers L, Inouye SK Arch Intern Med. 2008 Jan 14; 168(1):27-32. F
8. Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Inouye SK, Schlesinger MJ, Lydon TJ Am J Med. 1999 May; 106(5):565-73.
9. Multicomponent targeted intervention to prevent delirium in hospitalized older patients: what is the economic value? Rizzo JA, Bogardus ST Jr, Leo-Summers L, Williams CS, Acampora D, Inouye SK Med Care. 2001 Jul; 39(7):740-52.
10. Consequences of preventing delirium in hospitalized older adults on nursing home costs. Leslie DL, Zhang Y, Bogardus ST, Holford TR, Leo-Summers LS, Inouye SK J Am Geriatr Soc. 2005 Mar; 53(3):405-9.
11. Replicating the Hospital Elder Life Program in a community hospital and demonstrating effectiveness using quality improvement methodology. Rubin FH, Williams JT, Lescisin DA, Mook WJ, Hassan S, Inouye SK J Am Geriatr Soc. 2006 Jun; 54(6):969-74.
12. Sustainability and scalability of the hospital elder life program at a community hospital. Rubin FH, Neal K, Fenlon K, Hassan S, Inouye SK J Am Geriatr Soc. 2011 Feb; 59(2):359-65.
Recruitment of volunteers to improve vitality in the elderly: the REVIVE study. Caplan GA, Harper EL Intern Med J. 2007 Feb; 37(2):95-100.
13. Grossmann et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2014, 22:19 http://www.sjtrem.com/content/22/1/19
14.Oh, Esther S., et al. "Delirium in older persons: advances in diagnosis and treatment." Jama 318.12 (2017): 1161-1174.