Managing and preventing delirium
If you have ever been with someone who has had delirium diagnosed, you will know that it can be very distressing to see a loved become confused, unable to speak coherently or focus their attention, become restless with rambling speech and fluctuate in and out of consciousness. It can also be very frightening for the patient.
It is a state that is more common with age, but is usually a sign of sickness. It can also be a result of conditions such as stroke, dementia or Parkinson’s disease. It is sometimes the only indication that an unwell senior with dementia is sick, as they might not otherwise appear sick.
To identify a clinical diagnosis of delirium, clinicians use a patient’s history, examination and special tools.
Unfortunately, delirium has a poor prognosis despite early identification and treatments. It is an independent risk factor for dementia and mortality. Research shows that older people who experience delirium in hospital are up to 5.5 times more likely to die within 30 days compared with those who did not. Delirium can worsen dementia symptoms or uncover previously undiagnosed dementia. Delirium can take any time between a few days, weeks, or even months to settle. Sadly, in some cases, the person never returns to the previous baseline cognitive state.
It is therefore important to prevent delirium as much as possible by focusing on managing risks and ensuring good hydration and nutrition. This can be challenging for our older loved ones and patients.
So what is it we need to look out for?
The most common causes of delirium can be remembered by the mnemonic Pinch Me. It stands for: pain, infection, nutrition, constipation, hydration, medication and environment.
This is because the sicknesses that result in delirium can be from infections, inflammation, chemical/electrolytes disturbances, intoxication, trauma, pain and constipation.
Frail and older people generally are less able to express their difficulties, so pay close and careful attention to their daily needs and routines.
People with delirium are unlikely to say they feel sick or are in pain. Unrecognised and uncontrolled pain can lead to other difficulties in addition to delirium — for example, poor appetite and intake of fluids can lead to infections. Painkillers can therefore help in these cases.
Infection and inflammation
Delirium can be a symptom of chest and urine infections, which are common in elderly patients. Inflammatory conditions such as arthritis, including rheumatoid and gouty arthritis, are sometimes only picked up as a result of the delirium, especially in patients with history of dementia or cognitive impairment. Antimicrobials and anti-inflammatory medications can help.
Older people are more likely to have nutritional deficiencies. Ageing guts can have poor absorption, and deficiencies can be made worse if the person has had vomiting and diarrhoea. Deficiencies can also be caused by certain medications used for chronic diseases including heart failure and high blood pressure. Attention to diet and a regular review of medications and blood tests with your physician can reduce these risks.
Chronic alcohol abuse is also a common cause of nutritional deficiencies and liver disease. Alcohol consumption itself can result in alcohol-related dementia, but nutritional deficiencies or an acute withdrawal of alcohol can also result in delirium.
Nutritional deficiencies should be addressed as soon as possible as it is essential to reduce incidence and severity of delirium as well as support long-term cognition. In certain scenarios, nutritional supplements by mouth or even feeding through nasogastric feeding tubes can help, although a holistic view of long-term goals have to be discussed.
Constipation is common in older people owing to multiple factors, including an ageing gut and poor or restricted diets. Poor mobility and medications also play a role. Regular routine toileting in addition to the use of laxatives can help. If left untreated for lengthy periods of time, constipation can affect appetite, cause nausea/vomiting and, in extreme occasions, bowel inflammation, perforation and obstruction, which can be life-threatening.
Older people, especially those with advancing dementia, often have reduced appetite and thirst sensation. This is unfortunately progressive. Long-term intravenous hydration is not shown to improve outcomes for these individuals and can potentially be harmful with complications such as infections getting into the blood stream and fluid overload in someone with heart failure. The best action is to encourage the regular drinking of water and finding food and drink the person likes, even if it is less than the ideal amount.
Medications should be under regular review by physicians whether in hospital or the community, as tolerance and benefits may change with time. Seniors are more likely to suffer side-effects from medications, even if they may have been taking them for a long time. Patients and families should work with their doctor to find a sensible balance of risk and benefit. Some medications can be prescribed by specialists for persistent delirium symptoms that fail to otherwise settle. These medications have variable evidence in helping to treat delirium. They can also increase the incidence of stroke and sometimes death. Patients and families should work in partnership with the specialist to carefully weigh if the potential harm from the delirium outweighs the possible side-effects.
Maintaining a safe environment that addresses the person’s needs is essential. Patients admitted to hospital can experience sensory deprivation, which can be disorienting. Ensure that patients have their glasses, hearing aids, walking aids and dentures at all times. Good lighting is essential with a clock and calendar visible to help with orientation. Families are advised to work in liaison with the hospital to ensure that basic information about patients’ needs, medications, preferences and advanced wishes are incorporated into their care plans. Bring some familiar items that comfort the patient and keep them visible by the bedside if safe to do so. Ensuring that voice levels are controlled and that patients are not overwhelmed with visitors can help to settle their delirium.
So, in summary, delirium can be prevented and managed through people-centred approaches. If your loved ones experience delirium, try to understand what they are going through, and continue to respect their identity and personal preferences. Along with good communication, this can bring comfort and ease. Work with the specialists to understand the risks and benefits of any treatments. For those who recover, be patient and explain what has happened as they may remember the experience and continue to be frightened.
• Zeinab Hussein is the chief of geriatrics at Bermuda Hospitals Board