HOSPITAL INDUCED DELIRIUM

April 8, 2019

 

What it is and What to Do About it.

 

Hospital induced delirium is a condition in which a patient becomes very disorientated and confused. According to new research, delirium may have longer lasting effects on a patient’s cognitive decline, including even accelerating dementia.    The combination of dementia with delirium results in significantly more rapid cognitive decline. Delirium may look like dementia but is actually an acute confused state, as opposed to dementia being a chronic condition of memory loss.  Extremely important to note that delirium can typically be linked to a human cause – it is estimated at least 40% of delirium cases are preventable. 

 

Unfortunately, symptoms are still mistaken as everyday signs of aging, it is often ignored or underdiagnosed, and because most of those affected are seniors, their complaints are often dismissed.  Seniors account for the majority of hospital emergency admissions including longer stays than any other group, their added time in the hospital further increases the susceptibility to delirium.  Once a patient has delirium they are more susceptible to repeated episodes of it in the future.  Seniors with delirium require more medical services and follow up care because it is a condition that triggers many long-term mental health problems. In vulnerable individuals’ delirium can be induced by infection, dehydration, trauma, pain, medications or simply the unfamiliar hospital environment.

 

How to Tell – not all of the symptoms have to be present to have delirium

 

Hyperactive Delirium– frequently associated with withdrawal from psychoactive drugs.

Increased motor activity; restlessness, picking at clothing or blankets, tapping fingers, hallucinations such as seeing someone who is not there, agitation, rapid mood changes, refusal to cooperate with care, possibly belligerent.

 

Hypoactive Delirium– more common

Decreased motor activity; staring off into space, withdrawn, moving very slowly, disturbed sleep excessive daytime sleeping and/or insomnia.

 

Mixed Delirium– patients fluctuate between the Hyperactive and Hypoactive states

 

Discovering what the underlying cause or causes is the first step in treatment;

 

  • Blood tests to detect anemia, abnormal blood sugar, nutritional deficiency, kidney function, thyroid function, imbalance in sodium, potassium or other electrolytes. 

 

  • Urine test to screen for UTI (urinary tract infection symptoms can cause confusion), dehydration, toxicity.

 

  • Chest Xray to check for pneumonia or heart complications.

 

  • Neurological assessment to check for a possible neurological disorder and signs of stroke.

 

  • Psychiatric consult to distinguish symptoms.

 

Risk Factors:                Sleep Deprivation

                                    Cognitive Impairment

                                    Immobility

                                    Dehydration

                                    Vision/Hearing Impairment

 

 

WHAT TO DO – Review these Prevention Tips

 

Advocate for your loved one, be certain the hospital team of Doctors and nurses are aware of the delirium and that they take action to treat the underlying cause of it.

 

Orientating Conversations

  • Get a calendar that your loved one can easily see and mark off each day. Be natural about discussing the day and their location so they are orientated to their surroundings and be sure to include their usual routine before hospitalization;

    • For instance; if they routinely shopped on Thursday’s then say “oh today is Thursday April 11, I remember you told me Thursdays are your usual shopping day.”

  • Discuss world topics with them each day so they can follow the flow and progression.  Simply reading the news headlines.

  • Discussing whatever their interests are; politics, gardening, weather, grandkids, etc. the key being following the progression or changes day to day on the topic.  

 

Mobile Orientation

  • Promote activity, being mobile seems contrary to being in the hospital but it is important part of staving off delirium.  If your loved one is not physically able to walk, pull up a wheelchair and go exploring.

  • Take them for walks outside of the hospital room and floor, even if they can only manage a couple of steps or if they tire easily you can bring along a wheelchair.  The emotional benefits are phenomenal.  Go to the gardens or cafeteria and if it is a nice day head outside to hear the sights and sounds.  Talk about what you saw, even better take a little video or picture and show it to them as a visual reminder when you talk about what you did and saw over the next few days.

  • Participation in Physical Therapy and decreasing sedatives has shown to decrease the rate of delirium.

 

 

Medication Management

  • Always have a up to date medication list for health professionals to consult.  Even if medications have not caused problems previously they can interact with new medications or given while in the hospital.

  • Many drugs that act on the brain can cause delirium; narcotic pain killers, sedatives (especially benzodiazepines), stimulants, sleeping pills, antidepressants, medications for Parkinson’s Disease and antipsychotics. 

  • One major pathway involves neurotransmitter acetylcholine. Seniors are more susceptible than younger people because they make less acetylcholine. When blood sugar falls too low or there isn’t enough oxygen to the brain – acetylcholine levels drop.   

  • Many anticholinergic medications including antihistamine diphenhydramine (Benadryl) and incontinence medications oxybutynin (Ditropan) and tolterodine (Detrol) can trigger delirium side effects.

  • Limit and minimize the use of sedatives at all opportunities.

 

Environment Management

  • Hospitals can be disorientating at the best of times; lights, loud noises, strangers all around, not to mention your own health concerns, but there are some steps to help make it a more comfortable environment. 

  • Keep the hospital staff’s overnight interruptions to a minimum, so patients are not woken up multiple times.

  • Request nurses organize their tests and care requirements to occur with minimal disruptions.   A positive less disruptive environment will help protect patients from stressors of hospitals, pain and illness.

  • Use ear plugs, eye covers and a sound machine to help prevent unnecessary waking’s from hospital noise and to promote good sleep free from as many disturbances as possible. 

  • Bring headphones and make a favourites playlist for the patient to enjoy.  

  • Bring familiar things; pictures, blanket, housecoat, favourite sweater, etc.

  • Insist they use their sensory aids; glasses, hearing aids, dentures. Often these are put away during a hospital stay but not using them will likely contribute to patient disorientation

  • Prevent the use of restraining devices.

 

Nutrition Management

  • Be there for meals to assist your loved one with eating and drinking an adequate amount. 

  • Nutrition is important, most people don’t eat well due to surgery, illness and the taste of hospital food.  Have family and friends bring some of your favourite healthy items like fruit, nuts or special favourites.

  • Be sure to follow the hospitals request for fluid and/or any dietary restrictions.

  • Stay hydrated, it is surprising how often this is forgotten.

 

Discharge Planning

  • Sometimes seniors can be sent home or to a rehabilitation facility while they are still delirious.  

  • Be sure you are present to advocate for your loved one and clearly understand the discharge instructions including what to look out for and when to call the doctor or return to the hospital. 

  • If your loved one is transferred to another facility it is important that you convey to the staff what level of functionality your loved one had prior to hospitalization. 

  • Ask for a complete medical review and see if they can discontinue some drugs, such as sedatives that were added during hospitalization.

 

 

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