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Family Health Magazine - growing older

Delirium in Old Age
One language of illness

Joan is a 77-year-old woman who has been living alone without the need for any help. Aside from some vision loss and arthritis, she is very healthy. Last year, Joan’s doctor diagnosed osteoarthritis in her right knee. After six months of medication adjustments, Joan’s knee pain is getting worse. She talks it over with her son Barry and decides to have a knee replacement.

After the surgery, she and Barry are told that everything went well. They expect a good recovery. For two days, Joan acts herself and feels somewhat relieved. When Barry arrives the next morning, the nurse manager tells him that his mother became confused during the night. She saw moving images on the wall and bugs on the ceiling. She climbed out of bed and constantly pulled off the bedsheets. Barry rushes to his mother’s room and finds her sound asleep at ten o’clock in the morning. When she wakes up, Joan seems like her usual self. After Barry tells her what happened, they don’t know whether to laugh or cry. “Am I going crazy?” Joan asks. Barry tries to reassure her, but he wonders, “Is my mother losing her mind? This is so unlike her.”

This experience may seem unbelievable, but happens often when older adults are hospitalized. In fact, it happens in up to half of older adults who have hip or knee surgery and one third who have heart surgery. Joan is experiencing something called delirium. It usually means that something is wrong. If left untreated, it can cause a loss of physical independence, a permanent decline in memory and even death. Delirium can be mistaken for other memory problems or physical illness, making it difficult for doctors and nurses to even notice it.

This may all be very worrisome. With the possibility of delirium, why would any senior voluntarily go into a hospital? Fortunately, delirium is treatable and preventable. Delirium is most likely to be recognized and treated when family members, nurses and doctors share their observations and work together.

What is delirium?

Delirium is a temporary state of confusion. It may start suddenly and come and go over the course of the day. It is mainly a problem with attention. Delirious people have difficulty focusing and are very disorganized in their thinking. They may also have changes to their memory, conversation skills, or ability to recognize people. Delirium may be quiet or hyperactive, but both are equally serious. With hyperactive delirium, there may be increased physical aggression. The person may have hallucinations (seeing or hearing things that are not there), delusions (believing something to be true in spite of good evidence to the contrary), and nighttime sleep disturbances. When it is quiet, delirium may seem like nothing more than excessive sleepiness.

Common to the experience of delirium is the sense that something is not right. People who have experienced delirium say that it is not enjoyable. Family members who know them will notice this and are also disturbed. Doctors and other health care providers who are not familiar with the person might think that the confusion was already there and take it less seriously.

When older adults take new medication or become ill, delirium may be the main symptom or side effect. Once delirious, they often cannot express their concerns or look for help. For the older adult, delirium must be viewed as the language of their illness. Once recognized, the root causes must be found and corrected. By alerting the nurses or doctors and by identifying some of the possible causes, family and friends can help to solve the puzzle. Family members also play a major role in treatment.

Causes of delirium

Think of delirium as an accident waiting to happen, almost like a forest fire. Before a forest fire starts certain conditions, such as lack of rainfall and high winds, can make the fire hazard high. Other events such as lightning or human error may spark a fire. When the fire hazard is high, humans can often prevent the fire. However, there is always a chance that fire will come in spite of our best efforts. In the same way, some conditions may set the stage for delirium, and other new problems can trigger it. Much can be done to reduce the risk, but delirium cannot always be prevented.

Who is at risk for delirium?

Certain conditions make a person at risk for delirium. Older age, being male, vision or hearing problems, memory loss, depression, physical impairments and poor mobility, and malnutrition can all contribute. The greater the burden of other illnesses, the greater the risk for delirium. Specific diseases such as dementia, past strokes, Parkinson’s disease and kidney failure are especially risky for delirium.

What can spark a delirium?

Delirium can be sparked by any medication or new illness. In this way, it becomes the language of new illness in those who are at risk for it. Usual medication suspects are strong painkillers, such as Demerol™.

Common illnesses related to delirium are infections of the bladder or chest, dehydration, and abnormalities in sodium, potassium, glucose, calcium, steroid hormones and thyroid hormones. New heart, lung, liver or kidney problems may also cause delirium. Sometimes delirium is triggered by a new brain condition such as a stroke or a seizure, but this is not usual.

How is delirium prevented and treated?

For families and caregivers, recognizing delirium and identifying the causes is the main task. If this is done skillfully, treatment is simply a matter of treating the root causes and supporting the patient. Support means helping the person get through the delirium and back to normal.

The same supportive approach that helps treat delirium can help prevent it from starting. Families play a major role in supporting their loved one and reducing the need for medications to control symptoms of delirium. Families can work with the hospital staff to recreate a comforting, familiar setting in the hospital. While there is no place like home, families can help by placing familiar objects around the room or simply being present as much as possible.

A calm, reassuring approach can make all of the difference. Physical pain and psychological stress should be reduced. Items that assist with communication should be used, such as hearing aids or glasses. Getting enough food, liquids and physical activity should be encouraged. Non-medicinal sleep strategies should be used at a set time in the evening.

Sometimes, there is a lag time of a few days between the recognition of delirium and the successful treatment of its causes. Though the right things are being done, delirium is still present. If the person is at risk of harming themselves or others, certain medications can calm the patient temporarily. Haloperidol and other similar drugs are commonly used. In special situations of withdrawal or seizures, a sedative may also be used.

Back to Joan

Those not familiar with delirium can find it terrifying to experience or witness. However, much can be done to demystify this temporary state of confusion. Seeing delirium as a language of illness, rather than illness itself, helps to encourage action. The key to resolving delirium is to recognize it, identify and treat its causes, and provide support until it is gone.

Barry and Joan were able to understand that delirium was possible. Barry alerted the doctors that Joan’s confusion was not at all like her. He spent time with her, making sure that she wore her glasses and ate her meals, and went for walks. He kept her awake during the day with activities that interested her. In the meantime, the doctor discovered that Joan had a urinary tract infection and treated it. Joan hadn’t noticed any symptoms of the infection. The only symptom was the delirium itself. Delirium was the language of her illness. Working together, doctor, nurse and son were able to get the old Joan back in a matter of days.