“How should delirium be managed in the hospital?”
This question came up during a Q & A session, as we were discussing the Choosing Wisely recommendation to avoid tying down older adults who become confused during a hospitalization.
Delirium is a common and very important problem for all older adults in the hospital. It doesn’t just happen to people with Alzheimer’s or a dementia diagnosis. (And, it’s not the same thing.)
But many family caregivers have hardly heard of hospital delirium. This is too bad, since there’s a lot that family caregivers can do to prevent this serious complication, or at least prevent an older loved one from being physically restrained if delirium does occur.
In this post, I’ll review what older adults and families absolutely should know about hospital delirium. And, we’ll cover some of the things you can do if it happens to your loved one.
Why hospital delirium is so important to know about
Delirium is a state of worse-than-usual mental function, brought on by illness or some kind of stress on the body or mind.
Although people with dementia are especially prone to develop delirium, delirium can and does affect many aging adults who don’t have Alzheimer’s or another dementia diagnosis. Here are some facts that all older adults and family caregivers should know:
- Delirium is very common during hospitalization. Delirium can affect up to half of older patients in a hospital. Risk factors include having pre-existing dementia and undergoing surgery. Having had delirium in the past is also a strong risk factor.
- Delirium is strongly associated with worse health outcomes. Short-term problems linked to delirium include falls and longer hospital stays. Longer-term consequences can include speeding up cognitive decline, and a higher chance of dying within the following year.
- Delirium is often missed by hospital staff. Busy hospital staff may not realize that an older person is more confused than usual, especially if the delirium is of the “quiet” type. (Although many people are restless when delirious, it’s also common for people to become quiet and “spaced out.”)
- Delirium is multifactorial. There often isn’t a single cause for delirium. Instead, it tends to happen due to a combination of triggers (illness, pain, medication side-effects) and risk factors (dementia, or pre-dementia). This means that treatment — and prevention — often require a multi-pronged approach.
To summarize, delirium is common, serious, and often missed by hospital staff.
Fortunately, there’s a lot that you can do as a family caregiver. In particular, you can help your loved one more safely get through a hospitalization by:
- Taking steps to prevent delirium;
- Keeping an eye out for any new or worse-than-usual mental states that might signal delirium;
- Making sure hospital staff address the problem if it does happen;
- Questioning things if the hospital resorts to tying a person down, before all other options have been tried. (This last one is a Choosing Wisely recommendation.)
How to prevent hospital delirium
Now, 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. Furthermore, many older adults are already delirious when they first get hospitalized.
Still, there are steps that can be taken to reduce the chance of a bad delirium. Experts estimate that about 40% of delirium cases are preventable.
The ideal is to be hospitalized in a facility that has already set up a multi-disciplinary delirium prevention approach, such as the Hospital Elder Life Program. Other hospitals have Acute Care for Elders units (also called “ACE” units) which also provide a special environment meant to minimize the hospital stressors that can tip an older person into delirium.
For elective surgeries, such as joint replacements, look for a hospital that has set up a geriatric co-management program for orthopedics, such as this one.
Here are some specific interventions that help reduce delirium, and how you can help as a caregiver:
- 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.
- Minimize vision and hearing impairments. Make sure the older person has glasses and hearing aids available, if they usually need them.
- 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.
- 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.
- 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.
- 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 non-drug relaxation therapies such as soothing music, massage, a cup of tea, and familiar companionship.
- 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 help an older patient bring it to the doctors’ attention.
For more useful ideas, see this family tip sheet from the Hospital Elder Life Program.
If you think your loved one has developed delirium, make sure the doctors and nurses know about it. You may want to ask them what their plan is for evaluating and managing it. This will help you stay up-to-speed on the hospital course.
Some hospitals may even interview families to help diagnose delirium, using something called the FAM-CAM (short for Family Confusion Assessment Method) tool. The Confusion Assessment Method is generally considered the gold standard for diagnosing delirium.
How hospital delirium is treated
To treat delirium, here’s what the doctors and nurses usually do:
- Identify and reverse as many triggers as possible. Remember, delirium is often multi-factorial. So even if there is a urinary tract infection that seems to have brought it on, the hospital team should try to spot any other factors that could be contributing (such as a medication side-effect, or a lack of glasses).
- Provide supportive care. It’s especially important to provide a calm restorative environment when a person is suffering from delirium. People may do better if they can avoid frequent room changes, and if they have a window allowing orientation to daylight.
- Prevent injury and manage difficult behaviors. This can be very challenging in those patients who become restless when delirious. Some hospitals have special “delirium rooms,” in which trained staff provide non-drug management of disoriented patients. As a last resort, the doctors do sometimes use low doses of medication. Research suggests that a small dose of antipsychotic, such as Haldol, is generally better than using a benzodiazepine (such as Ativan) which is more likely to make an older person’s confusion worse.
What you can do if an older person becomes delirious in the hospital
It can be scary to see an older person confused in the hospital, especially if you know that delirium can have serious consequences.
First and foremost, try not to panic. It’s time to hope for the best. Focus on doing what you can to help the delirium resolve.
As a family caregiver, you can play a very important role in providing a supportive and reassuring presence during an older person’s delirium. You can also:
- Advocate for minimum disruptions, and a quieter more pleasant room if possible.
- Make sure glasses and hearing aids are available, if needed.
- Help your loved one speak up if you think pain or constipation may be a problem.
- Question things if the hospital staff want to physically restrain the older person in bed. (This is a Choosing Wisely recommendation.) 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.
If you are of the really vigilant and proactive type, you may want to double-check that your loved one isn’t getting any sedatives or anticholinergic medications that make confusion worse. Even though these medications are risky for hospitalized older adults, it’s not uncommon for them to be prescribed!
What to expect after delirium: Even when all the right things are done — including 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.
For more on delirium, see:
- 10 Things to Know About Delirium (includes information on delirium vs. dementia)
- Delirium: How Caregivers Can Protect People With Alzheimer’s (includes a list of helpful online resources that I’ve reviewed)
- A Common Problem That Speeds Alzheimer’s Decline, and How to Avoid It
You can also listen to our podcast episode, featuring leading delirium researcher Dr. Sharon Inouye, the founder of the Hospital Elder Life Program:
062 – Interview: Preventing Hospital Delirium & Maintaining Brain Health
This article was first published in 2014, and was last updated by Dr. K in March 2022. As we are now at 200+ comments, the comments section has been closed to new comments. Thank you!
My 69yr old father who has Parkinson’s disease (12yrs) went into hospital on the 2nd April for a hip replacement. About 2 days after surgery he developed early signs of delirium. Day 9 He was then transferred to a nursing home to start rehab for his hip, his delirium had increased terribly by this stage. The nursing staff took him off all of his Parkinson’s medications saying they could be interfering with the delirium. They started him on a antipsychotic medication as well as strong pain killers but My question is, is it safe to just completely stop Parkinson’s medication without weaning?
Then whilst still in the nursing home, my father had a fall. He shattered his femur in the same leg he had the hip replacement and has since had surgery again to fix the break and is still in hospital now. His delirium is worse than ever and nothing seems to be helping him recover from it. They have put him back on all his Parkinson’s medications, but I can’t help but think that all this change would be totally messing up his head.
We really want to get him home to familiar territory and hope this will help with recovery.
This is so upsetting seeing him like this…
Leslie Kernisan, MD MPH says
Oh, this sounds awful for your father and also for your family, that’s really unfortunate that he fell in the nursing home.
I don’t usually manage parkinson’s medications (most patients have a neurologist overseeing that aspect of their care), but in general, my understanding is that suddenly stopping Parkinson’s medications should be avoided. That said, certain Parkinson’s medications can also make people prone to hallucinations, so I can see why it could be a challenge to manage Parkinson’s medications in the face of significant delirium.
I do know that it can take weeks or longer for vulnerable older adults to improve from their delirium. I hope he’s started to recover and that he gets better soon. Good luck!
My 90-year-old father had a toe amputated in April 2018. Within 24 hours he became delirious, trying to get out of bed, insisting he was on a ship and needed to go to the galley, thinking the wall facing the foot of his bed was a floor and that the TV was a window to the ocean, actually a porthole. This and much more went on for ten days in the hospital. I stayed every hour with him the entire stay. It was exhausting. Medicare tried to discharge him, but I gained two days grace. I thought the Vancomycin was the culprit and at my request, the doctor switched to another drug, although he said the Vanco was not causing the delirium. When he finally went home he began to come around, but now a year later he still has confusion about things such as whose house he is in. He has been loosely diagnosed with Lewy Body dementia and has been taking Lexapro for about 8 weeks now. Unfortunately, he is scheduled for another toe amputation in two days, same foot. I am scared of the delirium recurring and I have read that the odds are high that it will. To prevent it, I told the doctor I want to take him home as soon as possible after the surgery, like even within 12 hours, and have a daily visiting nurse, but he said the risks of bleeding, etc. are greater than the chances that he won’t develop the delirium at home anyway. Is that true? I thought just getting him home would prevent the confusion. Last year I was afraid to take him home and away from the medical support he was receiving at the hospital, but now I’m not so sure. Is it better to go home as soon as he can, or stay in for the medical care and IV medicines, etc.? The delirium was definitely easier to manage at the hospital than at home, but I felt like the unfamiliar surroundings were adding to the confusion. By the way, he is not diabetic. He has peripheral artery disease and osteomyelitis in his right foot.
Leslie Kernisan, MD MPH says
Glad you are being proactive and thinking about how to minimize your father’s delirium risk. It’s true he’s at risk of it happening again, based on his past history of delirium and also because he has dementia, which makes it easier for people to become delirious.
Being in a familiar environment can help but is no guarantee of avoiding delirium. I think with either option, you will be facing some risks and challenges. Probably there is no exact right answer, so pick one approach (do consider your ability to manage his post-operative care and wound if he goes home) and then hope for the best. Good luck!
Hi, I’m really hoping you can help as we are feeling very ill informed by the hospital. My grandfather has had arthritis in his legs and hip for a while now and even though walked badly was still using sticks and driving and very independent, he was very sharp and knowledgeable and if you wanted to discuss something complex he was the best to go to as he was so brainy! He’s 85, and four weeks ago had a fall at home and fractured his hip, as soon as he was admitted into hospital I noticed a slight change in his mental status I brought it up to hospital staff multiple times, the hospital decided he would not be a good candidate for a hip opp as he has a weak heart and the break is one which can be healed without. He was sent home a week after and seemed a little confused and irritable which is completely against his nature and even though told to stay seated until the physios arrive he got up and fell again. He was re admitted and some days he seemed ok but others he was confused, the Friday he seemed nearly himself and home was prepared again for his return Monday. However when visiting him Sunday he was completely confused again (hallucinations, not being able to speak or listen) I kept pushing the gps and nurses until they finnaly tested and he proved positive for a UTI he has had a week intravenous antibiot which finished last week but he has just continued to decline, now we walk into his hostpial ward and he doesn’t stir when he does now and again open his eyes he just babbles and the most distressing is his body keeps twitching and he keeps jolting his arms and legs and going stiff as if he’s in a lot of pain (he says he’s not when pushed to tell) on Friday a doctor told us to prepare for the worst which devastated us as he was only admitted with a fracture and was due to come home just last week , we went in yesterday and couldn’t stop crying as we thought this was it he seemed to be in a deep sleep hallucinating and unable to wake however a few minutes later a specialist doctor came in and told us his overall health has been improving and no problems with his brain scan and his heart has been working better as his fluid retention has gone and his blood pressure is good, but he has got delirium, they have said they have been monitoring him and it is just a case now of a waiting game, I don’t no who to believe anymore as we are constantly told conflicting information, he is eating and drinking well now. I have read all the posts and responses here and have not noticed anything about the body tensing and arms and legs randomly lashing around and the not being able to speak (just making noises instead) the specialist doctor said that is becouse of the delirium , would you think this to be true? Very sorry for this long comment we are a small family and struggling very badly, this is the hardest time of my life so far, many thanks Christina
Leslie Kernisan, MD MPH says
Sorry to hear of your grandfather’s fall and subsequent health issues. I think what you are describing does sound like delirium. It can be due to the stress of hospitalization but also it is easy to develop additional illness and complications in the hospital. (Plus you mentioned he has a weak heart.)
For someone like him, you can keep asking the doctors whether they think there is any particular medical condition currently causing his delirium. If not, then it’s just a matter of time and rest and he will probably improve with time. It can take a while though, and that is certainly hard for everyone involved. Try to remain hopeful and be with him, that is usually of great comfort to older adults during the stress of hospitalization. good luck!
Janine Burrier says
My significant other was recently hospitalized for liver problems that where result of his congestive heart failure which made his kidney problems worse and is now on dialysis. The doctors in the hospital told me that his state of confusion and memory loss was due to hospital delirium after they had corrected the ammonia levels from his kidneys that caused paddock encephalopathy. It has been over three weeks he is now in rehab and although he is better he is still very angry and sometimes confused combative end I don’t know what to do. He is 61 years old I don’t know if it could be dementia as well or it is delirium and will take time to resolve.
Leslie Kernisan, MD MPH says
Sorry to hear of your partner’s situation. 61 is pretty young for the more common causes of dementia, although it does happen. It’s also possible that his mental function is being affected somewhat by his liver condition. In general, it’s best to give a person time to recover from delirium before assessing for possible dementia. This is especially true for people who weren’t manifesting any memory or thinking problems prior to hospitalization.
Good luck, I hope he gets better soon.
Thank you for this article and the answers to previous asked questions. My mother-in-law has been in and out of the Hospital since the middle of December with UTIs, blood infections, and then she went through a time when she stopped eating which is her current state. She is currently with a feeding tube. He has had to be restrained due to wanting to remove the tube. She’s had many complications and has coded twice.I’m under the impression that they are trying to treat her delirium which wa the current issue until yesterday when they mentioned she may have some complications with her thyroid. She also is not able to pass a swallow test. I am not the point of contact so we (my husband and I) feel a bit in the dark. What we do know is she is agitated, seems to have lost her memory (names/events/doesn’t recognize us), makes some inappropriate comments to people, and continues to take off her hospital gown. (She is bedridden, but has asked to go to the bathroom and doctors tell her to go…due to catheter, she isn’t being offered the restroom.) Part of me questions delirium over dementia at this point, though she didn’t exhibit symptoms prior to December. What would be the difference? Thank you for your help and insight.
Leslie Kernisan, MD MPH says
Sorry to hear of your mother-in-law’s condition, it sounds like she’s been sick for quite a while, which must be very difficult for her and for the whole family.
I cover the difference between delirium and dementia in this article: Delirium vs. Dementia.
Good luck and hope she gets better soon.
Jennifer Reynolds says
My 76 year old father recently had a bowel obstruction removed, Feb. 23rd. In ICU he began complaining about the “honking” machines and all the people coming in an out the area. His agitation grew, and his determination to go home increased to the point of obsession. He began picking at his IV and bile tube. I came back from a daily mandatory 2 hour visitor leave and saw a lot of commotion from his room. Within the two hours I was gone, he had removed his IVs, his bile tube, and was working on his catheter. Everything was replaced, and they restrained him and gave him a sedative to force him to calm down. There was no reasoning with him, and he often would ask for a knife to cut thru his restraints, but then would at another point ask us to take his hands from his pockets as if not understanding he was restrained. He could answer questions about his childhood, military service, and was still as sharp memory wise as when he was admitted. But he did not understand why he was in the hospital, actually believing he had maybe been in a car accident. I spent one night physically wrestling with him to keep him in the bed so they would not restrain him and sedate him. They had told him he would be moving to the step down unit, which he interpreted as going home, and he had no intention on waiting. At this same time he would tell us what he was going to eat when he got home… pizza, ice cream, etc. This was a comfort to us actually because due to the bowel obstruction he did not have a good appetite prior to surgery,
When moved to the step down unit, things did improve. He started to clear mentally, but there was still some confusion. As I’m writing this now, he is still in the hospital. He communicates well, seems much more himself, but he has a complete refusal to eat. He is very weak, and when we plead with him to eat his response is he can’t or he makes excuses why the food is inedible. Being that physically he has recovered from the surgery itself, his doctor is discharging him, even with the fact that he’s extremely weak and on day three of not eating, and in my opinion, depressed. But, we were told that home health was set up for him, coming in home to rehabilitate him. I saw this as a positive, as I felt getting him out of the hospital setting would help the delirium to clear more, and maybe being home would spark his interest to start eating again. But now we are being told that the physical therapist requests he goes to a nearby rehab facility instead, so he’s going right back into a hospital setting, depressing and foreign and will more than likely need a feeding tube. I’ve read many articles about how these patients only seem to recover when they get away from the hospital, so this was not the news I was hoping for,
My main question is about the refusal of food. Could this still be a symptom of the delirium, and the fact that we can’t seem to reason with him about how his eating is dependent on him getting his strength back and going home?
Leslie Kernisan, MD MPH says
Sorry to hear of your father’s situation, sounds like he has had a rough time with his illness and hospitalization.
He certainly could still be experiencing some delirium, but in that case, I would expect him to have some symptoms (e.g. confusion, inattentiveness, being spaced out) at times. Just refusing food and otherwise behaving normally sounds unusual for delirium.
You could try to see if they can get a nutrition consult. Or a speech therapist might be able to check his swallowing. Good luck, I hope he gets better soon!
Melissa Guillory says
I realize this is an older post, My Dad had a total knee replacement done on April 10, 2018 he was 78 years old. My Dad was very active drove to a city near by to visit friends every weekend. Did his finances, grocery shopping, yardwork etc. Surgery went well said they fixed his knee and then my nightmare began. The first day after surgery he was given pain meds every 5 to six hours and slept alot. The next day he was so groggy that my sister voiced her concerns… I however thought it was the meds and though when they taper off Dad will be back to his normal self… That did not happen he had confusion and bouts of pure meaness that was never a trait of his before. For instance he told a nurse that tried to give him meds are you as ugly on the inside as you are on the outside? Then he began refusing to take meds , talked of people from the past and it was so scary. There were times when he seemed ok and was better only to get back up to the hospital to have him swatting flies that wasnt there or having a shouting match with a caregiver. Again my dad went into surgery perfectly fine and came out almost childlike… he was in the hospital for a week and then We did therapy in the hospital for 14 days and then we were called in to have a meeting, not one doctor was there only therapist telling storys of how aweful my dad was. And ‘if ” a skilled nursing facility would take him we could go there. No nursing facility wanted to be bothered with his behavior, or they were full. we took him home and have 5 days of sleepless nights, got home health and therapy invovled and thought we were going to beat this deliurum thing when he got sick to his stomach and was dehydrated we had him brought to er and all his levels were out of wack… 5 days in hospital with dilerum my dads heart exploded almost one month to the date of this total knee replacement. I miss my father and have so much sympathy for anyone going through this. No one warns you about this before your elderly parent elects to have surgery of they did not us. Prayers to whoever has this same nightmare
Leslie Kernisan, MD MPH says
Oh, that is quite a story and I’m sorry that it came to a sad ending. Yes, you are right, older adults and families are often advised to consider the risk of delirium and other complications that can occur after surgery. The good news is that more and more hospitals are creating programs to be proactive about preventing and treating delirium, so perhaps fewer families will be affected by delirium in the future. I’m sorry for your loss and take care.
So much of this applies to my dad, but I need some help. In January, my dad was able to use his walker to go to restroom, walk across the house, and even go out to the car with minimal assistance. He’s been a multiple myeloma patient for 12 years and is now 84. He went into hospital a month ago because of going into kidney failure due to lack of movement-likely caused by getting a cold and feeling bad-so he didn’t eat much. After a week in hospital, he was better and went to rehab. At that rehab he was eating well and seemed pretty alert, but they did not do much “rehab” there. We moved him after a week to a different rehab that he was in last year. He developed a cough, and they treated him for pneumonia preventatively. On weekly bloodwork it showed up that his hemoglobin was 7.0 so they transferred him to er for blood. There, they found he actually had pneumonia so they started IV antibiotics. They were giving him fluids and 2 units of blood because his hemoglobin had dropped to a 5. The day after the blood, he was back to how he was acting 2 months ago…very conversational, ate 3 meals for the first time in over a month, wanted his cell phone, things that had not happened in over a month. He was still good the day after that, though a little less alert-but still eating well for him. Then yesterday he ate some,but he was not as alert as two days before, but he was medically stable (hemoglobin 9.6 and creactin was 1.0) so they sent him back to the post acute rehab he was in- that is three days after his transfusion and one day after taking him off his fluid drip. This morning, he is so lethargic. He keeps saying how tired he is, and he barely ate. I am so discouraged! Obviously, the 2 units of blood and a few days of fluid got him on the right track, but how do we keep that up??? I really think he has hospital delirium having not been home in a month, and we SO want to bring him home, but we need him to get to where he can at least toilet again! In the hospital, they did a CT of the brain and abdomen, and there was no evidence of stroke and they only saw minimal stool in the bowel so they gave him some medicine. They supposedly did some more tests to see why his hemoglobin would fall from a 7 to a 5 in a day, but they have not found anything conclusively. I wanted to know if there is anything he can take, a vitamin, etc that would help him keep up the energy and congnitive level he had the day after the blood transfusion!? Any suggestions? I was so encouraged this weekend because he was feeling so good, so I know he is capable of feeling like that!!! Thank you for any suggestions.
Leslie Kernisan, MD MPH says
Hm. From what you describe I’m not sure he is experiencing delirium. It sounds odd that his hemoglobin would drop from 7 (which is low) to 5 (really low), but that they wouldn’t have found the cause of this.
Honestly, he sounds like one of those medically challenging patients who stumps the doctors for a bit and needs extra evaluation before they figure out what’s going on. It’s really not possible to determine what he can take to maintain his energy and cognition without knowing more about what’s causing his symptoms and health problems in the first place. 2 units of blood and fluids is essentially the equivalent of a fancy bandaid on a wound; it does not tell you what caused the problem in the first place.
I hope that either by now they have figured out what was going on with him, or that he is better. Good luck!
Dan Saia says
I just have a quick question. Is TV ok during the day for someone with Delirium. My father seems to slowly be coming around after a very long stretch in the hospital and significant delirium. He seems to be just a little better every day. But the one thing I notice, he just stares at the ceiling or stares straight ahead. Now…if I talk to him or get up and move around he will look at me (he can’t talk right now as he is on a ventilator with a tracheotomy), but he can shake his head and answer yes or no sometimes if he is more lucid. I want him to be stimulated during the day and I often play music, but is TV ok too, or is that too much stimulation? Thank you so much for this site and what you are doing.
Leslie Kernisan, MD MPH says
Hm, that’s a good question. Well, it IS good to provide some stimulation, especially stimulation that is social, reassuring, and pleasant for the person. And you also want to avoid overstimulating or exhausting the person. What to do about TV probably depends on the person, whether they generally liked TV beforehand, what kind of TV programming is being displayed, and also on the specifics of where they and their brain are at now. There’s really no substitute for trying it and seeing how he responds. The company of a live person would be better but if that’s not possible, I’d think about trying some programming that is more likely to be restful, e.g. nature documentaries with minimal advertising breaks.
Re music, probably what’s most important is to play music your father likes. And always, try to keep observing how he responds so you can figure out what he seems to find restorative. Good luck!
Elizabeth Ensign says
Hi Dr. Kernisan, I want to thank you for sharing this information about Delerium in the elderly. I am currently in the middle of a situation with my mother who is 76 (77 in April). On Thursday1/31, my dad sent me a message asking me if I could come over to the house and help him as my mother wasn’t feeling well. When I arrived my mother was throwing up and definitely miserable. She was able to give short yet delayed one word repsonses when we asked her about what she was feeling and whether she was ok with us taking her to urgent care. We got her to urgent care and the ruled out flu(by rapid swab) but told us we needed to go to the nearby hospital to rule out stroke. At this point she was growing agitated, was able to recite her name and dob (over and over) and was still doing one to two word delayed responses. We took her over to the hospital and she was diagnosed with a mild uti and they said there was an issue with her thyroid medication “working to well”. I believe she has hypothyroidism. Another issue to note is my mother had back surgery a month prior (12/27) and was still in some pain (in the days prior to us taking her to urgent care and the hospital) and she was taking both tramadol and Vicodin routinely at night. The week before her admission my mother was her usual self. She was driving herself places, went out to eat with the family,and played bridge with friends as recenly as four days before the urgent care visit in 1/31. They admitted my mother to the hospital on 1/31 and in the morning on 2/1 she did not know my name or my dad’s name. This has never been an issue for her. I was shocked. Since that time they have run multiple MRI’s, CT scans, blood and urine testing, and even a lumbar puncture. Her veins evidently disappear and they have had to change her Iv multiple times which has really upset her. Her hospital room has u fortunately been well trafficked by nurse and dr’s each day which she has complained about in her more lucid moments. Since 1/31 my mother has gone in and out of confusion and agitation. At times she has a blank look on her face and her eyes don’t track. She becomes non responsive and sort of stares into space. Then moments later she can snap out of it and her sense of humor comes through and she is oriented to time and place. This goes back and forthe through the day and is consistently happening when it gets dark. Her test results have ruled out stroke and meningitis and I imagine many other things. Her WBC count is now normal. She began A-fib while at hospital and developed wheezing and coughing. She is still a-fib and i saw it go as high as 130. The respiratory therapist says the wheezing is In Her throat area and not her lungs. She was hyperventilating yesterday and they finally moved her to the icu which is calmer and much less activity. They gave her a PIK line yesterday and gave her Ativan to do it. They also had to hold her arms down because she was so agitated. I’ve seen her unable to keep her arms still several times through the day, every day she has been at the hospital. I read your information about delirium last night and asked Mom’s ICU nurse about it. She had previously told me her mother had dementia and that mom’s symptoms were similar. When I asked her this morning about delirium she was quite dismissive. She said that if Mom was suffering from delirium she would be hallucinating all day long and basically be seeing purple unicorns all day long. She said delirium does not come and go. I thought her description perhaps better matched The DT’s people get when withdrawing from alcohol not necessarily the delirium you speak of. She also told me today Mom doesn’t really have any underlying medical conditions now as her WBC count is now normal and they have ruled out so many things. She said she thought in the next day or two the dr would recommend sending mom home and emphasized that home would be better than skilled nursing because she would benefit from being in her home that is familiar to her. From what you have written I am wondering if perhaps mom is suffering from delirium rather than dementia. I am willing to accept a dementia diagnosis if a neurologist dx’s Her as such but I am also concerned the hospital is over looking delirium and they could be actively helping mom and us in how to best address it. I didn’t get a chance to speak to her Dr about delirium this morning because i had to leave for work. My dad plans to discuss it with her Dr. Thoughts? Thank you so much for your time!
Leslie Kernisan, MD MPH says
So sorry to hear of your mother’s illness, it must be so hard for you to see her this way.
If I understood correctly, the ICU nurse said “delirium does not come and go.” This is not true, the DSM-V criteria for delirium say that “the [mental] disturbance develops over a short period of time (usually hours to a few days), represents an acute change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day.”
What you are describing does sound like a very typical case of hospital delirium in an older adult. Now, some older adults do have pre-existing dementia and this can be “unmasked” by the delirium. Most neurodegenerative dementias, including Alzheimer’s, cause brain changes for 10-15 years before symptoms are obvious, so a big stressor on brain function can allow symptoms to seem to suddenly emerge. To determine whether actual underlying dementia is likely, we normally would have to talk to family and others, to determine whether there were signs of deteriorating memory or thinking prior to the person’s illness.
The main thing that health providers should do, if they suspect delirium, is to keep checking for triggers and aggravators. Otherwise, even when no triggers or aggravators are present, it can take days or longer for delirium to resolve. During this time, the person needs “supportive” care: rest, reassurance, exposure to daylight, mobilization, hydration, etc.
Hope she gets better soon. Good luck!