Clearing the Confusion Around Delirium

The nurse who was teaching him how to lie so that he could pass a police interrogation.

Another nurse who was trying to poison him.

“At one point, I was so convinced they were trying to poison me that I had my wife FaceTime with my daughter (a pharmacist) so she could watch them give me my meds,” Gregg recalls. “I think I may have been a handful for the staff.”

Gregg, of Michigan, experienced delirium during his early days as a patient at Select Specialty Hospital – Oakland.

What is delirium?

Delirium is a fast-developing type of confusion that affects a patient’s awareness and ability to focus. It causes a fluctuating mental state, simply put, delirious episodes come and go.

Delirium is often a symptom of an underlying medical issue and is typically temporary, if the underlying cause is resolved.

What are the symptoms of delirium?

Symptoms can vary greatly among patients and even from one episode to the next.

They include:

• Reduced awareness of surroundings: Difficulty focusing, easily distracted and seeming dazed
• Disorientation: Not knowing the date, time, place or even who they are
• Cognitive impairment: Memory problems, difficulty thinking clearly and trouble speaking or understanding
• Behavioral changes: Agitation, restlessness, irritability, hallucinations or sudden mood swings
• Sleep disturbances: Insomnia or excessive sleepiness

What are the types of delirium?

There are two types of delirium, hypoactive and hyperactive. The difference between these two types lies in the symptoms experienced.

Hypoactive delirium causes a person to be very lethargic, quiet and withdrawn. This is the most common type of delirium. Diagnosing hypoactive delirium can be difficult due to the symptoms.

Hyperactive delirium manifests as agitation, hallucinations, outbursts and restlessness. Those who experience this type of delirium are worked up and are harder to calm down.

Patients can wax and wane between the two types of delirium from episode to episode.

What causes delirium?

Delirium is usually caused by a combination of factors that disrupt brain function. Common causes include:

• Infections: Urinary tract infections (UTIs), pneumonia and sepsis
• Medications: Certain medications, or changes in medication dosage
• Dehydration and electrolyte imbalances: Low sodium, potassium or calcium levels
• Withdrawal from alcohol or drugs: This can trigger severe delirium tremens in some individuals
• Surgery and anesthesia: Post-operative delirium is common, especially in older adults
• Neurological conditions: Stroke, head injury and brain tumors

Environmental factors also contribute to delirium. This is seen most often in those who experience an extended hospital stay and is commonly referred to as hospital-acquired delirium. A long hospital stay can cause isolation from daily routines and activities and make it hard for patients to stay oriented to time and day. Hospital environments are commonly noisy and can cause poor sleep; all can contribute to delirium.

Who is at risk for developing delirium?

Patients with pre-existing cognitive impairments, dementia or other mild cognitive impairments or those who previously experienced delirium are at a higher risk. Additionally, the more underlying health problems and medical interventions, the greater the risk. Research indicates that as many as four out of five patients recovering from a critical illness or injury will experience delirium. Those who take multiple medications increase their risk of delirium from drug interactions and side effects.

Delirium most commonly impacts older adults due to age-related changes in brain function and increased vulnerability to medical conditions.

How is delirium diagnosed?

Diagnosing delirium can be a challenge. Often, family members are the first to notice that something isn’t quite right with their loved one.

If a patient is believed to be experiencing delirium during a hospital stay, a bedside questionnaire known as the Confusion Assessment Method or CAM-ICU test is used to evaluate attention, orientation and memory. This assessment method involves a health care professional monitoring behaviors while asking specific questions to evaluate mental state.

Since delirium does not physically manifest in the brain, it cannot be seen on a brain scan such as a CT or MRI.

How is delirium treated?

Treatment varies depending on the underlying cause. It may involve:

• Treating infections: Antibiotics for infections like UTIs or pneumonia
• Adjusting medications: Discontinuing or changing medications
• Correcting electrolyte imbalances: Replenishing fluids and electrolytes intravenously
• Creating a supportive environment: Providing a calm, quiet environment with adequate lighting and familiar objects
• Reorientation: Regularly reminding the patient of the date, time, and place and supporting a regular sleep schedule

It’s not uncommon for patients who are experiencing delirium to need extended post-acute care, such as a critical illness recovery hospital or inpatient rehabilitation hospital. Helping patients to eat, breathe, walk, talk and think independently reorients them to their normal lives and is often a big factor in recovery.

In a critical illness recovery hospital or an inpatient rehabilitation hospital, patients’ performance is monitored while they are provided the basics to challenge their brain. These basics include occupational, physical and speech therapy.

If your loved one is experiencing delirium and you believe a rehabilitation setting may be right for them, talk to their doctor or contact us.

What are the possible complications of delirium?

Every day of delirium can reduce the survival of the patient. Delirium causes the body to undergo additional metabolic stress and can increase immune-suppression, preventing proper recovery.

Delirium can have serious consequences if left untreated, including:

• Increased risk of falls and injuries
• Prolonged hospital stay
• Long-term cognitive impairment
• Increased risk of dementia
• Reduced functional ability

Delirium can also impede a patient’s ability to participate in their own care and communicate with their care team and family.

Can hospital-acquired delirium be prevented?

In many cases, hospital-acquired delirium can be prevented. Strategies include:

• Maintaining good hydration and nutrition
• Reviewing medications regularly with a doctor or pharmacist
• Treating underlying medical conditions promptly
• Providing a stimulating and engaging environment
• Promoting regular sleep-wake cycles
• Avoiding unnecessary use of sedatives
• Providing sensory aids, such as glasses and hearing aids
• Regular visits from family and friends

How to help a loved one experiencing delirium

Loved ones can play a huge role in both recognizing and treating delirium. The more time family and friends spend at the bedside, the better. This helps with reorienting the patient and can bring a sense of familiarity to an unfamiliar environment.

While at the bedside, focus on reorienting your loved one by talking about daily life, bringing in photos or treasured items and discussing hobbies or enjoyable family moments. During delirious episodes or hallucinations, do as Gregg’s family did and provide reassurance and comfort (see sidebar). Don’t try to talk the patient out of their distorted perception of reality.

During appropriate moments, it’s also important to encourage your loved one to eat, stay hydrated, maintain a regular sleep schedule and to get up and move. If the patient is able to do some of the activities they regularly do, the chance of recovery is higher.

What else can you do to help? Work in collaboration with the care team. Talk about your loved one’s life and medications at home to establish a baseline and stay abreast of what’s being done to identify the cause.

By understanding the causes, symptoms and management strategies, patients with delirium can regain their cognitive clarity. Early identification and intervention is key to a successful recovery.