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What is Delirium and How To Avoid It

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Top Takeaways

  • Delirium is a relatively rapid change in mental functioning.
  • It’s common in seniors.
  • It’s often due to a new medical problem or worsening of a previously diagnosed condition. Medications, factors in the environment, or surgery can also trigger or aggravate delirium.
  • It requires immediate medical attention.
  • Although it may look like dementia, delirium is different than dementia.
  • Medical professionals can treat or reduce the severity of delirium when it occurs.
  • There are multiple things you can be proactive about to help reduce the risk of delirium. These tips are listed in this article.

 

Introduction

 

Delirium is a sudden change in mental functioning, and is common in the elderly. It requires immediate medical attention. This article will review:

  • What delirium is
  • What typically triggers episodes of delirium
  • Why should you know and care about delirium
  • What settings delirium usually occurs in
  • How medical professionals treat delirium
  • Tips for you to help avoid delirium in your loved one

 

What is Delirium? 

 

  • It’s the somewhat rapid onset (over hours or days) of confusion and disorientation. It’s a somewhat sudden and abrupt change in mental functioning and behavior. Delirium can include hallucinations, wild emotional swings, and behaviors that are not typical for your loved one (including violent or dangerous actions).

 

  • It’s caused by abrupt changes in how the brain handles information and disorder of thought processes. 

 

  • It’s often an indicator that a severe underlying medical problem is present, so it requires immediate attention. 

 

  • It can happen to anyone, but it’s a particularly common event in the elderly. 

 

  • It usually lasts hours or days but can last for weeks.

 

  • The symptoms can rapidly change, as often as every few minutes.

 

  • There are two main types of delirium. A patient can rapidly switch between these two types:

 

    • Hyperactive - The patient is overactive and agitated. They can be shouting, punching, kicking, spitting, trying to remove medical devices, and having wild hallucinations.

 

    • Hypoactive -  The patient is sleepy, hard to arouse, not very aware of their surroundings, and not moving much.

 

  • It tends to occur more frequently in patients who already have dementia, but it can happen without baseline dementia.

 

  • It is not the same thing as dementia. Dementia progresses over a prolonged time, with gradual changes. On the other hand, delirium is a relatively sudden event that occurs typically without much warning.

 

What Triggers Delirium?

 

There are numerous potential triggers of delirium. This is a list of common ones, but there are more causes than are listed:

 

1. Drugs

Many drugs can trigger an episode of delirium, especially when a senior is on multiple medications simultaneously (known as “polypharmacy”). Typical drug triggers include:

    • Antihistamines (used for allergies or as sleep aids)
    • Anti-inflammatory drugs – Drugs like Motrin™ (ibuprofen) or Naprosyn™ (naproxen) for treating pain and inflammation. Many of them are over-the-counter without a prescription.
    • Opioid analgesics  - These are commonly known as “narcotics” and are prescribed for significant pain.
    • Sedatives – Most sedatives are associated with a higher risk of delirium.
    • Tagamet™ (cimetidine) - Commonly used for stomach upset.
    • Diuretics (“water pills”) – Commonly used to treat high blood pressure, liver failure, and heart failure.
    • Alcohol-containing medications.
    • Use of, or abrupt discontinuation of frequently consumed alcoholic beverages
    • Steroids (such as cortisone or prednisone) – Commonly used for many conditions, including certain types of arthritis, immune diseases, and breathing conditions like emphysema.

 

2. Medical factors 

Common examples include:

    • Significant pain
    • Severe infections
    • Need for hospitalization due to emergency conditions
    • Organ failure
    • Kidney damage
    • Dehydration
    • Blood test abnormalities
    • Abnormal breathing or other causes for low blood oxygen
    • Significant constipation or retention of urine (unable to fully empty the bladder)

 

3. Factors in the environment or related to patient care 

Common examples include:

    • Absence of family or friends and other appropriate social interaction
    • Use of restraints when not necessary
    • Remaining in bed too much
    • Not having something to tell time with (watches or clocks) and calendars to look at
    • Catheters (medical tubes), such as urinary bladder catheters
    • Other medical devices that are placed on or in the patient
    • Frequent sleep interruptions
    • Frequent moves from one room to another when in the hospital

 

4. Surgery

Surgery and anesthesia place significant stress on the body and brain. It’s not unusual for an operation to trigger sudden delirium in seniors.



Why Should You Know and Care About Delirium?

 

Anyone who’s providing care for a senior loved one should know about and understand delirium because:

 

  • It’s very common – it can occur in approximately 10-50% of elderly patients at some time when they’re hospitalized or in a facility.

 

  • It’s frequently a signal that a new underlying medical condition or other circumstance triggered it.

 

  • It requires evaluation and identification of the condition or situation that caused it.

 

  • It requires urgent intervention and medical care.

 

What Settings Delirium Usually Occurs In

 

Delirium can occur in just about any setting.

 

  • At home, it may occur if there’s a new medical condition not yet diagnosed and/or adequately treated. Remember: delirium requires urgent and rapid medical attention!

 

  • In the hospital, including following surgeries.

 

  • At senior facilities, such as skilled nursing facilities.

 

  • In palliative care (care to relieve pain and discomfort) programs. This often includes hospice care, although not always. If your loved one is in hospice, it may not be feasible or desirable to “cure” the delirium; discuss the options with the hospice doctor.

 

How Medical Professionals Treat Delirium

 

There are many steps doctors take to treat active delirium. These steps typically include:

 

1. Diagnosing and treating/correcting the trigger for the episode

All of the things listed above in the section titled “What Triggers Delirium?” can trigger an episode of delirium.

 

2. Keeping the patient physically safe

This often includes modifying the physical environment for safety, and specially trained sitters who stay by the bed and watch the person.

 

3. Maximizing use of treatment methods that don’t involve administering additional medications:

    • Trying to engage the patient in their surroundings and with people
    • Keeping the patient up and moving around as much as is feasible from medical and safety standpoints
    • Reducing or discontinuing psychiatric drugs suspected to be aggravating the situation. Seniors are uniquely sensitive to mental status changes that psychiatric drugs can cause.

 

4. Using additional medication

Delirium is often not controlled by the above steps; in these cases, doctors use various psychiatric drugs. They are typically needed when:

    • There’s a danger the patient will harm themself or others
    • The patient is so agitated that medical professionals cannot administer proper medical care
    • The patient is very distressed by their symptoms

 

5. Doctors tend to consider delirium treatment successful if it’s gone for a minimum of two days

    • If delirium doesn’t resolve, doctors need to see if additional factors remain that are triggering it. They will also evaluate whether there is underlying dementia that wasn’t known beforehand.



Tips for You to Help Prevent Delirium

Delirium occurs and is treated most commonly while a senior is in a hospital or other facility. You should be aware of multiple things to help your loved one receive care to decrease the risk of developing delirium. Here are some useful tips.

 

1. Tips that don’t involve using medications

 

    • Confirm that the facility has a plan in place to prevent delirium 

This should be tailored to your loved one’s specific situation.

 

    • Assess your senior for delirium regularly 

The healthcare team should assess your senior for delirium regularly, and if the care team notes unusual behaviors, they should promptly assess for delirium. 

 

Specific interventions include:

      • Ensuring your loved one is aware of all treatments and interventions that are taking place during their stay (subject to their ability to understand).
      • Having clear signage in the room
      • Having clocks and calendars that are within sight of your loved one. This can help keep them oriented to time/dates and day/night cycles.
      • Having adequate lighting during the day 
      • Enabling adequate sleep at appropriate times (usually at night). Have staff avoid interrupting your loved one from sleep at night to the extent that’s doable.
      • Encouraging avoidance of daytime sleeping
      • Ensuring sufficient frequency of visits from family and friends
      • Providing adequate mental stimulation, such as reading, talking, or remembering shared events
      • Ensuring mobility to the extent possible given your senior’s overall condition 
        • Ensuring appropriate physical and/or occupational therapy sessions are taking place. (Assist devices (canes, walkers) are often used.)
        • Your loved one should start getting out of bed followed later by walking as soon as possible (to the extent their condition permits and it’s OK’d by the doctor).
        • Besides helping prevent delirium, there are many other medical benefits to physical activity as soon as possible.
        • Never take it upon yourself to engage your loved one in physical activity, mobility, or moving them around. Doing so could be very dangerous to both you and your senior. Always check with the doctor or nurse to confirm which physical activities or movements are safe.
      • Ensure hearing aids and glasses are available
      • Avoiding room assignment changes unless it’s necessary

 

2. Tips for medications

      • Ask if the doctors are minimizing the use of psychiatric medications to the appropriate extent
      • Ask the doctor to periodically review the list of drugs to ensure there aren’t unnecessary or duplicated classes of medicines being given. An example of a duplicated class of medication is two different pills where both are sleeping pills.
      • Ask the doctor to minimize the use of any medications which can cause delirium (to the extent that’s safe and appropriate for the care of your loved one). 
      • Confirm with nursing that they’re giving the same medicines the doctor thinks your senior is receiving. This includes dose and frequency.

 

3. Tips for nutrition and hydration

    • Fluid intake:
      • Fluids can help prevent dehydration.
      • Dehydration can contribute to delirium. 
      • Encourage adequate fluid intake by mouth (only if the doctor or nurse tells you it’s safe). 
      • Good hydration can help with constipation, which is another potential trigger for delirium.

 

    • Nutrition
      • Proper nutrition may decrease the risk for delirium
      • Inquire whether nutritional needs are being met. You can check with the doctor, the nurse, or the dietician.
        • Depending on your senior’s medical conditions, nutrition may be by mouth, a stomach tube, or intravenously (by vein).
      • If your senior uses dentures and is allowed to safely take food orally, be sure dentures are available while eating.
      • Always check with the doctors, nurses, or dieticians to see if it’s safe to have your loved one take food or liquid orally. There can be multiple reasons why it might not be safe for your senior to intake food or liquid by mouth at any particular time.

 

4. Tips for managing pain

Pain, and the drugs used to treat it, can trigger delirium. Ask the medical team if they are paying attention to your senior’s pain (if any). Ask the medical team if they’re using the lowest doses of pain medicines that will adequately treat pain and discomfort.

 

5.  Tips for catheterization (medical tubes that are typically placed in the urinary bladder or a vein)

Check with the medical team that they’re using the minimum number and type of catheters needed for safe and necessary treatment. 

    • Urinary or vein catheters can aggravate agitation in delirium. 
    • Delirious patients often pull at and try to remove these catheters forcibly. This can result in injury.
    • Unnecessary urinary catheters can lead to urinary tract infections, which can trigger or aggravate delirium.
    • Unnecessary vein catheters can result in infections that may cause or worsen delirium.
Stephen Engle, MD

Stephen Engle is a United States-trained physician (M.D.) and Diplomate of the American Board of Internal Medicine who is board-certified in internal medicine. He has experience as a medical director in administrative medicine with the largest private payer in the US, as well as experience in internal medicine at all levels (clinic, urgent care, emergency room, inpatient general and intensive care, clinical consultative medicine, and peer review.)

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