Judd Matsunaga
Have you ever noticed sudden changes in your senior’s awareness, mood, attention, perception and thinking? Has your senior ever seemed completely “out of it?” If so, they might be experiencing delirium, especially if they are in the hospital or very ill. Delirium is common, showing up in about 80 percent of patients in the intensive care unit and up to one-third of all patients staying in the hospital.
Delirium is a state of worse-than-usual mental function, brought on by illness or some kind of stress on the body. Delirium affects people of all ages, but especially older adults in hospitals who are acutely ill.
Many family caregivers have never heard of hospital delirium. This is unfortunate since “developing delirium is linked to worse outcomes in older people in the hospital, and it is associated with a higher risk of declining health and death,” says Dr. Esther Seunghee Oh, co-director of Johns Hopkins Memory and Alzheimer’s Treatment Center (source: www.hopkinsmedicine.org).
In people who have Alzheimer’s or another form of dementia, just the stress and unfamiliarity of the hospital setting can be enough to tip them into increased confusion. Sensory impairments, such as uncorrected vision or hearing, can also help tip a vulnerable older person into delirium. Some common causes and triggers of hospital delirium include dehydration, sleep deprivation, infections and blood electrolyte imbalances.
The good news is that family caregivers can do a lot to prevent delirium, or at least prevent it from escalating into a serious complication. According to Dr. Oh, the best way to treat delirium is to find and treat the thing that’s causing it. Sometimes, the person’s health-care provider may need to order many tests to find the cause of the delirium. These tests can include blood tests, X-rays, brain imaging (such as MRIs and CT scans) and electrocardiograms.
Once the cause of the delirium is found, treatment can start. There are no medications that treat delirium itself. Instead, the person’s health-care provider may give them medication to treat what is causing the delirium. Or, they may give them medication to treat certain delirium symptoms.
Of course, not all hospital delirium can be prevented. Some people are very sick, or very prone to delirium, and it’s certainly possible to develop delirium even when all triggers and risk factors have been addressed. It is sometimes referred to as “hospital confusion” or “hospital sundowning.” And if it happens in the intensive care unit, it is sometimes referred to as “ICU psychosis.”
Unfortunately, delirium is often missed by hospital staff. Busy hospital staff may not realize that an older person is more confused than usual. “No one knows the patient better than friends and family members,” says Dr. Oh. “If you notice something not quite right about your loved one, telling the nurse or doctor is very important. The sooner delirium is identified, the sooner the team can address it.”
Experts estimate that about 40 percent of delirium cases are preventable. There are also steps that you, the caregiver, can take to reduce the chance of a bad delirium. Board-certified geriatrician Dr. Leslie Kernisan has listed seven steps that you can take to prevent delirium (source: www.betterhealthwhileaging.net).
1) Minimize sleep deprivation. Consider asking the nurses if it’s possible to avoid blood pressure checks in the middle of the night. A quieter room can help. Do NOT ask for sleeping pills, however! Even a mild sedative, such as diphenhydramine (brand name Benadryl) increases the risk of developing delirium. Sleeping pills can also make delirium worse in someone who is already affected.
2) Minimize vision and hearing impairments. Make sure the older person has glasses and hearing aids available, if they usually need them.
3) Provide familiar objects and reassuring companionship. A few family photos can bring some soothing cheer to an older person’s hospital stay. Family or friends at bedside are also often very helpful, especially since they can help gently reorient an older person to where he is and what’s been going on.
4) Avoid overwhelming or overstimulating the person. Try to minimize mental strain or emotional stress for the person. A calm reassuring presence is ideal. If you need to give instructions or discuss something, try to keep things simple.
5) Encourage physical activity and mobilization. Although many older people are sick or weak while in the hospital, it’s important to encourage safe activity as soon as possible. Physical therapy and minimizing bladder catheters (which can tether an older person to the bed) can help.
6) Avoid sedatives and tranquilizers. Especially if the older person is restless or having difficulty sleeping, it’s not uncommon for sedatives such as diphenhydramine (brand name Benadryl) to be prescribed. But these can increase the risk of delirium and should be avoided. So instead, try nondrug relaxation therapies such as soothing music, massage, a cup of tea and familiar companionship.
7) Minimize pain and discomforts. Ask the older person if he or she feels bothered by pain or constipation. If so, bring it up to the doctors. It’s not uncommon for pain to go inadequately treated unless family caregivers helping an older patient bring it to the doctors’ attention.
In conclusion, as the family caregiver, you can play a very important role in providing a supportive and reassuring presence during an older person’s delirium. Question things if the hospital staff wants to physically restrain the older person in bed. In many cases, if a person is dangerously restless, it’s better to start by trying a low dose of anti-psychotic, as mentioned above. Physically restraining a person often increases agitation and can lead to injury.
It can be hard to talk to someone with delirium, but it’s important to be patient and understanding. According to the experts, keep conversations basic. Speak clearly, softly and use short, simple sentences. Make sure the person can hear you and understand what you say. Repeat things, if needed.
When you’re talking to the person or asking them a question, give them some time to respond. They may need a minute to think about what they want to say. If the person is confused or scared, remind them of where they are and what is happening. Talk to them in a calm and soothing voice. Reassure them and tell them you’re there to help and keep them safe (source: www.mskcc.org/cancer-care-patient-education/delirium).
Finally, even after getting the person home to a restful familiar environment — it often still takes a while for delirium to get better. In fact, it’s pretty common for it to take weeks — or even months — for delirium to completely resolve in an older adult. In some cases, the person never recovers back to their prior normal.
Judd Matsunaga is the founding attorney of Elder Law Services of California, a law firm that specializes in Medi-Cal Planning, Estate Planning and Probate. He can be contacted at (310) 348-2995 or judd@elderlawcalifornia.com. The opinions expressed in this article are the author’s own and do not necessarily reflect the view of the Pacific Citizen or constitute legal or tax advice and should not be treated as such.
